You know menopause can cause hot flashes. But did you know it can also lead to a dry mouth, heart palpitations or recurring urinary tract infections?

Though only a handful of them get much attention, there are more than two dozen known symptoms of menopause and perimenopause, the time leading up to and immediately following your last period.

The symptoms are so varied because your ovaries are ramping down production of estrogen and progesterone, sex hormones that have played key roles in all kinds of physiological processes since puberty. Estrogen is the biggest factor: As it declines, tissues in many parts of your body get drier, your bone density decreases and your body changes in lots of other ways.

The direct symptoms of changing hormone levels, like hot flashes, are associated with further effects, including poor sleep and changes to cardiovascular and cognitive health. Other mechanisms, not fully understood, are probably at play, too.

Here’s a guide to the many ways this midlife transition can affect your body, top to bottom — and what you can do about it.

Your Brain

Much of this highly complex organ is sensitive to changes in estrogen levels.

This is one reason that many symptoms of menopause begin in the brain.

This is, for instance, where hot flashes originate. Estrogen helps regulate neurons in the hypothalamus, a region in the brain that regulates body temperature.

As estrogen levels fluctuate during perimenopause and ultimately fall, those neurons can start overreacting.

Hot flashes often lead to insomnia. Sleep deprivation can in turn affect attention and cognitive processing, helping to explain the brain fog that many women report.

Even without sleep deprivation, perimenopause is linked to memory changes, specifically in learning and remembering word-based information, whether from a conversation or a grocery list.

Mood changes like depression, anxiety and irritability are also common, though not fully understood. Poor sleep may be one factor, but more research is needed on others, including the effects of hot flashes and how estrogen and progesterone interact with the neurotransmitters that affect our emotions.

Your Mouth and Throat

Estrogen encourages moisture in various parts of the body, including the mouth.

The loss of estrogen can change the way your mouth and throat work, feel and sound.

For example, many women experience dry mouth leading up to and after menopause.

That dry mouth — and specifically, the lack of saliva — can change your sense of taste and affect oral health more broadly.

Your voice may also get deeper, or become hoarse: Declining estrogen can affect hydration, mucous membranes and muscle tone in the larynx, causing vocal changes.

Many women gain weight and lose muscle during perimenopause. Added fat in the neck, less estrogen for receptors in the epiglottis (that flap that protects your windpipe) and a loss of muscle tone in the tongue combine to increase the risk of sleep apnea.

Your Heart

Premenopausal women generally have a lower risk of heart disease than men, but this starts to shift in perimenopause.

The lower risk of heart disease for younger women is in part because estrogen helps keep cholesterol in check, prevent plaque from forming and make arteries more open and elastic.

But typically, during and after perimenopause, cholesterol and blood pressure increase, arteries become stiffer and your risk of heart attack and stroke rises. After menopause, women’s risk of heart disease is about equal to men’s.

Fluctuations in estrogen during perimenopause can also contribute to heart palpitations, a sensation that your heart is racing or beating irregularly. These are worth getting checked out, but they don’t necessarily indicate a serious problem.

And while headaches may not seem like a cardiovascular symptom, they may sometimes arise in part from your blood vessels constricting as they lose elasticity — increasing blood pressure and reducing blood flow.

Your Metabolism

Menopause is associated with a redistribution of weight.

Many women begin to accumulate more fat in the abdomen and less in the hips and thighs.

It is also common to gain weight during perimenopause, though not a huge amount — perhaps 5 to 10 pounds can be attributed to menopause itself. Added pounds beyond that are likely to have other causes.

Many factors contribute. Some of it may be directly related to estrogen. But some is probably a secondary effect of insomnia, since poor sleep can increase hunger. It also increases insulin resistance, another common menopausal shift.

Your Genitals and Urinary Tract

Hormonal and vascular changes have major effects on your reproductive organs and surrounding areas.

As a result, infections, vaginal discomfort and sexual changes are common.

A hallmark is vaginal dryness, since estrogen is so important for moisturizing tissues. Less lubrication can make sex painful, and the dryness and irritation can also cause pain during daily activities like sitting or walking.

But the sexual effects of menopause can go further. Declining estrogen and other factors often cause low libido, and many women find it harder to orgasm.

That difficulty can be because of pain, but estrogen loss can also narrow blood vessels, decreasing blood flow to the clitoris; decreased testosterone can affect the clitoris, too. Plus, weakening of the pelvic muscles can reduce orgasms’ intensity.

Your vaginal tissue and microbiome also change. The vagina becomes less acidic. You lose cells containing a compound called glycogen that promotes moisture and elasticity. Useful bacteria called lactobacilli decrease.

All of this creates dry, irritated tissue in which harmful bacteria can thrive. That can lead to recurrent urinary tract infections and to leakage and frequent urination.

Your Bones and Muscles

Your body is constantly breaking down old bone and building new bone, and estrogen plays an important role in that process.

With less estrogen, that balance shifts, and bone breakdown starts to outpace bone building.

This leads to lower bone density. Some women may have losses of 15 percent or more.

Joint pain and body aches are also common. How menopause causes these symptoms isn’t fully understood, but experts say they may stem from the loss of moisture and elasticity in connective tissues like tendons.

None of these symptoms affect all women, and many can be caused by things other than menopause. Your mouth could be dry because of a medication you’re taking. Joint pain could be arthritis. And aging causes plenty of ailments on its own.

Even doctors can’t always confirm whether any one symptom a woman experiences is linked to menopause.

But often, it is menopause. In those cases, some symptoms will fade as your body adjusts to life with less estrogen. Others, sorry to say, will persist.

For many women, systemic hormone therapy can safely alleviate a wide range of symptoms. Local estrogen products applied to the vagina can treat urinary and sexual symptoms. And thanks to recently introduced drugs, nonhormonal options are increasing.

Sources

We consulted Dr. Stephanie Faubion, the director of the Mayo Clinic’s Center for Women’s Health and medical director of the Menopause Society; Dr. Melissa Kaufman, a professor of urology at Vanderbilt University Medical Center; Dr. Gina Lundberg, the clinical director of the Emory Women’s Heart Center; Pauline Maki, a professor of psychiatry, psychology, obstetrics and gynecology at the University of Illinois Chicago; Dr. Mary Jane Minkin, a clinical professor of obstetrics, gynecology and reproductive sciences at the Yale School of Medicine; Dr. Rachel Rubin, a urologist and sexual medicine specialist; Dr. Jessica Starr, an endocrinologist and bone health expert at the Hospital for Special Surgery; Dr. Lauren Streicher, a clinical professor of obstetrics and gynecology at Northwestern University Feinberg School of Medicine; and Rebecca Thurston, an associate dean for women’s health research and professor of psychiatry at the University of Pittsburgh.

Produced by Deanna Donegan and Claire Merchlinsky.