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Levels of estrogen and progesterone shift unevenly and unpredictably through perimenopause, causing hormonal symptoms, which include: Irregular periods and reduced fertility Hot flashes Insomnia Night sweats Changes in mood: depression, mood swings, and irritability Changes in sexual function: vaginal dryness and atrophy, painful intercourse, low libido, reduced sexual arousal, difficulty achieving orgasm Weight gain Breast tenderness Brain fog, forgetfulness, and difficulty concentrating (7, 30) Reductions in estrogen levels are also associated with increased risk for vaginal and urinary tract infections, osteopenia, osteoporosis, dyslipidemia, and heart disease (39)