Symptoms
The fluctuating, declining hormones
of perimenopause effect every part
of your body.
Scroll down to understand the role of reproductive hormones throughout your body, and the symptoms you might experience when those hormones start to fluctuate and decline with age. Don't want to get into the science of it all -
Estrogen: Helps regulate temperature, mood, sleep, appetite, and thyroid function.
As estrogen starts to decline, you might notice:
• hot flashes and night sweats¹²
• trouble staying sleep¹²
• increased anxiety or depression¹³
• fatigue and brain fog⁴
• sensitivity to cold⁵
• change in weight (and you aren't doing anything different)⁶• new or worsening thyroid symptoms despite “normal” labs
Estrogen: Helps the body use glucose efficiently to keep energy and blood sugar steady.
As estrogen starts to decline, you might notice:
• increased insulin resistance 67
• weight gain (especially abdominal) 6
• blood sugar swings 6
• stronger cravings 7• energy crashes 7
Estrogen & Progesterone : Help with stress tolerance, so you aren't solely relying on cortisol (stress hormone) to handle stress.
As estrogen and progesterone start to decline, you might notice:
• less tolerant of stressful situations¹⁰
• a “wired-but-tired” feeling¹⁰
• exaggerated reactions to stress (to situations that never used to register)¹⁰
aka - flying off the handle, losing my sh*t, freaking out
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¹ Rance, N. E., & Dacks, P. A. (2012). The hypothalamic control of menopause-related changes in body temperature. Frontiers in Neuroendocrinology, 33(4), 303–314. https://doi.org/10.1016/j.yfrne.2012.09.003
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² Thurston, R. C., & Joffe, H. (2011). Vasomotor symptoms and menopause. The Lancet, 378(9796), 2103–2114. https://doi.org/10.1016/S0140-6736(11)60750-5
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³ Gordon, J. L., et al. (2016). Perimenopausal changes in stress sensitivity. Menopause, 23(6), 674–684. https://doi.org/10.1097/GME.0000000000000603
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⁴ Weber, M. T., Maki, P. M., & McDermott, M. P. (2014). Cognition and mood in perimenopause. Clinical Obstetrics and Gynecology, 57(3), 541–556. https://doi.org/10.1097/GRF.0000000000000041
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⁵ Davis, S. R., et al. (2012). Understanding weight gain and thyroid-like symptoms at menopause. Climacteric, 15(5), 419–429. https://doi.org/10.3109/13697137.2012.707385
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⁶ Mauvais-Jarvis, F., et al. (2013). Estrogen and glucose homeostasis. Endocrine Reviews, 34(3), 309–338. https://doi.org/10.1210/er.2012-1055
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⁷ Barros, R. P. A., & Gustafsson, J.-Å. (2011). Estrogen receptors and metabolism. Cell Metabolism, 14(3), 289–299. https://doi.org/10.1016/j.cmet.2011.08.005
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⁸ Carr, M. C. (2003). The emergence of the metabolic syndrome with menopause. JCEM, 88(6), 2404–2411. https://doi.org/10.1210/jc.2003-030242
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⁹ Viau, V. (2002). Functional cross-talk between the HPG and HPA axes. Journal of Neuroendocrinology, 14(6), 506–513. https://doi.org/10.1046/j.1365-2826.2002.00810.x
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¹⁰ Brinton, R. D., et al. (2015). Perimenopause as a neurological transition state. Nature Reviews Endocrinology, 11(7), 393–405. https://doi.org/10.1038/nrendo.2015.82
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¹¹ Prior, J. C. (2014). Perimenopause: the complex endocrinology of the menopausal transition. Endocrine Reviews, 35(3), 297–331. https://doi.org/10.1210/er.2013-1061
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¹² Schiller, C. E., et al. (2015). Reproductive steroid regulation of mood and behavior. Neuroscience, 191, 21–39. https://doi.org/10.1016/j.neuroscience.2014.11.038
HAIR
SKIN
NAILS
Estrogen: Preserves skin thickness and elasticity, supports moisture retention and barrier function by promoting collagen synthesis and maintenance.
Estrogen: Helps regulate hyaluronic acid and sebaceous (oil) production, skin hydration and resilience.
As estrogen starts to decline, you might notice:
• Skin that's thinner, drier and less elastic skin becomes thinner, drier, and less elastic
• More wrinkles
• Slower wound healing fragility¹
•Dry, itchy, sensitive skin³
Estrogen: prolongs your hair's growth phase, supporting hair density and thickness. As estrogen starts to decline, you might notice:
As estrogen starts to decline, you might notice:
• Less hair growth
• More hair shedding
• Gradual hair thinning⁴
Estrogen: contributes to connective tissue strength, keratin production, normal nail growth.
As estrogen starts to decline, you might notice:• Brittle, thin nails
• Slower nail growth
• More nail splitting and breaking
Estrogen: contributes to connective tissue strength, keratin production, normal nail growth.
