Perimenopause rarely starts with hot flashes. Cycle-length change, broken sleep and new irritability usually come first, and are easy to blame on stress or age.
Cycle and bleeding changes, hot flashes and night sweats, sleep disruption, mood and cognitive symptoms, joint aches and body changes, and genitourinary symptoms such as dryness and urinary urgency. Most women have a handful, not all of them.
In the early transition cycles vary in length, premenstrual irritability worsens and sleep lightens. In the late transition gaps of 60 days or more appear and hot flashes peak. Genitourinary symptoms begin later and tend to persist without treatment.
Thyroid disease, iron deficiency, PMDD, sleep apnoea and depression share many of the same symptoms. Timing across weeks, plus targeted tests such as TSH and ferritin, separates them.
Treat sleep first, discuss hormone therapy on individual risk, treat vaginal and urinary symptoms separately with local oestrogen, and build strength training and reduced alcohol into the base.
Bleeding after sex or between periods, any bleeding a year after periods stop, flooding, symptoms before 45, or low mood most days for two weeks all need medical assessment.