During perimenopause, you may notice changes in your body. Some changes are subtle and others are more obvious. You might have:

• Irregular periods. As ovulation becomes more unpredictable, the time between periods may be longer or shorter, your flow may be light to heavy, and you may skip some periods. If the length of your periods is consistently different by seven days or more, you may be in early perimenopause. If you go 60 days or more between periods, you're likely in late perimenopause. If you go 12 months without a period and then start bleeding, talk to your healthcare professional right away. This could be a sign of a health issue.
• Hot flashes. Many people have hot flashes during perimenopause. Hot flashes can vary in how strong they are, how long they last and how often they happen.
• Sleep problems. Trouble sleeping is often due to hot flashes or night sweats, but not always. Changes in sleep patterns can happen in perimenopause even without hot flashes or night sweats.
• Mood changes. Mood swings, irritability or increased risk of depression may happen during perimenopause. Mood changes can happen for other reasons that are not related to perimenopause. For example, people with a history of hormonal mood changes such as premenstrual syndrome, premenstrual dysmorphic disorder or postpartum depression are more likely to have mood changes during perimenopause. People who have had mood disorders in the past, such as depression or anxiety, are also at risk.
• Vaginal and bladder problems. As estrogen levels drop, your vaginal tissues may become drier and less elastic, causing pain during sex. This dryness also can cause burning when you urinate, even if you do not have a urinary tract infection. It also can make you more likely to have urinary or vaginal infections. And you might leak urine more often, need to go more frequently or feel a stronger urge to go.
• Decreasing fertility. As ovulation becomes less regular, it's harder to get pregnant. However, if you're having periods, pregnancy is still possible. If you don't want to get pregnant, use birth control until you've gone 12 months without a period.
• Changes in sexual function. During perimenopause, sexual arousal and desire may change. Some women may not enjoy sex as much, while others enjoy it more. If you are concerned about your sexual health during or after perimenopause, talk to your healthcare professional.
• Loss of bone. As estrogen levels lower, you start to lose bone more quickly than you replace it. This increases your risk of a disease that causes fragile bones, called osteoporosis. People with osteoporosis are at risk of bone breaks.
• Changing cholesterol levels. Less estrogen may lead to changes in your blood cholesterol levels. This can include an increase in low-density lipoprotein (LDL) cholesterol, also called the "bad" cholesterol, which increases the risk of heart disease. At the same time, high-density lipoprotein (HDL) cholesterol, also called the "good" cholesterol, decreases in many women as they age. Together, these changes increase the risk of heart disease.

When to see a doctor

Some women see a healthcare professional for their perimenopausal symptoms. But others either tolerate the changes or don't have symptoms that bother them. Because symptoms may be hard to notice and can happen slowly, you may not realize they are caused by perimenopause.

If any symptoms of perimenopause bother you, see your healthcare professional.

Perimenopause is caused by changes in two key female hormones: estrogen and progesterone. As you go through perimenopause, estrogen and progesterone rise and fall. Many of the changes you have during perimenopause are caused by lower estrogen.

Menopause is a natural phase of life. It may happen earlier in some women than in others. For example, in some women it may start early, such as before age 40, or between ages 40 and 45. Certain factors may make it more likely for perimenopause to start at an earlier age, such as:

• Smoking. Menopause happens 1 to 2 years earlier in smokers than in nonsmokers.
• Family history. Women with a family history of early menopause also may go through early menopause.
• Cancer treatment. Cancer treatments such as chemotherapy and pelvic radiation therapy have been linked to early menopause.
• Hysterectomy. A hysterectomy that removes your uterus, but not your ovaries, usually doesn't cause menopause right away. Your ovaries still make estrogen even though you don't have periods. But this surgery can sometimes cause menopause to happen earlier than usual. Also, if you have one ovary removed, the ovary you still have might stop working sooner than expected.

Some health conditions also may make early menopause more likely, such as thyroid disease, rheumatoid arthritis or other autoimmune diseases.

Irregular periods are common in perimenopause. Most of the time this is nothing to be concerned about. See your healthcare professional if:

• Bleeding is very heavy.
• Bleeding lasts longer than seven days.
• Bleeding happens between periods.
• Periods are usually less than 21 days apart.

