Hot flushes, irregular bleeding and loss of libido are common changes that occur in the years leading up to the big change—menopause. While none of them are enjoyable, it's natural to write them off as normal perimenopausal symptoms. And that's exactly what they are, at least most of the time.

In some cases, the very same symptoms that are often caused by natural hormonal fluctuations can instead be signs of dangerous, even life-threatening, health issues. Here's a look at what else these changes might signal and how to sort it out.

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Hot flashes

It’s understandable that hot flushes (or their PM counterpart, night sweats) would be written off as normal when you’re in your 40s or 50s. After all, an estimated 80% of perimenopausal women experience them. But these sudden waves of body heat can also be triggered by an overactive thyroid or, less commonly, Hodgkin's lymphoma, says Dr Mary Jane Minkin. 

How to know what’s causing your flushing and sweating? If your thyroid is to blame, you’ll likely also experience other symptoms, including a racing heart, unexplained weight loss, lots of trips to the bathroom and extreme fatigue. Hodgkin’s, a type of cancer that starts in the white blood cells, also tends to be accompanied by other signs, such as swelling of lymph nodes in your neck, armpits or groin; persistent fatigue; fever and chills; and unexplained, rapid weight loss.

Another tip-off that your hot flushes aren’t due to perimenopause: The lifestyle changes and other remedies that are usually recommended to quell them don't work.

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Irregular bleeding

Hormonal levels get wacky during perimenopause, which can lead to irregular bleeding or spotting. Some months, your period may be longer and heavier; other months, it may be shorter and lighter—or you may not have a period at all. Though abnormal periods are common during this time, alert your doctor if you experience bleeding between periods, very heavy bleeding, bleeding that lasts longer than normal or that occurs more often than every three weeks, or bleeding after sex.

It might simply be perimenopause, "but both uterine (endometrial) and cervical cancers can present with heavy bleeding and spotting,” says Minkin. Play it safe and get checked out—you could have this syndrome and not know it.

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Heart palpitations

A pounding or fluttering heart during perimenopause is probably related to the release of a large amount of fight-or-flight hormones like epinephrine (aka adrenaline), which is likely involved with hot flushes too, says Minkin. This surge can be blamed on a drop in estrogen, which sets off a response in your body similar to when you see a bear and need to flee—hence the boost in your heart and breathing rate and blood pressure. But Minkin advises women not to assume that their palpitations are harmless flutters.

“Before I write them off to perimenopause, I ask my patients to have a cardiac evaluation, since heart disease ramps up around this time too.” Among other things, an irregular heartbeat can be a symptom of atrial fibrillation, the abnormal firing of electrical impulses that cause the atria (the top chambers in the heart) to quiver (or fibrillate).

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Mood swings

Nearly a quarter of women transitioning into menopause experience mood changes. Hormone fluctuations, life stresses, sleep interrupted by night sweats and concerns about body image, infertility and ageing may all cause emotional distress that can leave you feeling stressed and cranky.

Sometimes, hormonal-induced moodiness can develop into full-blown depression; in other instances, women of perimenopausal age develop depression that has nothing to do with the approach of menopause, says Minkin. In fact, research suggests that mood swings during this transition is usually much more complex than just fluctuating hormones, and includes factors like past emotional distress and a history of clinical depression. To get to the bottom of what’s causing your mood swings, talk to your doctor. Whatever the cause, effective treatment is available.

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Low libido

There’s no question that the symptoms of perimenopause can take a toll on sexual desire, and a recent study found that women who were most troubled by them reported significantly lower libido. But as with mood swings, a low sex drive can sometimes be a symptom of depression.

Depression can be both a cause and a result of a sexual problem: A woman’s loss of desire may contribute to depression, or her interest in sex might decline as a result of feeling depressed. In addition to a lack of interest in sex, women suffering from depression can find it more difficult to achieve orgasm.

If you also have other depression symptoms—especially sadness that lasts more than two weeks and impacts your ability to lead a normal, active life—seek medical help.

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