As estrogen starts to decline, you might notice:• Skin becomes more sensitive
• More inflammation and puffiness
• New or worsening of skin conditions such as acne⁵
Testosterone : contributes to skin thickness and structural integrity, supports collagen, regulates hair follicles and oil glands.
As testosterone starts to decline, you might notice:
• Thinner, duller skin
• Hair growth in new places⁶
• Crown and front of scalp hair thinning⁷
These changes can occur even when testosterone levels remain within the “normal” range.
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¹ Brincat, M. (2000). Hormone replacement therapy and the skin. Maturitas, 35(2), 107–117.
https://doi.org/10.1016/S0378-5122(00)00103-1 -
² Shuster, S., Black, M. M., & McVitie, E. (1975). The influence of age and sex on skin thickness, skin collagen and density. British Journal of Dermatology, 93(6), 639–643.
https://doi.org/10.1111/j.1365-2133.1975.tb05113.x -
³ Verdier-Sévrain, S. (2007). Effect of estrogens on skin aging and the potential role of selective estrogen receptor modulators. Climacteric, 10(4), 289–297.
https://doi.org/10.1080/13697130701434874 -
⁴ Messenger, A. G., & Sinclair, R. (2006). Follicular miniaturization in female pattern hair loss. British Journal of Dermatology, 155(5), 926–930.
https://doi.org/10.1111/j.1365-2133.2006.07446.x -
⁵ Lucky, A. W. (2004). Hormonal correlates of acne and sebaceous gland activity. Journal of Investigative Dermatology, 123(3), 458–463.
https://doi.org/10.1111/j.0022-202X.2004.23443.x -
⁶ Thornton, M. J. (2002). The biological actions of estrogens on skin. Experimental Dermatology, 11(6), 487–502.
https://doi.org/10.1034/j.1600-0625.2002.110601.x -
⁷ Davis, S. R., & Wahlin-Jacobsen, S. (2015). Testosterone in women—The clinical significance. The Lancet Diabetes & Endocrinology, 3(12), 980–992.
https://doi.org/10.1016/S2213-8587(15)00284-3
Estrogen: Supports learning, memory, cognitive efficiency, supporting verbal fluency and information processing.
As estrogen starts to decline, you might notice:
• Trouble remembering words
• Memory issues• Forgetting why you walked into a room
• Takes longer to process information subjective memory complaints¹
Estrogen: Influences pain processing in both the central and peripheral nervous systems.
As estrogen starts to decline, you might notice:
• Lower pain thresholds
• Worsening migraines• Exacerbated chronic pain²
Estrogen: Helps keep the nervous system calm at rest by supporting parasympathetic (“rest-and-digest”) activity and preventing too much sympathetic (“fight-or-flight”) activation.
As estrogen starts to decline, you might notice:
EMOTIONAL SYMPTOMS• increased anxiety or unease
• irritability or emotional reactivity
• feeling “on edge” or easily startled
• lower stress tolerance
• mood swings or emotional volatility
Why: With less estrogen, the nervous system amplifies stress signals and takes longer to settle after them⁴.
MENTAL SYMPTOMS• racing or looping thoughts
• difficulty concentrating or “brain fog”
• reduced mental flexibility (feeling mentally stuck or overwhelmed)
• increased sensitivity to noise, stimulation, or multitasking
Why: The brain remains in a higher-alert state, making calm focus harder to sustain³.
PHYSICAL SYMPTOMS
• increased anxiety or unease
• irritability
• feeling “on edge” or easily startled
• lower tolerance for stressful situations
• mood swings
Why: With less estrogen, the nervous system amplifies stress signals and takes longer to settle after them⁴. These are physiologic stress responses, not character or coping failures.
Progesterone : A GABA-modulater (a calming neurotransmitter) it reduces stress reactivity and supports sleep initiation and continuity.
As progesterone starts to decline, you might notice:
• increased anxiety
• more sensitivity to stress
• sleep fragmentation and insomnia
Why: The loss of progesterone’s calming effect contributes to nervous system hyperarousal⁶.
These symptoms are frequently misattributed to anxiety alone, despite their clear neuroendocrine basis⁷.
Testosterone : Enhances motivation and reward signaling, influences spatial cognition and processing speed.
