Perimenopause: When You Feel Less Like Yourself

If you suddenly feel like a more anxious, irritated, exhausted, or forgetful version of yourself, it may not be “just stress.” Perimenopause is the transition leading up to menopause. It can start years before the final menstrual period and often brings

changes in hormones, sleep, mood, focus, energy, body composition, menstrual cycles, urinary health, and sexual health.¹ ²

Hot flashes get most of the attention, but perimenopause rarely follows a predictable script. For some people, the first sign is not hot flashes or waking up drenched in sweat. It's snapping at people more easily, forgetting words, not sleeping, feeling foggy, or feeling “off” and less like themselves. Some people have obvious menstrual changes. Others are still having periods and assume that means hormones are not involved.

Symptoms can include changes in menstrual cycle length, heavier or lighter bleeding, hot flashes, night sweats, poor sleep, anxiety, irritability, depressive symptoms, brain fog, joint or muscle pain, fatigue, body composition changes, low libido, vaginal dryness, pain with sex, urinary urgency, leaking, recurrent UTIs, constipation, or pelvic pressure.¹ ²

Someone may go to a provider for sleep. Then anxiety. Then weight changes. Then urinary symptoms. Then painful sex. Each issue may get treated like a separate problem when we don’t realize the bigger picture is that the body is moving through a hormonal transition.

Why It Gets Brushed Off

Perimenopause is easy to overlook because, at first, it can look a lot like regular life. You are tired because you are busy. You are irritable because you are stressed. You are not sleeping because you have too much going on. You feel scattered because you are juggling work, family, appointments, and everyone else’s needs. A lot of people do not think about perimenopause unless they are having obvious hot flashes or their periods have stopped. So, when the first signs are anxiety, low mood, brain fog, poor sleep, urinary changes, pain with sex, or feeling like your body is suddenly unfamiliar, those symptoms can get explained away and may not be seen as connected to each other.

“But I’m Too Young for This”

Actually, that's a common misconception. Perimenopause is often talked about like it only happens in the late 40s. For many, that is true. But symptoms can begin earlier. Current clinical guidance recommends considering perimenopause when menstrual changes or vasomotor symptoms (those hot flashes and night sweats) are present in women ages 40 to 45. It also recommends evaluating for premature ovarian insufficiency in women under 40 when symptoms such as menstrual irregularity, fertility concerns, or menopause-like symptoms are present.²

There is also emerging research on ADHD and perimenopause. Some women with ADHD report more intense perimenopausal symptoms, especially in areas like mood, sleep, focus, physical comfort, urinary health, and sexual wellbeing.³ This does not mean ADHD causes early perimenopause, and it does not mean every person with ADHD will have a harder transition. But it may help explain why some people feel like their usual coping strategies suddenly are not working as well.

If you are in your mid-to-late 30s or 40s and your ADHD symptoms feel harder to manage, your brain fog is worse, your mood feels less predictable, or your sleep has changed, hormones may be worth considering as part of the bigger picture.

Nutrition, Strength, and Bone Health

When bodies change in midlife, the advice women hear is usually some version of: eat less, lose weight, walk more. That advice can do real damage when it is the only advice being given. During perimenopause, the body is already dealing with hormone shifts that can affect sleep, mood, digestion, muscle, bone, energy, and metabolism. Making uninformed changes to diet or movement can make some of those issues worse, especially if it leads to not getting enough protein or fiber. That can mean more constipation, less muscle, and less support for bones that already need extra attention during this stage.⁴ ⁵

Many perimenopausal women are not meeting recommended intake for nutrients like fiber, vitamin D, calcium, and iron.⁴ A well-rounded diet that includes enough protein, fiber, healthy fats, and key vitamins and minerals can support energy, digestion, mood, muscle, and bone health during this transition.⁴ ⁵ So when someone is struggling, the answer should not automatically be “just change your diet.” A better starting point is asking whether the body is getting enough of what it needs.

Strength training is one of the most useful tools we have for protecting muscle, mobility, and bone health as hormones shift. Research has shown that exercise can support bone mineral density in premenopausal women, and supervised resistance and impact training can improve bone mineral density and physical function in postmenopausal women with low bone mass.⁶ ⁷

Pelvic Floor, Urinary, and Sexual Health

Urinary leaking, urgency, vaginal dryness, pain with sex, low libido, recurrent UTIs, constipation, pelvic pressure, and pelvic pain are common, but they should not be brushed off as “just aging.” These symptoms can be connected to pelvic floor changes, hormone changes, or both. If ignored, they may become harder to treat over time.⁸

Depending on the symptoms, treatment might include pelvic floor physical therapy, gynecology or urogynecology care, bladder treatment, constipation support, vaginal estrogen or other local treatment options, and sexual health support.