These symptoms may mean there's an issue with your reproductive health that needs diagnosis and treatment. If you have gone 12 months without a period and then start bleeding, tell your healthcare professional. You could have a health issue that needs attention.

Perimenopause is a gradual change. There is no single test or symptom to tell if you've started perimenopause. Your healthcare professional looks at many things, including your age, menstrual history, and what symptoms or body changes you're noticing.

Some healthcare professionals may order tests to check hormone levels. But other than checking your thyroid, which can affect hormone levels, hormone testing isn't usually helpful to know if you're in perimenopause. That's because hormone levels in perimenopause change unpredictably.

Medicines are often used to treat perimenopausal symptoms.

• Hormone therapy. Systemic estrogen is hormone therapy for the whole body. It comes as a pill, skin patch, spray, gel or cream. It is the best treatment for hot flashes and night sweats. Based on your health history, your healthcare professional may recommend estrogen in the lowest dose that helps your symptoms. If you still have your uterus, you'll need a progestogen in addition to estrogen. Systemic estrogen may help with bone loss, but it can increase the risk of stroke, blood clots and breast cancer. Talk to your healthcare professional about all the benefits and risks of systemic estrogen.
• Vaginal estrogen. Estrogen can be used in the vagina with a vaginal tablet, ring or cream. This treatment releases just a small amount of estrogen into the vaginal tissue. It can help with vaginal dryness, pain during sex and some bladder symptoms. Vaginal estrogen also may help prevent urinary tract infections.
• Antidepressants. Some types of antidepressants called selective serotonin reuptake inhibitors (SSRIs) may reduce hot flashes during menopause. This can be helpful for women who can't take estrogen or for women who need help with treating a mood disorder.
• Fezolinetant (Veozah). This is a hormone-free medicine that treats menopause hot flashes. It works by blocking a pathway in the brain that helps regulate body temperature.
• Oxybutynin. This medicine is mainly used to help with overactive bladder symptoms and bladder leakage but also can help with hot flashes.
• Gabapentin (Neurontin). Gabapentin is a medicine usually used for seizures or pain, but it also can help with hot flashes. It may be a good option for women who can't take estrogen or who struggle with sleep, pain or migraines.

Before choosing a treatment, talk with your healthcare professional about your options and the risks and benefits of each. Check in yearly to make sure your treatment is still right for you, as your needs and treatment options may change.

These healthy lifestyle choices may help ease some symptoms of perimenopause and promote good health as you age:

• Ease vaginal discomfort. Use over-the-counter, water-based vaginal lubricants (JO, Pink, Sliquid Organics, others) or moisturizers (Replens, Hyalofemme, Sliquid Satin, others) to help with vaginal dryness. Avoid products with glycerin or parabens. Glycerin can cause burning or irritation in some people, and parabens may increase the risk of cancer. Staying sexually active also can help improve blood flow to the vagina.
• Eat a healthy diet. Because there is a higher risk of osteoporosis and heart disease during perimenopause, a healthy diet is crucial. Eat a low-fat, high-fiber diet that's rich in fruits, vegetables and whole grains. Add calcium-rich foods. Avoid alcohol and caffeine if they trigger hot flashes. Ask your healthcare professional if you need calcium or vitamin D supplements, and how much to take.
• Be active. Regular exercise helps prevent weight gain, improves sleep and elevates mood. Aim for 30 minutes or more most days, but not right before bed. Regular exercise — especially with weights — helps keep your bones strong and lowers your risk of broken hips as you age.
• Get enough sleep. Try to go to bed and wake up at about the same time each day. Avoid caffeine, which can make it hard to sleep. And avoid drinking alcohol, which can interrupt sleep.
• Do stress-reducing activities. When done regularly, activities such as mindfulness meditation or yoga can help you relax and stay healthy at any age. Moving meditation such as tai chi also can help with balance.

In addition to traditional therapies, many people want to know about complementary and alternative treatments for menopause symptoms. Researchers are looking into these therapies to see how well they work and if they are safe and effective. But more research is needed.

Herbs and supplements

Some alternative options studied are:

• Black cohosh. Some people use this herb extract to treat hot flashes and other menopausal symptoms. But there's not enough research to know if it really works, and experts also are not sure of the risks. Some studies suggest that black cohosh harms the liver. Researchers also are unsure if it is safe for women with breast cancer or at risk of breast cancer.