As testosterone starts to decline, you might notice:
• Less energy and motivation
• Lower stress tolerance
• Lower cognitive drive and mental stamina⁸
¹ Weber, M. T., Maki, P. M., & McDermott, M. P. (2014). Cognition and mood in perimenopause. Clinical Obstetrics and Gynecology, 57(3), 541–556.
https://doi.org/10.1097/GRF.0000000000000041
² Martin, V. T., & Behbehani, M. (2006). Ovarian hormones and migraine headache. Headache, 46(S2), S3–S23.
https://doi.org/10.1111/j.1526-4610.2006.00483.x
³ Brinton, R. D., et al. (2015). Perimenopause as a neurological transition state. Nature Reviews Endocrinology, 11(7), 393–405.
https://doi.org/10.1038/nrendo.2015.82
⁴ Gordon, J. L., et al. (2016). Perimenopausal changes in stress sensitivity. Menopause, 23(6), 674–684.
https://doi.org/10.1097/GME.0000000000000603
⁵ Rance, N. E., & Dacks, P. A. (2012). The hypothalamic control of menopause-related changes in body temperature. Frontiers in Neuroendocrinology, 33(4), 303–314.
https://doi.org/10.1016/j.yfrne.2012.09.003
⁶ Schiller, C. E., et al. (2015). Reproductive steroid regulation of mood and behavior. Neuroscience, 191, 21–39.
https://doi.org/10.1016/j.neuroscience.2014.11.038
⁷ Brinton, R. D. (2009). Estrogen-induced plasticity from cells to circuits. Journal of Neuroscience, 29(41), 12786–12788.
https://doi.org/10.1523/JNEUROSCI.4059-09.2009
⁸ Davis, S. R., & Wahlin-Jacobsen, S. (2015). Testosterone in women—The clinical significance. The Lancet Diabetes & Endocrinology, 3(12), 980–992.
https://doi.org/10.1016/S2213-8587(15)00284-3
Estrogen: regulates smooth muscle contraction and coordination, helping to maintain normal transit time through the gastrointestinal tract.
As estrogen starts to decline, you might notice:
• constipation
• bloating¹
Estrogen: maintains mucosal barrier in the gut (and reproductive tract), by strengthening tight junctions, enhancing protective mucus production (e.g., MUC2), and reducing inflammation.
As estrogen starts to decline, you might notice:• worsening inflammatory bowel conditions
• increased GI sensitivity³• "leaky gut"
Estrogen : influences bile composition and gallbladder motility.
As estrogen starts to decline, you might notice:
• increased gallbladder issues
• Bloating after meals, especially after fatty foods
• Nausea or a mild queasy feeling after meals
• Greasy, loose, or pale stools (signs fat isn’t being digested well)
• More gas or abdominal pressure
• Right-upper abdominal discomfort (under the ribs), especially after rich or fatty meals (gallbladder)
• Pain that radiates to the back or right shoulder blade
• Intermittent sharp or crampy pain that comes and goes (often mistaken for indigestion)
Estrogen: interacts with gut-derived hormones such as ghrelin, leptin, and cholecystokinin, which regulate appetite, satiety, and digestive signaling.
As estrogen starts to decline, you might notice:
•Changes in appetite and fullness cues
•Altered eating patterns
•Post-meal discomfort
¹ Kim, Y. S., & Kim, N. (2018). Sex-gender differences in irritable bowel syndrome. Journal of Neurogastroenterology and Motility, 24(4), 544–558.
https://doi.org/10.5056/jnm18082
² Baker, J. M., Al-Nakkash, L., & Herbst-Kralovetz, M. M. (2017). Estrogen–gut microbiome axis. Gut Microbes, 8(4), 384–398.
https://doi.org/10.1080/19490976.2017.1290759
³ Straub, R. H. (2007). The complex role of estrogens in inflammation. Endocrine Reviews, 28(5), 521–574.
https://doi.org/10.1210/er.2007-0001
⁴ Marschall, H.-U., & Einarsson, C. (2007). Gallstone disease. Journal of Internal Medicine, 261(6), 529–542.
https://doi.org/10.1111/j.1365-2796.2007.01802.x
⁵ Mauvais-Jarvis, F. (2015). Sex differences in metabolic homeostasis. Biology of Sex Differences, 6, 14.
https://doi.org/10.1186/s13293-015-0033-y
⁶ Chang, L., et al. (2006). Gender, age, society, culture, and the patient’s perspective in functional gastrointestinal disorders. Gastroenterology, 130(5), 1435–1446.
https://doi.org/10.1053/j.gastro.2005.09.071
⁷ Wald, A. (2007). Constipation in women. Current Treatment Options in Gastroenterology, 10(4), 343–349.
https://doi.org/10.1007/s11938-007-0029-6
Estrogen: supports normal urethral closure pressure, bladder mucosal thickness, collagen content, tissue elasticity, and blood flow to urogenital tissues.
As estrogen starts to decline, you might notice:
• tissues become thinner, less elastic, and more fragile
• urinary urgency and frequency
• dysuria (burning or discomfort with urination)
• urinary incontinence¹
These changes are now recognized as part of the **genitourinary syndrome of menopause (GSM)**².
Estrogen: maintains and supports beneficial bacteria in the urinary tract and reduces bad bacteria. As estrogen starts to decline, you might notice:
• increased susceptibility to recurrent urinary tract infections (UTIs)³ (a common and often under-recognized midlife symptom.)
