My high school friends and I — a gaggle of 40-somethings — were on a long-anticipated midwinter trip to the white sandy beaches of Naples, Fla. when my period hit, unexpectedly and with a vengeance. Luckily, I had a just-in-case tampon in my travel kit. (Perimenopause pro move!) The weird thing was, the heavy flow continued beyond the usual five days, then beyond seven … then beyond 10. Only after a full 14 days (!) did it finally leave as abruptly as it had arrived. WTF? So much for being a “peri-pro.”

That’s the reality of perimenopause in your 40s: Your ovaries start phoning it in, forgetting their rhythm and throwing hormones like estrogen, progesterone and testosterone all out of order. Sometimes your period goes missing, sometimes it barges in like a houseguest who overstays and eats all the snacks.

And periods are just the beginning. Perimenopause in your 40s can mess with your sleep, mood, skin and even your joints — which is why perimenopause is often described as the “wild ride” before menopause. Here’s what’s really going on in this stage, and how to get some control back.

 

When does perimenopause start and how long does it last?

Perimenopause, officially called the “late reproductive stage” is basically the long on-ramp to menopause. It begins when estrogen levels start to decline and your period is consistently late or early by seven days. For some women this happens in their mid- to late-30s. For others, perimenopause kicks into full gear in their early- to mid-40s, and it can last about eight to 10 years, says Dr. Sherry Ross, a board-certified ob-gyn at Providence Saint John’s Health Center in Santa Monica, Calif. That tracks, since 51 is the average age of menopause in the U.S. (Learn more about the difference between perimenopause, menopause and postmenopause.)

 

What are the most common perimenopause symptoms in your 40s?

Unlike other midlife transitions, like the slow creep of wrinkles and graying hair, perimenopause can sometimes come in like an unexpected tornado. “During perimenopause, your body has to crank hormones higher to recruit eggs, which leads to bigger peaks and deeper troughs. It’s almost like PMS on steroids,” says Dr. Robin Noble, an ob-gyn and chief medical officer of Let’s Talk Menopause, a nonprofit working to improve menopause care.

Of course, “everyone has a different experience and different severity of symptoms,” says Ross. My perimenopause symptoms may feel intense, my friend might say hers are totally manageable and that annoying lady down the road might be all “I still feel 22!” No matter, low estrogen levels lead to lots of symptoms, not just “period stuff.” Here are some of the most common perimenopause symptoms in your 40s:

• Irregular periods

• Hot flashes and night sweats

• Poor sleep

• Irritability and mood changes

• Fatigue

• Brain fog

• Vaginal dryness

• Bladder issues (leakage, UTIs)

• Bone density loss

• Weight changes

Some lesser-known — but equally annoying — symptoms include:

• Joint pain, including frozen shoulder

• Body odor

• Migraines

• Dry eyes

• Dry skin, acne, slow healing

• Rosacea

• Hair loss

• New or worsening allergies

• Higher cholesterol

 

How does perimenopause in your 40s affect mental health?

When your hormones are spiking and crashing, your mood can ride right along with them. Experts say it’s because the body and mind don’t operate in separate lanes. “Psychological and physical symptoms can compound each other,” says Noble. “For example, if you’re already prone to depression, hormones can magnify that.” In fact, a systematic review found there’s a distinct “window of vulnerability” for depression and anxiety during the menopause transition — and women with a history of depression are more than twice as likely to relapse during perimenopause compared to those without one.

Even if you’re not especially susceptible to depression, mood changes are common in this stage, according to the American College of Obstetricians and Gynecologists. After all, bad sleep from night sweats and midnight runs to the bathroom, plus the frustration of simply not feeling like yourself (something 63% of folks in perimenopause experience, according to 2024 study in the journal Menopause) can pile up, leaving you exhausted, foggy, irritable and decidedly on edge.

The upshot? Addressing perimenopausal symptoms in your 40s can make a meaningful difference for your mental health. For example, meds containing estrogen can help calm hot flashes and lessen depressive symptoms in perimenopause, ACOG notes. Selective serotonin reuptake inhibitors (SSRIs) have also been shown to deliver a triple benefit of helping to ease depression, improve hot flashes and aid sleep.

 

What are the best treatments for perimenopause symptoms?

By your 40s you may already be eating better, sleeping more, cutting booze and lifting weights to protect your bones — hopefully. If not, experts urge you to get to it to help improve your health as you age and quell certain perimenopause symptoms and side effects. But, let’s be real, busting out the ol’ resistance bands is not going to help with vaginal dryness, amiright? Here, other treatment to look into for perimenopausal symptoms in your 40s:

Birth control pills for perimenopause symptoms

Think of the Pill as hormone therapy for perimenopause, with built-in protection against unwanted midlife motherhood. Birth control pills deliver a steady stream of hormones so you can avoid severe peaks and valleys. And if you had a not-so-great reaction to them in, say, your college years, it may be time to reconsider. “Today’s versions have changed a lot. It’s worth giving it a shot,” says Noble. “Try it for a few months, if it doesn’t work for you, pivot to something else.” A low- (or very low-) dose combination pill that contains estrogen and progestin may help with:

• Irregular or heavy bleeding

• Preventing bone loss

• Improving acne

• Stopping unwanted hair loss and growth

• Easing hot flashes

• Decreasing migraines

• Lowering your chances of iron deficiency and anemia

• PMS symptoms that often worsen during perimenopause

Not a Pill popper? Noble notes that a hormone patch or vaginal ring like NuvaRing or Annovera can deliver similar results. “The vaginal ring can be left in place for an extended period, in some cases for up to a year, so you get that steady dose of hormones without having to remember to take a daily pill,” she says.

