Menopause and fatigue: Why energy drops during perimenopause

Around 40% of perimenopausal women report sleep problems, and the connection between hormonal changes and persistent fatigue is real and well-documented.

Fatigue during perimenopause and menopause refers to an ongoing sense of physical and mental exhaustion that isn't relieved by rest. Unlike typical tiredness, it's the feeling that your energy reserves are depleted. This can affect your ability to function at work, maintain relationships, or simply get through your daily routine. 

The hormonal fluctuations that occur during perimenopause affect multiple systems in your body, from sleep regulation and metabolism, to brain chemistry and energy production. Understanding why these changes happen can help you recognize what you're experiencing and find effective ways to feel better.

In this article, we’ll cover:

• How perimenopause affects your energy levels
• The connection between hormones, sleep, and fatigue
• Why metabolism and brain chemistry change during this transition
• Evidence-based strategies to manage exhaustion
• When to seek professional support

Understanding perimenopause and fatigue

Perimenopause is the transitional period leading up to the end of menstruation, i.e. menopause. It typically begins in your 40s and can last anywhere from two to ten years before menopause officially occurs. During this time, your ovaries gradually produce less estrogen and progesterone, which have a profound impact on more than just your menstrual cycle.

These hormones influence cognition, mood, and sleep through their effects on the central nervous system. The areas of the brain that control sleep and circadian rhythms are rich in estrogen receptors; estrogen helps regulate your sleep-wake cycle, supports mental clarity, and influences mood. Progesterone has a calming effect on the brain and acts as nature's sleep aid, helping you relax and fall asleep more easily.

What makes perimenopause particularly exhausting is your brain struggles to adapt to constantly changing hormone levels instead of simply adjusting to a lower amount. These fluctuations disrupt sleep patterns, influence stress hormone production, and interfere with how your brain uses energy. It's the unpredictability that keeps your body in a constant state of adjustment.

The impact on sleep is significant. Research shows that 40–60% of people in perimenopause experience sleep disturbances, with 56% sleeping less than seven hours per night compared to 32.5% of premenopausal people. Lower estrogen levels are associated with poor sleep quality, including less efficient sleep, more nighttime waking, and shorter total sleep time. You might be in bed for eight hours but wake up feeling like you barely slept at all.

The science behind energy changes in menopause

Changing hormone levels impact your body’s fundamental energy systems, from how your cells produce energy to when your body signals it's time to rest.

Your cellular power plants slow down

Estrogen plays a vital role in how your mitochondria function. Think of mitochondria as tiny power plants inside each cell that convert food into usable energy. When estrogen levels drop or fluctuate during perimenopause, these power plants become less efficient. 

Your body has to work harder to produce the same amount of energy, which leaves you feeling depleted even when you haven't done anything particularly strenuous. Since your brain represents about 2% of your body weight but consumes 20% of your energy, the decline in overall energy production impacts cognitive function too.

Your muscles lose their repair power

Declining estrogen also affects your muscles directly. Your skeletal muscles have specific estrogen receptors, and estrogen helps stimulate the cells that repair and maintain muscle tissue. The activity of those cells decreases when estrogen levels drop, which leads to reduced muscle mass and strength. When your muscles become less efficient, physical tasks that once felt effortless can leave you exhausted.

Your mood and sleep signals get disrupted

Estrogen and progesterone regulate serotonin and melatonin, which are essential chemicals for stable moods and restorative sleep. Melatonin is your body's natural sleep signal, but levels decrease during perimenopause, especially at nighttime. This means the signal that it's time to sleep may arrive late, be weaker than usual, or both. You might find yourself lying awake despite feeling exhausted, or waking at odd hours unable to fall back asleep.

When estrogen levels drop, serotonin levels can fall too, contributing to increased irritability, anxiety, and sadness. Lower serotonin also impacts melatonin production, since melatonin is made from serotonin. This creates a cascading effect where hormonal changes disrupt both your emotional well-being and your ability to get restorative sleep.

Thyroid complications add another layer

Your thyroid regulates metabolism and energy levels, but perimenopause and thyroid problems often occur simultaneously and share remarkably similar symptoms. Both can cause low energy and fatigue. Research shows that estrogen levels may impact thyroid hormone levels, so when estrogen fluctuates unpredictably during perimenopause, your thyroid function can be affected.

Distinguishing fatigue from other conditions

One of the challenges of fatigue during perimenopause is that fatigue can be a symptom for multiple conditions, including anemia, thyroid disorders, or depression. Hormonal fluctuations certainly cause fatigue, but attributing everything to perimenopause can sometimes lead to overlooking other treatable conditions.