• more susceptibility to yeast infections
Estrogen: helps regulate muscle stability, bladder sensory thresholds, and capacity.
As estrogen starts to decline, you might notice:
• increased bladder sensitivity
• overactive bladder
• reduced bladder capacity
• waking up in the middle of the night to pee
• urinary urgency⁴
Estrogen: supports the connective tissue and smooth muscle surrounding the urethra, helping maintain continence.
As estrogen starts to decline, you might notice:
• urinary stress incontinence (particularly with coughing, sneezing, laughing, or exercise)
• weakened pelvic floor⁵
Progesterone : influences lower urinary tract function and supports neuromuscular coordination of bladder emptying.
As progesterone starts to decline, you might notice:
• increased urinary urgency
• sensation of incomplete bladder emptying⁶
¹ Cardozo, L., et al. (2001). The role of estrogens in female lower urinary tract dysfunction. Urology, 57(6 Suppl 1), 75–79.
https://doi.org/10.1016/S0090-4295(01)01128-7
² Portman, D. J., & Gass, M. L. S. (2014). Genitourinary syndrome of menopause. Menopause, 21(10), 1063–1068.
https://doi.org/10.1097/GME.0000000000000329
³ Raz, R., & Stamm, W. E. (1993). A controlled trial of intravaginal estriol in postmenopausal women with recurrent UTIs. New England Journal of Medicine, 329(11), 753–756.
https://doi.org/10.1056/NEJM199309093291102
⁴ Coyne, K. S., et al. (2012). Overactive bladder and menopause. International Journal of Clinical Practice, 66(11), 1044–1056.
https://doi.org/10.1111/ijcp.12002
⁵ Hannestad, Y. S., et al. (2003). A community-based epidemiological survey of female urinary incontinence. Journal of Clinical Epidemiology, 56(12), 1150–1157.
https://doi.org/10.1016/S0895-4356(03)00201-1
⁶ Smith, P. P. (2014). Aging and the underactive detrusor. Current Bladder Dysfunction Reports, 9(4), 302–309.
https://doi.org/10.1007/s11884-014-0267-3
Ovarian Aging: The Starting Point¹Perimenopause starts with a decline in both the number and quality of ovarian follicles.
As ovulation becomes less predictable:
• hormone levels becomes erratic
• production of estrogen and progesterone gradually decline
Progesterone: estrogen stimulates endometrial proliferation, while progesterone stabilizes and differentiates the endometrium.
Progesterone declines first, when that happens you might notice:
Estrogen: Maintains the thickness, elasticity, blood flow, and lubrication of vaginal tissues.
As estrogen starts to decline, you might notice:
• vaginal dryness and irritation
• pain with intercourse
• increased infection risk(now collectively termed the genitourinary syndrome of menopause⁵)
Estrogen: supports the connective tissue and smooth muscle surrounding the urethra, helping maintain continence.
As estrogen starts to decline, you might notice:
• urinary stress incontinence (particularly with coughing, sneezing, laughing, or exercise)
• weakened pelvic floor⁵
Testosterone: plays an important role in sexual desire and arousal, genital tissue sensitivity, and ability to orgasm.
As testosterone starts to decline, you might notice:
•reduced libido
•takes longer to climax⁷
¹ Broekmans, F. J., et al. (2009). Ovarian aging: mechanisms and clinical consequences. Endocrine Reviews, 30(5), 465–493.
https://doi.org/10.1210/er.2009-0006
² Prior, J. C. (2014). Perimenopause: the complex endocrinology of the menopausal transition. Endocrine Reviews, 35(3), 297–331.
https://doi.org/10.1210/er.2013-1061
³ Munro, M. G., et al. (2011). The FIGO classification of causes of abnormal uterine bleeding. International Journal of Gynecology & Obstetrics, 113(1), 3–13.
https://doi.org/10.1016/j.ijgo.2010.11.011
⁴ Portman, D. J., & Gass, M. L. S. (2014). Genitourinary syndrome of menopause. Menopause, 21(10), 1063–1068.
https://doi.org/10.1097/GME.0000000000000329
⁵ Santoro, N., et al. (2015). The menopausal transition. Endocrine Reviews, 36(3), 275–312.
https://doi.org/10.1210/er.2015-1012
⁶ Davis, S. R., & Wahlin-Jacobsen, S. (2015). Testosterone in women—The clinical significance. The Lancet Diabetes & Endocrinology, 3(12), 980–992.
https://doi.org/10.1016/S2213-8587(15)00284-3
NOTE ON AUTOIMMUNE DISEASES:
Autoimmune diseases disproportionately affect women and often change in activity during reproductive transitions.
Hormonal decline during perimenopause and menopause is associated with:
• increased incidence of certain autoimmune conditions
• worsening symptom severity in existing autoimmune disease
• altered immune tolerance and regulation⁶
These changes reflect hormone-driven immune shifts, not new external triggers alone.