One quirk (or perk?) of using hormonal birth control for perimenopause symptoms: You may not notice when menopause officially hits, since the Pill can mask periods. The clinical definition is 12 months without bleeding, but if you’re unsure, your provider can run labs and help decide when — or if — you might want to switch to a lower-dose option, like standard hormone therapy (Learn the ins and outs of HRT with our beginners’ guide.)

Other treatment options

For those who have a history of breast or uterine cancer or a history of blood clots, birth control pills aren’t an option. But Ross’s colleague Dr. Yvonne Bohn, a fellow ob-gyn at Providence Saint John’s Health Center, says you’ve got other choices, including:

• Vaginal estrogen creams: They act locally to help vaginal dryness, irritation and recurring UTIs without too much absorption into the bloodstream, which means they’re considered safe even if you are restricted from taking hormone therapy.

• Veozah: Also called fezolinetant, this drug targets the neurons in your brain that control temperature regulation. It’s been shown to reduce the frequency of hot flashes by about 60%.

• Antidepressants: Brisdelle (paroxetine), Effexor Xr (Venlafaxine), Paxil (paroxetine) and others have been shown to help ease hot flashes and night sweats

• Store-bought symptom-soothers: Products like cooling fans or special mattress toppers can help you weather hot flashes with a little more ease. “But keep in mind, they can’t prevent hot flashes from happening, so be careful of marketing promises,” warns Noble. For other effective hot flash relief strategies, check out our hot flash guide.

What diet helps with perimenopause symptoms?

There is no perimenopause diet that’ll — poof — make your symptoms disappear. But research shows what you eat really can make a difference. For instance, enjoying a low-fat, plant-based diet with daily soybeans has been shown to cut moderate-to-severe hot flashes by 88% in just 12 weeks, according to a randomized trial in the journal Menopause. While the study was on post-menopausal women, researchers note that the same food pattern — more plants, more fiber, less fat, plus soy — may also help those in perimenopause.

Looking to baby step into this kind of healthy eating? Bohn recommends you:

• Prioritize protein

• Load up on all the veggies

• Choose high-fiber fruit, like blueberries or apples with the skin on

• Cut back on simple carbs like bread, pasta and sweets

• Limit alcohol. It’s basically liquid sugar and a total sleep wrecker. Sure, that nightcap might help you doze off, but the sugar crash will wake you up — and keep you from hitting deep, restorative REM sleep, according to a 2024 report in Frontiers in Nutrition.

Do supplements help with perimenopause symptoms?

That depends. Do you have insufficient levels of vitamin D, zinc, omega 3s, B vitamins or magnesium? If so, supplementing under the guidance of your health care team might help with certain symptoms. But nutrition shortfalls are in no way universal, so getting tested first is key.

At the same time, some women swear by herbal supplements such as chasteberry, black cohosh, Siberian rhubarb, ashwagandha and royal jelly for relieving perimenopause symptoms, but Ross points out that these menopause supplements are not regulated by the FDA. That means, unlike prescription drugs, supplements don’t have to prove they work — or even that they contain what the label says — before they’re sold. Not to mention, some supplements interact with other medications — you shouldn’t add a new product to your daily regimen without clearing its use with your doctor.

Noble adds that the placebo effect is real: Sometimes you feel better, even though the supplement isn’t what’s driving the change. “If you take a harmless product and feel better, I’m fine with that — you do you,” she says. But again, check in with your provider first and know that quality is a big issue. A Harvard analysis found that only about 40% of supplements actually contained what they claimed, half had the wrong amounts and 12% contained FDA-prohibited additives. And since there isn’t strong data showing these remedies work, some companies may be capitalizing on women who are desperate for relief, warns Noble. It’s important to be a skeptic and to check with your provider before investing in every new supplement promise.

For more on what perimenopausal supplements can and can’t do — and expert picks — read our deep dive.

 

Preparing for perimenopause in your 40s

One of the hardest parts of going through this stage? Not knowing what’s happening until you’re in deep. That’s why Noble is a big proponent of anticipatory guidance, where your doctor basically gives you information about future life stages so you know what to expect. “As a physician, I feel it’s my responsibility to educate patients about what’s happening to their bodies, and I find that simply explaining the ‘why’ behind it can provide so much relief,” she says.

Knowing in advance what might come means you can recognize the symptoms sooner and be proactive about finding relief instead of being blindsided. And it saves you from spinning through specialists for years in search of answers. Bottom line: Don’t let anyone shrug this off. If your ob-gyn brushes you off with “this is just what women go through,” push back — hard. There are treatments, so you don’t just have to white-knuckle your way through this particular roller-coaster ride. And if your provider still seems reluctant to help you proactively navigate this stage of life, look up a licensed menopause expert through the Menopause Society’s database or explore a reputable online menopause clinic. Use our online menopause clinic tips as a guide.