While overlap is common, certain patterns can help point toward a specific condition:

• Depression is a common risk during perimenopause, and while it may be temporary for some people, others may benefit from more specific treatment. if you're experiencing persistent fatigue alongside feelings of hopelessness, worthlessness, or loss of interest in activities you once enjoyed, depression may be contributing.
• Hypothyroidism has very similar symptoms to perimenopause, but a few unique ones include cold sensitivity, constipation, and weight gain that seems disconnected from diet or activity changes. Research shows that thyroid disorders and perimenopause frequently occur together, so even if you're clearly in perimenopause, thyroid testing may still be warranted.
• Anemia typically causes breathlessness after minimal exertion and pale skin, particularly noticeable in nail beds and inner eyelids. If you have heavy menstrual bleeding during perimenopause, your risk of iron-deficiency anemia increases.
• Chronic Fatigue Syndrome is characterized by profound fatigue that worsens after physical or mental exertion — also known as post-exertional malaise — which differs from perimenopause fatigue that's generally constant.

When to seek medical evaluation

If you've addressed sleep hygiene, stress management, and basic lifestyle factors without seeing improvement after several weeks, your care provider can help investigate other potential causes.

Consult your care provider if you're experiencing: 

• Fatigue that interferes with daily functioning
• Symptoms that don't match the perimenopause pattern
• Heavy menstrual bleeding

Seek immediate medical attention if your fatigue comes with:

• Chest pain
• Severe headaches
• Unexplained bruising
• Sudden significant weight loss

Lifestyle factors that worsen lack of energy during menopause

While hormonal changes are the primary driver of perimenopause fatigue, certain lifestyle factors can intensify exhaustion. Understanding these contributing factors empowers you to make targeted changes that can help improve your energy levels.

• Poor sleep habits compound the disruption hormones already cause, so good sleep hygiene is critical. Irregular sleep schedules confuse your circadian rhythm, and screen time before bed suppresses melatonin production. Caffeine stays in your system for hours and can interfere with sleep, and alcohol disrupts REM sleep even though it makes you drowsy.

• Chronic stress worsens fatigue by keeping cortisol elevated, which interferes with sleep and destabilizes blood sugar. This creates a challenging cycle where stress worsens perimenopausal symptoms, and perimenopause symptoms create more stress.

• Your nutritional needs change during perimenopause. Iron deficiency is common, especially with heavy periods, and leads to profound fatigue. As you age, your body becomes less efficient at absorbing B vitamins like B12, which are critical for energy metabolism. Magnesium and vitamin D deficiencies can both manifest as fatigue or sleep problems, and compound menopausal bone loss challenges.

• A sedentary lifestyle worsens fatigue while regular movement improves energy levels. Declining estrogen accelerates muscle loss, and women can lose 3–8% of their muscle mass per decade after age 30. Regular physical activity — particularly resistance training — improves sleep, regulates cortisol, and maintains the muscle mass essential for energy production.

Evidence-based strategies to improve energy

You can't stop the hormonal changes of perimenopause, but you can significantly improve how your body responds to them. Research shows that targeted interventions, such as sleep optimization or specific types of exercise, can meaningfully reduce fatigue during this transition.

Sleep optimization techniques

• Cognitive behavioral therapy for insomnia (CBT-I) is recommended as the first-line treatment for chronic insomnia in adults. It works by changing thoughts and behaviors around sleep, including using your bed only for sleep, initially limiting time in bed to match actual sleep time, and addressing anxiety about sleep itself. 

• Light exposure can help regulate your circadian rhythm; light therapy shows some promise for treating insomnia. Bright light during daytime hours may help boost your ability to sleep at night, as well as improve mood and alertness. Light exposure in the evening however, particularly blue light from screens, suppresses melatonin production and can disrupt your circadian rhythm. To minimize this effect, avoid bright screens beginning two to three hours before bed. 

Targeted nutrition for hormonal balance

Strategic nutritional choices during perimenopause can support hormone regulation, energy production, and overall health. Key nutrition recommendations to support menopausal health include:

Exercise choices that boost energy without overexertion

• Strength training is beneficial for multiple menopausal symptoms. It can preserve muscle mass, support bone density, improve insulin sensitivity, and enhance mitochondrial function. Bodyweight exercises like squats, lunges, push-ups, and planks can be a great place to start.

• Moderate aerobic exercise, such as walking, cycling, swimming, or dancing, improves cardiovascular fitness and supports sleep quality in menopausal women. The key is moderate intensity where you can still carry on a conversation. Morning or early afternoon exercise tends to boost energy for the rest of the day.

Mind-body interventions

• Yoga has demonstrated multiple benefits for perimenopausal women, from improving sleep quality to decreasing anxiety and depression. Restorative yoga styles activate the parasympathetic nervous system, which helps counter chronic stress.