Estrogen: regulates activation and survival of immune cells (T cells, B cells, macrophages), balances pro- and anti-inflammatory cytokine production¹.
As estrogen starts to decline, you might notice:
• increased inflammation (joint pain, muscle aches, fatigue)
• get sick easier and recover slower
• worsening or new autoimmune and inflammatory conditions²
• increased allergic reactions
Estrogen variability—not just low levels—is particularly destabilizing to immune balance³.
Progesterone : functions as an anti-inflammatory brake on the immune system. An immune calming hormone, it suppresses excessive inflammation and promotes immune tolerance (important for preventing autoimmune responses)
As progesterone starts to decline, you might notice:• More inflammatory flare ups
• worsening autoimmune or allergic conditions
• more stress-related immune activation
• increased tissue inflammation (skin, gut, joints)
Testosterone : suppresses excessive immune activity, reduces pro-inflammatory cytokine production, supports immune regulation rather than immune strength⁵. Even at lower levels in women, testosterone has meaningful immunologic effects. As testosterone starts to decline, you might notice:
• reduced stress resilience (stress amplifies immune activation)
• indirect worsening of autoimmune or inflammatory symptoms
¹ Straub, R. H. (2007). The complex role of estrogens in inflammation. Endocrine Reviews, 28(5), 521–574.
https://doi.org/10.1210/er.2007-0001
² Whitacre, C. C. (2001). Sex differences in autoimmune disease. Nature Immunology, 2(9), 777–780.
https://doi.org/10.1038/ni0901-777
³ Brinton, R. D., et al. (2015). Perimenopause as a neurological transition state. Nature Reviews Endocrinology, 11(7), 393–405.
https://doi.org/10.1038/nrendo.2015.82
⁴ Hughes, G. C. (2012). Progesterone and autoimmune disease. Autoimmunity Reviews, 11(6–7), A502–A514.
https://doi.org/10.1016/j.autrev.2011.12.003
⁵ Klein, S. L., & Flanagan, K. L. (2016). Sex differences in immune responses. Nature Reviews Immunology, 16(10), 626–638.
https://doi.org/10.1038/nri.2016.90
⁶ El Khoudary, S. R., et al. (2020). Menopause transition and health outcomes. Circulation, 142(11), 1063–1076.
https://doi.org/10.1161/CIRCULATIONAHA.120.047782
NOTE ON OBSTRUCTIVE SLEEP APNEA
Epidemiologic studies show that postmenopausal individuals have significantly higher rates of OSA than premenopausal individuals of similar age and body mass index⁵.
Estrogen: Relaxes and widens bronchial airways, reducing muscle constriction and increasing airflow.As estrogen starts to decline, you might notice:
• shortness of breath
• chest tightness
• new or worsening asthma symptoms².
Estrogen: has anti-inflammatory effects within the respiratory system, helping to regulate immune activity in lung tissue and limit excessive airway inflammation. As estrogen starts to decline, you might notice:
• increased airway inflammation
• less regulated immune responses in the lungs
• greater susceptibility to inflammatory respiratory conditions
This can worsen asthma, chronic cough, and airway hypersensitivity³.
Progesterone : a potent respiratory stimulant. It increases sensitivity of the respiratory center to carbon dioxide, supports steady breathing patterns, and helps maintain ventilation during sleep.
As progesterone starts to decline, you might notice:
• breathing that feels shallower or less steady, especially at night
• not getting enough air during sleep, even without waking fully
• restless or disrupted sleep tied to breathing changes
• breathing problems during sleep, like sleep-disordered breathing⁴
¹ Carey, M. A., et al. (2007). It’s all about sex: Gender, lung development and lung disease. Trends in Endocrinology & Metabolism, 18(8), 308–313.
https://doi.org/10.1016/j.tem.2007.08.003
² Macsali, F., et al. (2012). Respiratory health in women: Hormonal influences. European Respiratory Review, 21(125), 313–323.
https://doi.org/10.1183/09059180.00007112
³ Tam, A., et al. (2011). Sex differences in airway remodeling in asthma. Proceedings of the American Thoracic Society, 8(1), 27–34.
https://doi.org/10.1513/pats.201007-046MS
⁴ Dempsey, J. A., et al. (2004). Pathophysiology of sleep apnea. Physiological Reviews, 84(2), 349–392.
https://doi.org/10.1152/physrev.00043.2002
⁵ Bixler, E. O., et al. (2001). Prevalence of sleep-disordered breathing in women. American Journal of Respiratory and Critical Care Medicine, 163(3), 608–613.
https://doi.org/10.1164/ajrccm.163.3.9911064
⁶ Davis, S. R., & Wahlin-Jacobsen, S. (2015). Testosterone in women—The clinical significance. The Lancet Diabetes & Endocrinology, 3(12), 980–992.
https://doi.org/10.1016/S2213-8587(15)00284-3
Estrogen: supports healthy blood vessels by enhancing endothelial function, increasing nitric oxide production (which promotes vasodilation), maintaining arterial flexibility, and reducing vascular inflammation and oxidative stress.
