Turning 40 and Feeling Off? How to Recognize Perimenopause Before the Hot Flashes Hit

Perimenopause isn’t a switch that flips overnight—it’s a gradual, whole-body transition that can unfold over the course of a decade. Many women begin experiencing symptoms in their late 30s or early 40s, often long before the classic hot flashes or skipped periods. These early signs are frequently mistaken for stress, aging, or other medical issues, leaving women feeling confused or dismissed.

As a board-certified Internal Medicine physician and Menopause Specialist, I’d like to share the early perimenopausal symptoms I see most often in my clinic. Understanding these early hormonal changes can empower you to better understand your body, seek timely support, and reduce unnecessary suffering to protect your long-term health. 

Early Signs of Progesterone Deficiency

One of the earliest hormonal changes is a decline in progesterone during the luteal (second half) phase of the menstrual cycle. This shift often precedes the dramatic estrogen fluctuations that define later perimenopause.

This can show up as:

Heightened anxiety and disrupted sleep: Often before any noticeable changes in menstrual regularity, you may start experiencing anxious thoughts, tense feelings, and middle-of-the-night awakenings without a clear cause.  These symptoms can be particularly worse during the premenstrual period, or during the 1-2 weeks before your period.  These changes, though subtle, can affect everything from energy levels to food choices and physical activity.

Shifts in your menstrual cycle: Periods may become heavier, longer, more painful, or closer together—an indication of declining progesterone levels.

Treatment options do exist, and include hormonal support, such as gentle progesterone supplementation, non-hormonal medications, and lifestyle adjustments.  When symptoms are caught early, even small interventions can provide meaningful relief.

“Estrogen Dominance”

Before estrogen begins to decline steadily, many women experience fluctuating or relatively higher estrogen in relation to progesterone—sometimes called “estrogen dominance.”

This may show up as:

Fluid retention, bloating, and breast tenderness: These symptoms are often attributed to diet or stress, prompting unnecessary food restrictions or guilt. In reality, they’re often hormonally driven.

Worsening headaches or migraines: If your premenstrual headaches are becoming more intense or frequent, hormonal shifts—especially fluctuating estrogen—may be a contributing factor.

These symptoms often respond well to supportive treatments like hormone therapy, anti-inflammatory approaches, and nutrition-focused interventions.

Subtle Genitourinary Changes

Even in early perimenopause, changes in estrogen and testosterone can affect the urinary and vaginal tissues— and be significant contributors to decreased quality of life. 

You might notice:

Increased urinary frequency or mild stress incontinence: This could mean waking up to urinate in the middle of the night or leaking slightly during exercise, coughing, or sneezing.

Vaginal dryness or irritation: You don’t have to be experiencing painful intercourse for vaginal changes to be present. Early on, women will describe mild itching, dryness, or increased sensitivity to underwear.

Don’t ignore these symptoms! Early treatment - including vaginal estrogen, lubricants, or pelvic floor therapy - can significantly slow and reverse the progression of urinary and vaginal symptoms.

Skin and Hair Changes

Hormonal shifts also affect our skin and hair.

Acne, rosacea, and dryness: Estrogen supports skin elasticity and hydration. As levels drop, women may notice accelerated signs of aging.  Women prone to rosacea can experience a worsening of hyperpigmentation.  Furthermore, an imbalance of estrogen with testosterone can lead to increased sebum production, clogged pores, and acne. 

Hair thinning and loss: Estrogen and androgens play a key role in the hair growth cycle. When hormones fluctuate, hair can become thinner, more brittle, and shed more easily.

If you’re noticing changes in skin texture, pigmentation, or hair volume, a conversation with a menopause-informed physician can help identify whether hormonal imbalance is playing a role—and guide you toward the right treatments.

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How to Differentiate Perimenopause from Other Conditions

Unfortunately, the 30s and 40s are also a time when chronic illnesses begin to emerge. Many symptoms of perimenopause overlap with other conditions, which can make diagnosis tricky. Recognizing these signs and differentiating perimenopause from other medical conditions requires a nuanced approach rooted in knowledge and experience. 

A few examples include:

Hormonal mood symptoms vs. primary mood disorders: Perimenopausal mood changes often fluctuate with the cycle. Mood tracking alongside your period can help uncover a hormonal pattern, whereas depression or anxiety unrelated to cycles may suggest another root cause.

Estrogen deficiency vs. thyroid disease, iron deficiency, or other conditions: Thyroid dysfunction can often coexist with or mimic perimenopause.  Similarly, iron deficiency can cause fatigue, insulin resistance can cause night sweats, and obstructive sleep apnea can cause insomnia.  

Joint pain: hormonal vs. autoimmune vs. mechanical: Body aches and pains are one of the most common complaints from women in this age group. Estrogen deficiency contributes to joint dysfunction, but autoimmune diseases (like lupus or rheumatoid arthritis) often also arise during this time. Joint pain can also arise from the wear-and-tear of aging and lifestyle that result in osteoarthritis. 

When Should You Seek Menopause-Specific Care?

In short, the earlier the better!

Now, this doesn’t necessarily mean you have to start hormone replacement immediately.  Rather, it means that having a thoughtful, evidence-based conversation with a physician trained in menopause medicine can help: 

-  Help put you at ease as to the cause of your symptoms

-  Identify how your individual health and lifestyle may contribute to your menopause experience 

- Help you implement early changes interventions to optimize your health in the next decades

Every woman in her late 30s to early 40s will benefit from a detailed discussion about the hormonal and non-hormonal options available to her, as well as the risks and benefits of hormone therapy tailored to her individual health.  Then she can be best informed and prepared for the changes to come. 

The Bottom Line

Perimenopause doesn't have to be a disruptive or isolating experience. With the right guidance, you can recognize the early signs, get the support you need, and take proactive steps toward thriving through this important transition.

Looking for support from a physician who understands how your hormones fit into your whole-body health?

Schedule a visit with Vida Family Medicine to receive personalized, compassionate care that partners with you to help you live your best life.