Perimenopause or stress?

Is it stress or perimenopause? The symptoms they share

Put the NHS page on stress next to its list of perimenopause symptoms and a good half of each list could be copied onto the other. These are the ones that turn up on both:

• Sleep. Stress can mean sleeping too much or too little. Perimenopause brings sleep problems, often with night sweats waking you.
• Irritability and mood. The stress page says "irritable and snappy". The perimenopause list has mood changes, low mood and anxiety.
• A faster or pounding heartbeat. Stress hormones such as adrenaline speed the heart up, and palpitations are a recognised perimenopause symptom. Our page on palpitations in perimenopause covers the signs that need a same-day call.
• Forgetfulness and poor concentration. Stress makes it hard to focus and decide. The transition brings the brain fog many women describe.
• Headaches. Both lists have them. Perimenopause headaches often follow the cycle.
• Aches. Stress causes muscle tension and pain, and perimenopause brings muscle aches and joint pain.
• Less interest in sex. The stress page names sexual problems, and lower libido is on the perimenopause list.

The NHS also says something that matters here: it is "not always easy to recognise when stress is the reason you're feeling or acting differently". The same goes for perimenopause, which is why the questions below are about pattern and timing more than about any one symptom.

What points to perimenopause

The strongest clue is your cycle. The first sign of the transition is usually a change in periods: closer together or further apart, heavier or lighter, or skipped. A run of cycles shorter than 24 days or longer than 38, the range ACOG treats as normal, is worth noting. Our guide to irregular periods in perimenopause describes how cycles usually change.

Other signs belong to the transition and have no place on the stress list:

• hot flashes, sudden waves of heat in the face, neck and chest, and night sweats that soak the sheets
• vaginal dryness, discomfort during sex, or urine infections that keep coming back
• symptoms that carry on through a calm week, a holiday or a good stretch at work
• being 45 or over, which is the age at which the NICE menopause guideline says perimenopause is recognised from symptoms and cycle changes, with no hormone test needed

Mood that swings with the cycle points the same way. If irritability or low mood builds in the days before a period and lifts once it starts, read our page on PMDD or perimenopause too.

Stress symptoms in women in their 40s that point elsewhere

The NHS describes stress as usually a reaction to mental or emotional pressure, often tied to a feeling of losing control. It names the usual sources: work, family (relationship problems, divorce, caring for someone), money and health. Midlife tends to stack several of these at once, with teenagers, ageing parents and a demanding job in the same year.

Signs that lean towards stress:

• stomach problems, which are on the stress list and missing from the perimenopause one
• changes in behaviour: eating much more or less, avoiding certain people or places, drinking or smoking more
• constant worry and a sense of being overwhelmed that follows a particular problem
• symptoms that ease when the pressure lifts and come back when it returns, whatever the date of your period

None of this rules perimenopause out. The NHS adds that sometimes stress has no obvious cause, and a woman whose periods have started to change can be under real pressure at the same time.

Burnout or perimenopause?

Burnout has a narrower meaning than most people give it. The World Health Organization lists it in ICD-11 as an "occupational phenomenon" and not a medical condition, resulting from chronic workplace stress that has not been successfully managed. It has three parts: exhaustion, growing mental distance or cynicism about your job, and reduced effectiveness at work. The WHO says the term refers to work only and should not be used for other areas of life.

That gives you a practical question. If the exhaustion and the cynicism are about your job, and your evenings, weekends and time off feel noticeably better, the picture fits burnout. If you wake drenched at 3am on holiday, your cycle has shifted and your concentration is just as patchy at home, the transition is part of it. Exhaustion and poor focus fit both, so they will not decide it.

When stress and perimenopause feed each other

For many women the honest answer is both. The NHS notes that poor sleep makes mood worse and that hot flashes can bring on anxiety, so perimenopause can make a stressful life harder to cope with, and a stressful stretch can make broken sleep and low mood feel worse.

Researchers are still working out the biology. A study in the journal Menopause followed 101 perimenopausal women aged 45 to 55 for 12 weeks with a weekly hot flash diary and saliva samples. Women with more frequent and more severe hot flashes had a smaller rise in the stress hormone cortisol after waking. The lead researcher said earlier studies had been mixed and that, because the study was observational, it cannot say which causes which. So read claims that perimenopause is "really a cortisol problem" with care.

A record that helps tell them apart

Because the symptoms overlap, the most useful evidence is how they line up with your cycle and with the pressure in your life. For four to eight weeks, note each day:

• whether you are bleeding, and the start date of each period
• each symptom you notice, rated mild, moderate or severe
• hot flashes and night sweats, and roughly when they came
• how stressful the day was, and what was behind it
• how you slept, and how many times you woke

After a month or two the pattern is often clearer than any single bad week. Symptoms that cluster before periods or come with night sweats point one way, and symptoms that track deadlines or family rows point the other. Our printable symptom diary has a grid for this, and the appointment summary builder turns your period dates and your worst symptoms into one page for the GP.

When to see a GP

The NHS suggests seeing a GP about stress if you are struggling to cope, if what you are trying yourself is not helping, or if you would rather be referred. In England you can also refer yourself to NHS talking therapies for anxiety and depression once you are 18, without going through a GP. For perimenopause, see a GP when symptoms are getting in the way of your day, at work or at home, or when a change in your bleeding worries you.

Some things need a doctor whatever you think the cause is:

• bleeding between periods or after sex, and periods that are much heavier or longer than usual (our guide to types of vaginal bleeding sets out which to report)
• chest pain, or palpitations with breathlessness, dizziness or fainting
• low mood most of the day, nearly every day, for two weeks or more, covered in our page on perimenopause or depression

If you need help urgently, call NHS 111. If you or someone else is in immediate danger, call 999 or go to A&E. If you need someone to talk to, the NHS points to Samaritans on 116 123.

My take

I'd start with the calendar, before any theory about cortisol or burnout, and I'd judge it by two things: your period dates and your nights. If your cycle has changed and you have night sweats, I'd treat perimenopause as part of the picture even if your life is stressful right now, because a stressful life does not explain a cycle that has moved by a week. If your cycle is steady, nothing wakes you hot at night and your symptoms clearly follow a problem at work or at home, I'd follow the NHS route for stress first. I'd skip online cortisol and "adrenal" tests, which none of the guidance we read uses to tell the two apart. Either way, a few weeks of notes will tell your GP more than "I'm just exhausted" can.

Related reading

The Is it perimenopause? topic gathers our pages on telling the transition apart from other causes, and the look-alike finder matches your symptoms against thyroid problems, low iron, depression and other common causes in one go.