As estrogen starts to decline, you might notice:
• blood vessels become less elastic
• endothelial dysfunction increases
• vascular stiffness rises
• blood flow becomes less efficient¹
Estrogen: influences cardiovascular control by supporting parasympathetic (“rest-and-digest”) activity, limiting excessive sympathetic (“fight-or-flight”) activation, and stabilizing vascular tone and blood pressure responses.
As estrogen starts to decline, you might notice:
• increased sympathetic activity
• reduced parasympathetic regulation
• greater blood pressure variability²
Health risk: higher rates of hypertension after menopause, even in individuals without prior blood pressure issues³
Estrogen : Lowers LDL (“bad”) cholesterol, supports HDL (“good”) cholesterol, and regulates triglyceride metabolism.
As estrogen starts to decline, you might notice:
• LDL cholesterol increases
• HDL cholesterol decreases
• Triglyceride levels rise⁴
Estrogen : limits vascular inflammation, stabilizes atherosclerotic plaques, slows plaque progression.
As estrogen starts to decline, you might notice:
• increased vascular inflammation
• accelerated plaque formation
• greater instability of existing plaques
Health risk- elevated risk of coronary artery disease and stroke, independent of chronological aging alone⁵
Progesterone : modulates vascular smooth muscle tone and influences fluid balance and blood volume. As progesterone starts to decline, you might notice:
• increased blood pressure fluctuations
• palpitations⁶
¹ Mendelsohn, M. E., & Karas, R. H. (2005). Molecular and cellular basis of cardiovascular gender differences. Science, 308(5728), 1583–1587.
https://doi.org/10.1126/science.1112062
² El Khoudary, S. R., et al. (2018). Menopause transition and cardiovascular health. Journal of the American College of Cardiology, 72(12), 1435–1448.
https://doi.org/10.1016/j.jacc.2018.06.066
³ Reckelhoff, J. F. (2001). Gender differences in the regulation of blood pressure. Hypertension, 37(5), 1199–1208.
https://doi.org/10.1161/01.HYP.37.5.1199
⁴ Carr, M. C. (2003). The emergence of the metabolic syndrome with menopause. Journal of Clinical Endocrinology & Metabolism, 88(6), 2404–2411.
https://doi.org/10.1210/jc.2003-030242
⁵ El Khoudary, S. R., et al. (2020). Menopause transition and cardiometabolic risk. Circulation, 142(11), 1063–1076.
https://doi.org/10.1161/CIRCULATIONAHA.120.047782
⁶ Stachenfeld, N. S. (2008). Sex hormone effects on body fluid regulation. Exercise and Sport Sciences Reviews, 36(3), 152–159.
https://doi.org/10.1097/JES.0b013e31817be928
Estrogen: the primary protector of bone. It maintains skeletal health by suppressing excessive bone breakdown by regulating calcium balance and normal bone turnover.
As estrogen starts to decline, you might notice:
• Bone loss
Progesterone: progesterone supports bone-building side by stimulating bone matrix formation.¹ As progesterone starts to decline, you might notice:
• Bone loss
• Risk of osteopenia and osteoporosis increases⁷
Testosterone : contributes to skeletal strength and structure, increasing bone size and geometry, and supporting cortical bone thickness³. As testosterone starts to decline, you might notice:
• Reduced bone mineral density
• Increased fractures⁶
¹ Prior, J. C. (1990). Progesterone as a bone-trophic hormone. Endocrine Reviews, 11(2), 386–398. https://doi.org/10.1210/edrv-11-2-386
² Khosla, S., Oursler, M. J., & Monroe, D. G. (2012). Estrogen and the skeleton. Trends in Endocrinology & Metabolism, 23(11), 576–581. https://doi.org/10.1016/j.tem.2012.03.008
³ Vanderschueren, D., et al. (2004). Androgens and bone. Endocrine Reviews, 25(3), 389–425. https://doi.org/10.1210/er.2003-0003
⁶ Davis, S. R., & Wahlin-Jacobsen, S. (2015). Testosterone in women—The clinical significance. The Lancet Diabetes & Endocrinology, 3(12), 980–992. https://doi.org/10.1016/S2213-8587(15)00284-3
⁷ Prior, J. C., et al. (1994). Spinal bone loss and ovulatory disturbances. New England Journal of Medicine, 330(6), 382–388. https://doi.org/10.1056/NEJM199402103300602
⁸ Compston, J. E., McClung, M. R., & Leslie, W. D. (2019). Osteoporosis. The Lancet, 393(10169), 364–376. https://doi.org/10.1016/S0140-6736(18)32112-3
NOTE ON MUSCLE LOSS
Sarcopenia is the progressive loss of skeletal muscle mass, strength, and function.⁵
made worse by the loss of overlapping hormonal protections:
↓ Testosterone → reduced muscle building
↓ Estrogen → poorer muscle repair and coordination
↓ Progesterone → reduced recovery and stability
Together, these changes:
• Reduce muscle protein synthesis
• Increase muscle breakdown
• Impair neuromuscular efficiency
Estrogen: enhances muscle protein synthesis, reducing inflammation and oxidative stress, improving muscle repair after injury or exercise, and supporting neuromuscular coordination.
