Is it perimenopause or something else? How to tell what your hormones are really doing

If you’re in your mid-to-late 30s or early 40s and suddenly feel like your body has changed overnight, it’s not far-fetched to think: Is this perimenopause or something else?

Maybe your anxiety is higher than it’s ever been. Sleep feels impossible. Your periods are out of whack–either heavier or lighter, and somehow both unpredictable and regular at the same time. But when you try to get answers, you keep hearing the same thing: “Your labs are normal.”

As we age and go through certain life stages, our hormones change, and those changes can sometimes cause physical and/or psychological symptoms. And the perimenopause timeline doesn’t fit into a neat box. Add that to the fact that the symptoms of perimenopause often overlap with a lot of other conditions, and it can be a confusing and frustrating time.

 Let’s break down what’s actually happening, how to tell the difference, and what to do when your symptoms are real, but the answers feel fuzzy.

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Explaining the confusion of perimenopause or something else

Perimenopause is the hormonal transition that leads up to menopause, but it doesn’t flip on like a switch. For many women, especially between ages 35 and 45, the transition happens slowly, over time, and not in a straight line.

At the same time, thyroid issues, stress-related hormone disruption, PCOS, and other forms of hormone imbalances can cause almost identical symptoms. Fatigue, anxiety, brain fog, sleep issues, and cycle changes can all fall under the umbrella of “hormonal symptoms,” which makes it hard to know what’s actually driving the changes.

That overlap is why so many women feel dismissed or confused. You know something is off, but it’s not clear what it is.

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What perimenopause actually is (And shat it isn’t)

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Perimenopause vs menopause: What’s the difference?

Menopause is a single point in time. It’s officially diagnosed after 12 consecutive months without a period. Perimenopause, on the other hand, is the stretch of years leading up to that point, when hormones fluctuate.

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Typical symptoms of perimenopause

Symptoms of perimenopause vary widely, but they’re commonly: irregular or changing periods, hot flashes or night sweats, poor sleep, increased anxiety, mood swings, brain fog, vaginal dryness, and changes in libido. Some women notice heavier or longer periods, while others experience spotting or shorter cycles.

These symptoms are driven less by low hormone levels and more by fluctuating hormone levels. Estrogen can spike one month and crash the next. Progesterone often declines earlier and more steadily, which can affect sleep and anxiety.

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Signs of early menopause at 35

The average age at which people start menopause transition is between 45 and 47, but it’s not unheard of for some people to start as early as their mid-30s. 

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What’s considered early or premature menopause?

Menopause before age 40 is considered premature ovarian insufficiency (POI), while before 45 is considered early. Though uncommon (~5% of women will enter menopause early), it does happen, sometimes due to genetics, autoimmune conditions, or medical treatments.

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Symptoms that may feel more severe or abrupt

Signs of early menopause at 35 mirror those of regular menopause, i.e., irregular periods, hot flashes and vaginal dryness or loss of libido. They just happen earlier and can feel more abrupt. 

If your cycles have disappeared rather than changed gradually, that’s worth investigating.

However, for many women in their mid-30s who worry about early menopause, it’s more likely that they are actually experiencing another hormone imbalance that looks similar.

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When it’s not perimenopause: Other hormonal conditions that look similar

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Thyroid Disorders

Thyroid dysfunction is one of the most common conditions mistaken for perimenopause. Symptoms like fatigue, weight changes, anxiety, depression, hair thinning, and irregular cycles can all point to thyroid issues. Hypothyroidism, specifically, can cause similar symptoms to perimenopause: fatigue, irregular menstruation, and cognitive problems like memory loss.

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PCOS and Androgen-Related Hormone Imbalances

PCOS doesn’t disappear with age. Women who’ve always had irregular cycles, acne, or insulin resistance may see symptoms shift in their late 30s and assume it’s perimenopause. Androgen-related hormone imbalance can coexist with or mask perimenopause.

