15 Symptoms You Didn’t Know Could Be Perimenopause

Hot flashes, night sweats, irregular periods… all of these are symptoms most women may expect to experience as menopause approaches. And while they may be the most common or obvious changes, this hormonal transition can actually affect far more than just your reproductive system.

During perimenopause, estrogen can fluctuate dramatically before ultimately declining, while progesterone also decreases. Because receptors for these hormones are found throughout the body—in your brain, bones, muscles, skin, cardiovascular system, urinary tract, and other tissues—the effects can show up in some unexpected places.

So, if you’re in your 40s or 50s and are experiencing strange or unexplained symptoms, you’re not alone—and there may be a hormonal explanation.

Dr. Karrie Hohn, concierge functional medicine physician at PALM Health, shares 15 not-so-obvious perimenopause-related symptoms or changes and the biology behind them.

1. Frozen Shoulder and Other Joint Pain

Estrogen has effects on inflammation, cartilage, and connective tissue. As estrogen levels become more erratic and eventually decline, inflammatory signaling and pain sensitivity may increase, potentially contributing to achy or stiff joints.

Many women report experiencing “frozen shoulder,” a stiffening and contracting of the shoulder capsule, but joint aches are not limited to this condition.

2. GI Upset

“There is a two-way relationship between the gut and hormones, specifically through the “estrobolome,” a collection of gut bacteria that helps process, metabolize, and recirculate estrogen,” says Dr. Hohn.

Because of this relationship, when estrogen levels fluctuate and decline during perimenopause, it can shift the microbial diversity and composition of the gut, which can lead to symptoms like bloating, constipation, diarrhea, reflux, or changes in digestion.

3. Brain Fog

Roughly 40% to 60% of women during the menopause transition report experiencing brain fog.

Estrogen helps keep neurons active, supports the formation of new brain cells and connections, and encourages brain cells to use glucose—the brain’s primary fuel—for energy. As estrogen levels fall, brain energy metabolism can temporarily decline, which may contribute to symptoms such as brain fog, forgetfulness, difficulty concentrating, word-finding problems, anxiety, and changes in mood.

4. Burning Mouth

A burning or tingling sensation in the tongue, lips, or mouth can occur around menopause. The exact mechanism is still being studied, but hormonal changes may affect oral tissues, saliva, taste, and the nerves responsible for pain perception. 

5. Fatigue

Hormones may affect energy regulation directly, but fatigue can also be multifactorial. Night sweats, insomnia, mood changes, and changes in metabolism can all leave you feeling depleted, even when you believe you are getting enough time in bed.

6. Dry Eyes

Sex hormones influence all three major components of tears: the watery layer, the oily layer that prevents evaporation, and the mucin layer that helps tears spread across the eye. In particular, androgens support the meibomian glands, which produce protective oils along the eyelids, so hormonal shifts may interfere with tear production and stability. The result can be dryness, burning, blurred vision, excessive tearing, light sensitivity, or a gritty sensation.

7. Dizziness

“Fluctuating estrogen and progesterone affect several systems involved in balance and circulation,” Dr. Hohn says. “Estrogen receptors are present in the inner ear’s vestibular system, which helps control balance, so changing estrogen levels may interfere with how that system functions and may also contribute to conditions such as vertigo.”

Hormonal shifts can additionally affect blood pressure and blood vessel function, heart rhythm, and blood sugar regulation, all of which can trigger dizziness. 

8. Urinary Symptoms

Estrogen helps maintain the tissues of the bladder, urethra, vagina, and pelvic floor. As estrogen declines, these tissues can become thinner and more vulnerable, contributing to urgency, frequency, leakage, burning, or recurrent urinary tract infections.

9. Headaches

Rapid fluctuations in estrogen can alter brain chemicals and pain pathways involved in migraine and headache signaling, making the nervous system more sensitive to triggers. 

For women who are hormonally sensitive, a sudden drop in estrogen is especially likely to provoke headaches or migraines, which is why symptoms can become more frequent or unpredictable during this transition.

10. Heart Palpitations

Estrogen decline may contribute to palpitations by affecting the autonomic nervous system—the system that regulates heart rate—as well as the body’s vasomotor response.

Changes in estrogen may make sympathetic “fight-or-flight” activity more pronounced, particularly during hot flashes and night sweats, which can temporarily increase heart rate or create the sensation of a racing, pounding, or irregular heartbeat.

11. Bone Loss

Estrogen normally helps limit the activity of cells that break down bone. As estrogen declines, bone resorption can accelerate, gradually lowering bone mineral density and increasing the future risk of osteoporosis and fractures.

12. Muscle Loss

Estrogen also plays a role in skeletal muscle function, repair, and metabolism. Its decline—combined with normal age-related muscle loss—can make maintaining muscle mass and strength more difficult without adequate resistance training, protein, and recovery.

13. Thinning or Unwanted Hair

Declining estrogen can shorten the hair growth cycle, contributing to scalp thinning. At the same time, changing estrogen-to-androgen balance can make androgen effects more noticeable, sometimes resulting in coarser hair on the chin or face.

14. Belly Fat and Weight Gain: The “Menopausal Middle”

Hormonal changes don’t automatically cause major weight gain, but declining estrogen can change where fat is stored. Fat distribution tends to shift from the hips and thighs toward the abdomen, while aging-related changes in muscle mass and energy expenditure can make weight management harder.

15. Tinnitus

Estrogen helps regulate blood flow in the inner ear, supports the sensory hair cells that convert sound vibrations into nerve signals, and helps stabilize brain networks that normally filter out unimportant background noise.

When estrogen levels rise and fall unpredictably, those systems can become less stable, contributing to auditory hypersensitivity in which faint or normally ignored sounds are amplified by the brain and perceived as tinnitus.

Hormonal shifts may also interact with inflammation and nervous-system changes, creating a migraine-like state of increased sensory sensitivity that can make ringing, buzzing, or other internal sounds feel louder and more intrusive.

The Bigger Picture

Perimenopause can come with a confusing host of symptoms that can feel overwhelming, frustrating, and disconnected. If you’ve experienced any of the above changes, talk to your provider; some treatments like Hormone Replacement Therapy may be helpful.

As Dr. Hohn reminds us, it’s always important to consider your symptoms as a part of a bigger picture of health. “Many of these changes can be perimenopause or hormone-related, but not necessarily so. Other health factors, predispositions, and conditions must always be considered, and treatments must be personalized to you,” she says.

A comprehensive evaluation can help determine what is hormonal, what isn’t, and what combination of lifestyle, medical, and hormonal therapies may be appropriate.