• Mindfulness-Based Stress Reduction (MBSR) has been shown to significantly reduce stress for people experiencing perimenopause. Some studies suggest MBSR can decrease the severity of other menopausal symptoms, but more research is needed. 

Medical and therapeutic interventions

For some people, lifestyle modifications alone aren't enough to manage profound perimenopause fatigue. When exhaustion significantly impacts your quality of life, medical interventions may be appropriate. Be sure to work with your care provider to receive evidence-based treatment tailored to your situation.

Hormone replacement therapy and its impact on fatigue

Hormone therapy (HT) directly addresses fluctuating hormone levels, which are the root cause of perimenopausal fatigue. Multiple studies show that HT improves sleep quality, but more research is needed to understand why. Beyond sleep, the benefits of HT for menopausal women include preserving muscles and bones, regulating neurotransmitters that affect mood, and reducing hot flashes that disrupt rest.

There are many myths about HT, but don’t let them stop you from receiving this type of care if you need it. If you're considering hormone therapy or want to learn more about your options, finding the right specialist is key. Carrot's hormonal health support connects people with menopause specialists who provide personalized guidance on treatment options.

Non-hormonal medications and supplements

For people who can't or prefer not to use hormone therapy, several non-hormonal options exist to help relieve menopause symptoms that can influence sleep. You’ll want to collaborate with your care provider to determine the best course of action: 

• SSRIs and SNRIs can reduce hot flashes and improve sleep 
• Gabapentin helps relieve nighttime hot flashes and sweats
• Certain supplements may be appropriate too depending on your situation 
  
  • Magnesium for sleep quality
  • Vitamin D, vitamin B12, and/or iron if any deficiencies are confirmed

Keep in mind with supplements that there are various “natural” remedies on the market claiming to support menopausal health. However, most include blends of herbs that are not rigorously tested for either safety or effectiveness because supplements do not require FDA approval. The director of the Midlife Women’s Health Center at Massachusetts General Hospital, Dr. Jan Shifren encourages people to be wary of supplement marketing. As Dr. Shifren says, “A half-hour walk with a friend three times a week will do so much more for your midlife symptoms and health than swallowing any supplement.”

Frequently asked questions (FAQs)

What causes fatigue in perimenopause?

Perimenopause fatigue is primarily caused by fluctuating estrogen and progesterone levels. These hormonal changes affect your mitochondrial energy production, disrupt sleep-wake cycles, reduce muscle repair capacity, and interfere with brain chemicals like serotonin and melatonin. The unpredictability of these fluctuations keeps your body in constant adjustment, which is particularly exhausting.

Can menopause cause exhaustion?

Yes. Perimenopause and menopause can cause profound exhaustion that differs from typical tiredness. This fatigue is characterized by ongoing physical and mental depletion that isn't relieved by rest, affecting your ability to function at work, maintain relationships, and complete daily tasks. Research shows that 40% of people in perimenopause experience sleep disturbances, which directly contributes to persistent exhaustion.

How do I get my energy back during menopause?

To improve your energy during menopause, start with good sleep hygiene practices, and lifestyle changes that can also help with other perimenopausal symptoms. Focus on targeted nutrition, including adequate protein, omega-3 fatty acids, and sufficient calcium and vitamin D. Regular exercise — particularly strength training and moderate aerobic activity — improves energy production and sleep quality. Mind-body practices like yoga and mindfulness-based stress reduction can help manage chronic stress. If needed, seek professional support for more specific sleep optimization strategies like cognitive behavioral therapy for insomnia and strategic light exposure. For some people, hormone therapy or non-hormonal medications provide significant relief when lifestyle modifications aren't enough.

What vitamins can help fatigue during menopause?

Several vitamins and minerals can help address perimenopause fatigue when deficiencies exist. You’ll want to confirm any deficiencies with your care provider before starting supplements, because targeted treatment based on your specific needs is most effective. Vitamin D supplementation is particularly important during fall, winter, and spring in regions with limited sunlight. B vitamins, especially B12, can support energy metabolism. Iron supplementation can address anemia-related fatigue, particularly if you experience heavy menstrual bleeding. Magnesium may help improve sleep quality.

Conclusion: Menopause doesn't mean endless fatigue

Fatigue during perimenopause is real, it's rooted in biological changes, and it's also manageable. You don’t need to simply endure the hormonal fluctuations affecting your sleep, metabolism, and energy production. Know that:

• Fatigue, while often driven by hormonal changes, has multiple potential causes during this transition
• Ruling out other conditions like thyroid disorders, anemia, or depression ensures you receive appropriate treatment 
• A combination of targeted lifestyle strategies and medical interventions can significantly improve your energy levels and quality of life.

You don't have to navigate this alone. Work with your care provider to create a personalized treatment plan that gives you the best chance of feeling like yourself again.

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