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Low Progesterone and High Estrogen (Estrogen Dominance)

Low progesterone (particularly alongside relatively high estrogen) can cause symptoms such as heavy or painful periods, breast tenderness, anxiety, irritability, poor sleep, and intense PMS. This pattern can happen during perimenopause or completely independently. Ovulation triggers progesterone release, so when ovulation becomes irregular and/or infrequent, progesterone levels drop and allow for estrogen symptoms to take center stage.

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Chronic Stress and HPA Axis Dysregulation

Chronic stress affects cortisol, which interacts with reproductive hormones. When stress is constant, hormonal balance can suffer even if ovarian function hasn’t changed much yet. This is one reason symptoms often worsen during demanding or stressful situations.

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What hormone tests can (and can’t) tell you

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What low FSH levels in females really mean

Some clinicians use Follicle-Stimulating Hormone (FSH) to assess menopausal status, but it’s not a reliable standalone test during perimenopause. Levels fluctuate throughout the cycle and can change day to day. Low or normal FSH levels do not rule out perimenopause.

Low FSH levels could indicate an issue with the pituitary gland or hypothalamus. So it’s still worth checking with your provider.

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Other labs that may be helpful

Hormone testing can help rule out other possible causes for your symptoms and get you closer to an answer. But you should practice caution–estradiol, progesterone, and thyroid labs can offer context, but timing matters. Hormone testing should always be interpreted in light of symptoms, cycle history, and age, and should be performed under medical supervision. 

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Signs of hormonal problems that deserve follow-up

Due to the changing nature of hormones during your menstrual cycle, it’s normal to have shifts here and there. But some symptoms shouldn’t be brushed off as “just hormones.” Extremely heavy bleeding, bleeding between periods, bleeding after sex, sudden loss of periods, or severe pelvic pain should always be evaluated.

That is even if you are perimenopausal. Perimenopause can be uncomfortable, but it shouldn’t feel alarming or unmanageable without support.

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FAQs

Can you have perimenopause with regular periods?

Yes. It’s a common misconception that perimenopause only starts once your periods become irregular. In reality, many women experience other symptoms months or even years before their cycle changes. That’s because perimenopause can affect your body long before ovulation becomes inconsistent.

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How do I know if it’s perimenopause or something else?

The short answer: patterns matter more than one symptom or a lab test. Perimenopause usually comes with a cluster of symptoms that ebb and flow over time, especially around your cycle. 

But if your symptoms are sudden, severe, or don’t follow any hormonal rhythm, it could point to another issue like thyroid dysfunction, chronic stress, or a different hormone imbalance. 

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Can a hormone imbalance happen without perimenopause?

Yes–hormonal imbalances aren’t exclusive to perimenopause and can have several underlying causes. Thyroid disorders, PCOS, chronic stress, postpartum changes, and conditions involving low progesterone and high estrogen can all cause symptoms like fatigue, anxiety, irregular periods, and sleep issues. 

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What does low progesterone and high estrogen feel like?

An imbalance of these two critical reproductive organs can cause symptoms such as heavy or painful periods, breast tenderness, anxiety, irritability, poor sleep, and intense PMS. Progesterone also declines during perimenopause, though it’s not as broadly discussed as estrogen.

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What are the signs of hormonal problems that I shouldn’t ignore?

Even with perimenopause, there are certain symptoms you should discuss with your healthcare provider. These include extremely heavy bleeding, bleeding between periods, bleeding after sex, sudden loss of periods, severe pelvic pain, or symptoms that escalate quickly. While perimenopause can be uncomfortable, you shouldn’t be in pain or have alarming symptoms.

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Get the support you need for all of your perimenopause & hormone questions

Tracking your cycle, symptoms, sleep, and stress over time can reveal patterns that labs may miss. Working with a dedicated provider, like the hormone health-informed doctors at Allara, can help pinpoint what’s wrong. If you’re having symptoms, bring that information to your appointments so your provider has a complete and accurate picture of what’s going on so they can help you. The most important thing is to remember that you know your body best, and if something feels ‘off,’ that’s worth exploring until you have an answer and the support you deserve. 

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