• Phytoestrogens. These estrogens are naturally found in certain foods. Two main types of phytoestrogens are isoflavones and lignans. Isoflavones are in soybeans and other legumes and red clover. Lignans are in flaxseed, whole grains, and some fruits and vegetables. There are also plant-based compounds that act like estrogen in the body.

  Phytoestrogens are found in foods and supplements. But research is unclear on whether they help with menopause symptoms. It's also uncertain if they impact breast cancer risk.

• Dehydroepiandrosterone (DHEA). DHEA is hormone made in the body that's available as a supplement. It's thought to help with painful sex caused by vaginal dryness in menopause. Research on whether it helps is mixed. There also are some concerns about possible risks, such as cancer.

Natural hormone therapy

• Bioidentical hormones. The term "bioidentical" suggests that the hormones in the product are the same as the ones made in your body. However, all hormone therapy is made in a lab. But unlike synthetic hormones, bioidentical hormones are plant based. The U.S. Food and Drug Administration, also called FDA, has approved some bioidentical hormones as safe to use.

  Compounded bioidentical hormones — which are custom-mixed bioidentical hormones — aren't controlled by the FDA. Because of this, the quality and safety of these products can vary. There's also no research showing that compounded bioidentical hormones are safer or better than standard hormone therapy.

Talk with your healthcare professional before taking any herbal or dietary supplements for perimenopausal or menopausal symptoms. The FDA does not regulate herbal products, and some can be dangerous or change how other medicines work. This can put your health at risk.

Complementary therapies

Low-risk complementary therapies that may help with menopause symptoms or reduce stress include:

• Acupuncture. Acupuncture may help with hot flashes, but more research is needed to know for sure.
• Relaxation techniques. Activities such as yoga and mindfulness meditation can help reduce stress. This may in turn help with menopausal symptoms.
• Cognitive behavioral therapy. This type of talk therapy teaches coping skills that may help with mood and feelings of well-being. It also may improve sleep and reduce pain during sex.
• Hypnosis. Hypnosis is a state of deep relaxation and changed consciousnesses. Some studies show that it can help with hot flashes and sleep during perimenopause. Hypnosis also is called hypnotherapy.
• Weight loss. Losing weight has been shown to help with hot flashes and night sweats. Weight loss may be especially helpful in early menopause for people with obesity.

You'll likely see your primary care doctor, nurse practitioner or other healthcare professional as a first step to talk about your symptoms. If you aren't already seeing a healthcare professional who specializes in the female reproductive system, called a gynecologist, you may be referred to one. Or you may be referred to a different healthcare professional who specializes in perimenopause.

Consider taking a family member or friend along. Sometimes it can be hard to remember all the information given during an appointment. Someone who goes with you may remember something that you missed or forgot.

What you can do

To prepare for your appointment:

• Bring a record of your menstrual cycles. Keep a journal of your menstrual cycles for the past few months, including first and last dates of bleeding for each cycle, and whether the flow was light, moderate or heavy.
• Write down any symptoms you're having. Be specific. It may help to track your symptoms to see if they are related to your menstrual cycle. Include any symptoms that may seem unrelated, as well.
• Take note of key personal information. Include any major stresses or recent life changes.
• Make a list of all medicines and the amounts taken. Include prescription and nonprescription medicines, herbs, vitamins, and supplements.
• Prepare questions. Your time with your healthcare professional may be limited, so bring a list of questions to help you make the most of your time together.

Some basic questions to ask include:

• What's causing my symptoms?
• What else could be causing my symptoms?
• What kinds of tests do I need?
• Is my condition short term or lifelong?
• What are the next steps?
• What are some other options?
• I have other health conditions. How can I best manage them together?
• Are there things I should avoid doing?
• Should I see a specialist?
• Do you have any information I can take home with me? What websites do you recommend?
• How will I know if I need to come back for another appointment?

Questions your healthcare professional may ask

To learn more about how perimenopause is affecting you, your healthcare professional may ask:

• Do you still have periods? If so, what are they like?
• What symptoms are you having?
• How long have you had these symptoms?
• How much do your symptoms bother you?
• What medicines, herbs, vitamins or other supplements do you take?