When to Ask for Help

Consider talking with a healthcare provider if symptoms are new, worsening, confusing, or interfering with daily life. That includes heavy or unusual bleeding, hot flashes or night sweats that disrupt sleep, new or worsening anxiety or depression, brain fog that affects work or daily functioning, pain with sex, vaginal dryness, low libido, recurrent UTIs, urinary leaking, urgency, pelvic pressure, constipation, symptoms before age 40, significant symptoms in the early 40s, or a history of ADHD with new or intensified symptoms in the mid-to-late 30s.

Track what is happening if you can. Bring notes. Mention cycle changes, sleep, mood, hot flashes, urinary symptoms, sexual discomfort, medications, or anything that feels different.

Treatment Should Match the Person

Some people need help sleeping. Some need support with anxiety, irritability, or feeling emotionally all over the place. Some need pelvic floor physical therapy because they are leaking urine or having pain with sex. Some need nutrition support because they have been told to eat less for years and now they are exhausted, constipated, losing muscle, and feeling worse. Some need nonhormonal medication. Some need local vaginal treatment. Some need menopausal hormone therapy. Many need a mix.¹ ² That is why a real perimenopause appointment should be more than, “Are you having hot flashes?” It should include what has changed, what feels off, what your periods are doing, how you are sleeping, what your mood is like, what medications you take, what your medical risks are, and what you want to improve.

Hormone therapy is considered the most effective treatment for many menopausal symptoms for people who are good candidates.¹ ² Recommendations should come with an actual discussion, not a rushed yes or no. Your provider should be looking at your symptoms, health history, risks, benefits, contraindications, and preferences.¹ ² If your symptoms are affecting your work, parenting, sleep, focus, relationships, sex life, or ability to get through the day, ask what your options are. And if the answer is vague reassurance, or “that’s just aging,” or “you’re too young,” it is okay to ask for a referral to an OB/GYN or other medical provider who specializes in perimenopause/menopause.

A Little Validation

Perimenopause is a normal process but feeling like you are barely getting through the day doesn't have to be your new normal. Sleep, mood, relationships, work, body changes, urinary symptoms, sexual health, and overall daily functioning are all valid reasons to ask for more support.

If the information described above feels familiar, know that you are navigating a legitimate biological transition. Get the therapy to manage the emotional toll, talk to your provider about your physical symptoms, and request a referral to a menopause specialist if you aren't being heard. 

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References

1.      Magraith, K., & Jang, C. (2023). Management of menopause. Australian Prescriber, 46(3), 48–53. https://doi.org/10.18773/austprescr.2023.014

2.      Lumsden, M. A., Dekkers, O. M., Faubion, S. S., Lindén Hirschberg, A., Jayasena, C. N., Lambrinoudaki, I., Louwers, Y., Pinkerton, J. V., Sojat, A. S., & van Hulsteijn, L. (2025). European Society of Endocrinology clinical practice guideline for evaluation and management of menopause and the perimenopause. European Journal of Endocrinology, 193(4), G49–G81. https://doi.org/10.1093/ejendo/lvaf206

3.      Jakobsdóttir Smári, U., Valdimarsdottir, U. A., Wynchank, D., de Jong, M., Aspelund, T., Hauksdottir, A., Thordardottir, E. B., Tomasson, G., Jakobsdottir, J., Lu, D., Nevriana, A., Larsson, H., Kooij, S., & Zoega, H. (2025). Perimenopausal symptoms in women with and without ADHD: A population-based cohort study. European Psychiatry, 68(1), e133. https://doi.org/10.1192/j.eurpsy.2025.10101

4.      Murphy, M. B., Cuskelly, G., & Heavey, P. (2025). Nutrient intake and menopausal symptoms in perimenopausal women. Nutrients, 17(24), 3887. https://doi.org/10.3390/nu17243887

5.      Garg, R. (2026). Micro and macronutrient deficiencies and their correlation with menopausal symptoms. Journal of Mid-Life Health, 17, S3–S7. https://doi.org/10.4103/jmh.jmh_326_25

6.      Kelley, G. A., Kelley, K. S., & Kohrt, W. M. (2013). Exercise and bone mineral density in premenopausal women: A meta-analysis of randomized controlled trials. International Journal of Endocrinology, 2013, 741639. https://doi.org/10.1155/2013/741639

7.      Watson, S. L., Weeks, B. K., Harding, A. T., Horan, S. A., Beck, B. R., & Weis, L. J. (2018). High-intensity resistance and impact training improves bone mineral density and physical function in postmenopausal women with osteopenia and osteoporosis: The LIFTMOR randomized controlled trial. Journal of Bone and Mineral Research, 33(2), 211–220. https://doi.org/10.1002/jbmr.3284

8.      Chen, W., Gong, J., Liu, M., & Cai, Y. C. (2025). Long-term health outcomes and quality of life in women with untreated pelvic floor dysfunction: A single-center cohort study. Frontiers in Public Health, 12, 1495679. https://doi.org/10.3389/fpubh.2024.1495679