Perimenopause: What We Expect vs. What We Experience

Recent research highlights the gap between what we associate with perimenopause and what people are actually experiencing.

When we think about perimenopause, hot flashes and night sweats often come to mind first. But they're only part of the picture.

In the clinic, I often sit with women who have been noticing changes in their sleep, mood, energy, or ability to concentrate, sometimes for years, without realizing these experiences might be connected to the menopause transition.

Many are still having regular menstrual cycles. Some have never experienced a hot flash. And often, there's a sense of relief when we begin to connect some of these experiences with the physiological changes taking place.

A large international study published in January 2026 offers an interesting perspective on something I see regularly in practice. Researchers from Mayo Clinic and Flo surveyed 17,494 women across 158 countries, exploring both what people understand about perimenopause and what they're actually experiencing.

What they found was a significant gap between the symptoms people recognize as part of perimenopause and the symptoms they're living with.

I think this is an important conversation for us to be having.

What do we think perimenopause looks like?

When researchers asked participants which symptoms they associated with perimenopause, the most widely recognized were:

• Hot flashes — 71%
• Sleep problems — 68%
• Weight gain — 65%

But when researchers looked at what participants were actually experiencing, a different picture emerged.

What symptoms are people actually experiencing?

Among 12,681 survey participants aged 35 and older, the most commonly reported symptoms were:

Among participants who identified themselves as being in perimenopause, 95% reported physical and mental exhaustion, 93% reported fatigue, and 91% reported irritability.

Interestingly, hot flashes were the most widely recognized symptom of perimenopause, yet they weren't among the seven most frequently reported symptoms in the broader group aged 35 and older.

I find this disconnect really interesting. It may help explain why some experiences are overlooked, both by the people living with them and by healthcare providers. And it reminds us of the importance of listening carefully and asking questions that go beyond the symptoms we traditionally associate with perimenopause.

There are some important considerations when interpreting these findings. The study surveyed users of a menstrual health app who chose to participate, so people experiencing symptoms may have been more likely to respond. The researchers also found high rates of several symptoms among participants who didn't identify as being in perimenopause.

We can't assume that perimenopause was responsible for all the symptoms reported, or that these percentages reflect the experiences of everyone moving through this transition.

But the findings do highlight something clinically important: there may be many experiences worth paying attention to that aren't part of our traditional understanding of perimenopause.

Perimenopause is a neuroendocrine transition

Perimenopause is so much more than a change in menstrual cycles. It's a neuroendocrine transition involving changes in ovarian function and communication between the ovaries and brain.

Fluctuations in ovarian hormones, particularly estradiol and progesterone, can influence multiple systems throughout the body, including those involved in sleep, temperature regulation, mood, and cognition.

And these changes don't necessarily begin when menstrual cycles become irregular.

In the clinic, I hear from women who have been waking at 3 a.m. for months, feeling more anxious than usual, or struggling to find the same mental clarity they've always relied on.

But because their periods are still regular, perimenopause hasn't even entered the conversation.

Exhaustion deserves our attention

One of the findings that stood out to me was the prevalence of physical and mental exhaustion.

I hear about this so often.

Not necessarily the kind of tiredness that comes after a long day, but a deeper sense of depletion. Feeling like there's less energy available for things that once felt manageable. Waking unrefreshed. Having difficulty concentrating. Feeling overwhelmed by demands that previously felt easier to navigate.

And often, there's worry underneath it all.

Why am I finding everything so difficult? Why don't I feel like myself?

The physical and mental exhaustion measure used in this research also captures difficulties with performance, concentration, and memory, experiences that overlap with what many people describe as brain fog.

Sleep disruption can contribute significantly, and during perimenopause, changes in sleep may occur with or without night sweats.

But exhaustion is complex.

Iron deficiency, thyroid dysfunction, sleep apnea, mood disorders, medications, and other health conditions may all play a role. And of course, there's also the cumulative load of daily life. Work, caregiving, relationships, responsibilities, and the many things people are carrying, often with very little room for rest.

Recognizing exhaustion as a common experience during perimenopause doesn't mean we should automatically attribute it to hormones.

It means listening carefully, exploring what may be contributing, and taking these experiences seriously. There may be opportunities for treatment, additional support, and making daily life feel a little more manageable.

Mood changes are part of the picture, too

I was also interested in the high prevalence of irritability, low mood, and anxiety reported in this study.

In the clinic, I hear people describe feeling less patient than they used to, more easily overwhelmed, or more emotionally reactive. Sometimes there's a sense that their usual ways of coping aren't working quite as well. I think this can be particularly unsettling for someone who has always experienced themselves as relatively steady or capable of managing a great deal.

Research increasingly recognizes the menopause transition as a period of increased vulnerability to mood symptoms for some individuals. Hormonal fluctuations may contribute, alongside sleep disruption, previous mental health history, physical health, and the many changes and demands that often accompany midlife.

A related analysis of Flo users also found a greater burden of psychological symptoms among those identifying as perimenopausal, with exhaustion and irritability showing particularly notable differences.

What I appreciate about this research is that it helps us recognize these experiences as worthy of attention. Not something to dismiss as simply stress or an inevitable part of getting older. And not something we need to explain entirely through hormones, either. As with most things related to health, there's room for a much more nuanced understanding.

Understanding as a Form of Resourcing

One of the things I care deeply about in my clinical work is helping people make sense of the physiological changes taking place in their bodies.

I believe that information can be a powerful form of resourcing. Having a clearer picture of the menopause transition can help us connect experiences that may have felt confusing or unrelated, make informed decisions about our care, and build resilience along the way.

I've seen how meaningful it can be when someone begins to see these connections. Not because we've found one explanation for everything, but because we have a better place to begin asking questions, exploring what might be contributing, and identifying what could help.

Alongside the physiology, I want us to remain curious about the whole person. Their health, their relationships, their responsibilities, the resources available to them, and what their nervous system may be navigating. Sometimes that means investigating iron deficiency or sleep apnea. Sometimes it means considering menopause hormone therapy, non-hormonal treatments, or additional support for sleep and mood. Often, it's a combination of approaches.

If you've been noticing changes in your energy, mood, sleep, or cognitive function, you don't need to wait for irregular periods or hot flashes to begin a conversation with your healthcare provider. Paying attention to when symptoms began, how they've changed, and whether there are patterns in relation to your menstrual cycle can be a helpful starting point.

I also think there's something important about noticing changes in our capacity. We may begin to see where we need additional support, what might need tending, and whether the rhythm of our lives is still working for us.

This doesn't mean we need to find meaning in every symptom or turn every challenge into an opportunity for growth. Sometimes it means acknowledging that we need treatment, more rest, or a little more help carrying what life is asking of us.

A final reflection

What stays with me from this research is the importance of listening to what people are actually experiencing, rather than relying on what we've come to expect perimenopause to look like.

My hope is that these findings encourage more curiosity and conversation, both within healthcare and in our communities. Being heard, having access to appropriate care, and finding our bearings within this transition can make a meaningful difference. And I hope that, along the way, we can begin to meet ourselves and one another with a little more compassion.

References

Hedges M, et al. (2026). Global perspectives on perimenopause: A digital survey of knowledge and symptoms using the Flo application. Menopause: The Journal of The Menopause Society. DOI: 10.1097/GME.0000000000002730

Psychological Symptoms During Perimenopause: A Global Cross-Sectional Study. (2026). Menopause: The Journal of The Menopause Society. DOI: 10.1097/GME.0000000000002872