As estrogen starts to decline, you might notice:
• Increased muscle soreness
• Reduced endurance
• Gradual decline in muscle quality, even when activity levels remain unchanged¹
• Impaired balance and motor control, increasing fall risk over time²
Progesterone: influences muscle cell regeneration, fluid balance within muscle tissue, and inflammatory signaling.
As progesterone starts to decline, you might notice
• Impaired muscle recovery
• Feelings of muscle fatigue, heaviness, or weakness
Progesterone often declines earlier than estrogen, which can disrupt muscle recovery before obvious muscle loss occurs⁴.
Testosterone: supports lean muscle mass, improves strength and power, and enhances muscle recovery and adaptation.
As testosterone starts to decline, you might notice:
• Reduced muscle mass and strength
• Decreased motivation for physical activity
can occur even when testosterone levels fall within the “normal” range for women.³
¹ Vanderschueren, D., et al. (2004). Androgens and muscle. Endocrine Reviews, 25(3), 389–425. https://doi.org/10.1210/er.2003-0003
² Davis, S. R., & Wahlin-Jacobsen, S. (2015). Testosterone in women—The clinical significance. The Lancet Diabetes & Endocrinology, 3(12), 980–992. https://doi.org/10.1016/S2213-8587(15)00284-3
³ Enns, D. L., & Tiidus, P. M. (2010). The influence of estrogen on skeletal muscle. Sports Medicine, 40(1), 41–58. https://doi.org/10.2165/11319760-000000000-00000
⁴ Sipilä, S., et al. (2020). Muscle strength and body composition during the menopausal transition. Journal of Clinical Endocrinology & Metabolism, 105(8), e3019–e3028. https://doi.org/10.1210/clinem/dgaa246
⁵ Prior, J. C. (1998). Progesterone and human physiology. Journal of Obstetrics and Gynaecology Canada, 20(7), 703–715.
⁶ Cruz-Jentoft, A. J., et al. (2019). Sarcopenia: revised European consensus on definition and diagnosis. Age and Ageing, 48(1), 16–31. https://doi.org/10.1093/ageing/afy169
80% of OB-GYN residents
receive no menopause training.
Source: Menopause journal, ACOG-surveyed residency programs
Perimenopause Symptoms:
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CARDIOVASCULAR
• blood vessels become less elastic
• endothelial dysfunction increases
• vascular stiffness rises
• blood flow becomes less efficient¹
• increased sympathetic activity
• reduced parasympathetic regulation
• greater blood pressure variability
• LDL cholesterol increases
• HDL cholesterol decreases
• Triglyceride levels rise
• increased vascular inflammation
• accelerated plaque formation
• greater instability of existing plaques
• increased blood pressure fluctuations
• palpitations
DIGESTIVE
• constipation
• bloating
• worsening inflammatory bowel conditions
• increased GI sensitivity
• "leaky gut"
• increased gallbladder issues
• Bloating after meals, especially after fatty foods
• Nausea or a mild queasy feeling after meals
• Greasy, loose, or pale stools (signs fat isn’t being digested well)
• More gas or abdominal pressure
• Right-upper abdominal discomfort (under the ribs), especially after rich or fatty meals (gallbladder)
• Pain that radiates to the back or right shoulder blade
• Intermittent sharp or crampy pain that comes and goes (often mistaken for indigestion)
• feeling hungrier or less satisfied after meals, even when you’ve eaten enough
• different eating habits (snacking more, skipping meals, or craving different foods)
ENDOCRINE
• hot flashes and night sweats
• trouble staying sleep
• increased anxiety or depression
• fatigue and brain fog
• sensitivity to cold
• change in weight (and you aren't doing anything different)
• new or worsening thyroid symptoms despite “normal” labs
• increased insulin resistance
• weight gain (especially abdominal)
• blood sugar swings
• stronger cravings
• energy crashes
• less tolerant of stressful situations
• a “wired-but-tired” feeling
• exaggerated reactions to stress aka - flying off the handle, losing my sh*t, freaking out
HAIR/SKIN/NAILS
• Skin that's thinner, drier and less elastic skin becomes thinner, drier, and less elastic
• More wrinkles
• Slower wound healing fragility
•Dry, itchy, sensitive skin
• Less hair growth
• More hair shedding
• Gradual hair thinning
• Brittle, thin nails
• Slower nail growth
• More nail splitting and breaking
• Skin becomes more sensitive
• More inflammation and puffiness
• New or worsening of skin conditions such as acne
• Thinner, duller skin
• Hair growth in new places
• Crown and front of scalp hair thinning
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IMMUNE
• increased inflammation (joint pain, muscle aches, fatigue)
• get sick easier and recover slower
• worsening or new autoimmune and inflammatory conditions
• increased allergic reactions
• More inflammatory flare ups
• worsening autoimmune or allergic conditions
• more stress-related immune activation
• increased tissue inflammation (skin, gut, joints)
• reduced stress resilience (stress amplifies immune activation)
• indirect worsening of autoimmune or inflammatory symptoms
• increased incidence of certain autoimmune conditions
• worsening symptom severity in existing autoimmune disease
• altered immune tolerance and regulation⁶
MUSCULAR
• Increased muscle soreness
• Reduced endurance
• Gradual decline in muscle quality, even when activity levels remain unchanged
• Impaired balance and motor control, increasing fall risk over time
• Impaired muscle recovery
• Feelings of muscle fatigue, heaviness, or weakness
• Reduced muscle mass and strength
• Decreased motivation for physical activity
NERVOUS SYSTEM
• Trouble remembering words
• Memory issues
• Forgetting why you walked into a room
• Takes longer to process information subjective memory complaints
• Lower pain thresholds
• Worsening migraines
• Exacerbated chronic pain
• Racing or looping thoughts
• Difficulty concentrating or “brain fog”
• Reduced mental flexibility (feeling mentally stuck or overwhelmed)
increased sensitivity to noise, stimulation, or multitasking
• increased anxiety or unease
• irritability
• feeling “on edge” or easily startled
• lower tolerance for stressful situations
• mood swings
• heart palpitations
• hot flashes and night sweats
• sleep disruption or early waking
• fatigue with wired or jittery energy
• dizziness or lightheadedness
• digestive changes (bloating, urgency, constipation)
• increased muscle tension or jaw clenching
• headaches or migraines
• increased anxiety
• more sensitivity to stress
• sleep fragmentation and insomnia
• Less energy and motivation
• Lower stress tolerance
• Lower cognitive drive and mental stamina
REPRODUCTIVE SYSTEM
• irregular bleeding
• abnormal bleeding (heavy periods, lighter periods)
• vaginal dryness and irritation
• pain with intercourse
• increased infection risk
•reduced libido
•takes longer to climax
RESPIRATORY
• shortness of breath
• chest tightness
• new or worsening asthma symptoms
• increased airway inflammation
• less regulated immune responses in the lungs
• greater susceptibility to inflammatory respiratory conditions
• breathing that feels shallower or less steady, especially at night
• not getting enough air during sleep, even without waking fully
• restless or disrupted sleep tied to breathing changes
• breathing problems during sleep, like sleep-disordered breathing
SKELETAL
• Bone loss
• Bone loss
• Risk of osteopenia and osteoporosis increases
• Reduced bone mineral density
• Increased fractures
REPRODUCTIVE SYSTEM
• irregular bleeding
• abnormal bleeding (heavy periods, lighter periods)
• vaginal dryness and irritation
• pain with intercourse
• increased infection risk
•reduced libido
•takes longer to climax
RESPIRATORY
• shortness of breath
• chest tightness
• new or worsening asthma symptoms
• increased airway inflammation
• less regulated immune responses in the lungs
• greater susceptibility to inflammatory respiratory conditions
• breathing that feels shallower or less steady, especially at night
• not getting enough air during sleep, even without waking fully
• restless or disrupted sleep tied to breathing changes
• breathing problems during sleep, like sleep-disordered breathing
SKELETAL
• Bone loss
• Bone loss
• Risk of osteopenia and osteoporosis increases
• Reduced bone mineral density
• Increased fractures
URINARY
• tissues become thinner, less elastic, and more fragile
• urinary urgency and frequency
• dysuria (burning or discomfort with urination)
• urinary incontinence
• increased susceptibility to recurrent urinary tract infections (UTIs)
• more susceptibility to yeast infections
• increased bladder sensitivity
• overactive bladder
• reduced bladder capacity
• waking up in the middle of the night to pee
• urinary urgency
• urinary stress incontinence (particularly with coughing, sneezing, laughing, or exercise)
• weakened pelvic floor
• increased urinary urgency
• sensation of incomplete bladder emptying
URINARY
• tissues become thinner, less elastic, and more fragile
• urinary urgency and frequency
• dysuria (burning or discomfort with urination)
• urinary incontinence
• increased susceptibility to recurrent urinary tract infections (UTIs)
• more susceptibility to yeast infections
• increased bladder sensitivity
• overactive bladder
• reduced bladder capacity
• waking up in the middle of the night to pee
• urinary urgency
• urinary stress incontinence (particularly with coughing, sneezing, laughing, or exercise)
• weakened pelvic floor
• increased urinary urgency
• sensation of incomplete bladder emptying
