By Sophora Health Editorial Team · Medically reviewed · Published July 2026 · Last reviewed July 2026
Here is what nobody tells you before perimenopause starts: there are eleven hormones involved in what is about to happen. Eleven. Most people only hear about one. Which explains a lot about why the experience is so much more confusing than anyone prepared you for. Which means that when things start going wrong in your sleep, your mood, your weight, your memory, and approximately six other places at once, the explanation you have been given does not come close to covering it. This page covers all of them. Think of it as the introduction you should have had years ago.
First: what is actually happening?
Perimenopause is not your hormones going down. It is your hormones going haywire. The patterns that have been running reliably since puberty, the monthly rhythms, the signals that told your body when to sleep, when to feel calm, when to store fat and where, all of those start changing at once. Some hormones drop. Some spike. Some stop communicating properly with each other. Understanding which ones are doing what changes everything about how you make sense of what you are going through.
The Big Three: the ones driving most of what you are feeling
Oestrogen
The one everyone has heard of. Also the most misunderstood.
Oestrogen is actually three hormones: oestradiol, oestrone, and oestriol. Oestradiol is the one doing most of the work during your reproductive years. It regulates your cycle, keeps your bones strong, protects your heart, runs your brain chemistry, maintains the tissue in your vagina, keeps your skin plump and your eyes lubricated, and manages where your body stores fat. It is also responsible for how your body controls temperature.
The important thing to understand about oestrogen in perimenopause: the problem is not that it has gone low. The problem is that it will not stay still. It spikes. It crashes. It spikes again. Hot flushes are not caused by low oestrogen. They are caused by the drop after a spike. The brain’s temperature thermostat goes into crisis mode because the signal it was calibrating from has just pulled the rug out. This is why you can have a terrible month and then feel almost normal, then terrible again. The level is not the issue. The instability is. It is like trying to drive a car where someone else keeps randomly adjusting the accelerator.
Progesterone
The first one to decline. The one nobody mentions. And possibly the one behind your worst symptoms right now.
Progesterone is made after ovulation. During perimenopause, ovulation becomes unreliable. Sometimes it just does not happen. No ovulation means no progesterone that cycle. And progesterone is the hormone that acts on your brain’s calming system. It is why the second half of a normal cycle used to feel more settled than the first. When it declines, the calming system gets less reliable. Sleep becomes harder. Anxiety shows up without a reason. Irritability arrives that feels disproportionate to whatever caused it.
This can happen in the early to mid-40s while your periods still look completely normal. Which is why many women are told everything is fine when it very much does not feel fine. The blood test was normal. The experience was not. Both things are true. Progesterone declining first, before oestrogen has even started to drop, is the part of the story that most conversations leave out entirely.
Read the full progesterone guide
Testosterone
Yes, you have testosterone. No, it is not a mistake. It is doing important things.
Testosterone is made in your ovaries, adrenal glands, and brain. It drives libido, yes. But also energy, motivation, muscle strength, bone density, and mental sharpness. Testosterone receptors are found all over the female body from brain to bones to bladder. When it declines, women notice it most in their energy levels, their drive, their ability to think clearly, and their mood. Low libido tends to be the last thing they mention in a ten-minute GP appointment, because it tends to get the least sympathetic response. The fatigue and flat mood, at least, sound medical.
A study of 510 women treated with testosterone found that the biggest improvement was not in libido. It was in mood and anxiety. Women were surprised. They had expected one thing and got another. Testosterone is significantly underdiagnosed in women, not routinely tested, and currently only officially licensed for low libido despite evidence that it helps with much more than that. If fatigue, flat mood, and brain fog are still present after oestrogen and progesterone have been addressed, testosterone is the next conversation to have.
Read the full testosterone guide
The rest of the cast: hormones that make everything more complicated
FSH (Follicle-Stimulating Hormone)
FSH is made by the pituitary gland and its job is to tell the ovaries to produce oestrogen. During perimenopause, the ovaries become less responsive to those instructions, so the pituitary sends louder and louder signals. Think of it as the pituitary shouting into a room where the ovaries are wearing headphones. Elevated FSH is used as a clinical marker of perimenopause, but a single reading is not reliable because it fluctuates widely. Two or three measurements over time tell you far more than one.
LH (Luteinising Hormone)
LH triggers the release of an egg at ovulation. During perimenopause, the LH surge becomes erratic and sometimes fires without actually producing ovulation. You can get a positive ovulation predictor test and still not ovulate, and therefore still not produce any progesterone that cycle. The test is technically correct. The outcome it predicted did not happen. Perimenopause is full of these moments. This is one of the reasons anovulatory cycles (cycles without ovulation) are so common in perimenopause and why progesterone can be low even when cycles look regular.
DHEA
DHEA is made by the adrenal glands and is the raw material the body uses to make both oestrogen and testosterone. It declines steadily from the mid-30s onwards regardless of menopause timing. In postmenopause, vaginal DHEA applied locally converts to oestrogen and testosterone in vaginal tissue, which can improve dryness and comfort without affecting hormone levels elsewhere in the body. Worth knowing if systemic HRT is not an option.
Cortisol
Cortisol is the stress hormone. It is not a sex hormone. But it shows up in perimenopause like an uninvited guest who has decided to stay.
Cortisol and progesterone share a raw material called pregnenolone. Under sustained stress, the body uses more pregnenolone to make cortisol and less to make progesterone. So chronic stress does not only feel bad. It actively takes resources away from progesterone production. Additionally, as oestrogen and progesterone decline, the stress hormone system that they were helping to regulate starts running less smoothly on its own. The result is often a cortisol surge between 2 and 4am. If you are waking at that time with a racing heart and an anxious feeling that has no obvious cause, that is what is happening. It is hormonal, not psychological. You are not anxious because there is a reason to be anxious at 3am. You are anxious because cortisol has arrived early and your nervous system is running ahead of schedule.
Melatonin
Melatonin tells the body it is time to sleep. It declines during perimenopause. On top of progesterone already making sleep harder, you are also losing the signal that was cuing the body to settle into rest in the first place. This is why perimenopausal insomnia can feel genuinely different from the insomnia you have had before. It is not one thing going wrong. It is several things at once.
Thyroid hormones
Not a sex hormone. But possibly the most important one to know about in this context.
Thyroid dysfunction produces symptoms that are nearly identical to perimenopause: fatigue, brain fog, weight gain, mood changes, hair thinning, cold intolerance, poor sleep. It becomes more common in midlife. And because the symptoms overlap so completely, it gets missed, attributed to perimenopause and left untreated. If you are managing perimenopausal symptoms and they are not responding the way you would expect, getting a current thyroid panel is one of the most useful things you can do. It is a simple blood test. The results may change the conversation entirely, and if they do, you will be very glad you asked.
Insulin
Oestrogen improves insulin sensitivity. As oestrogen declines, insulin sensitivity decreases and the body starts storing fat differently. More of it goes to the abdomen rather than the hips and thighs. The mid-afternoon energy crash, the feeling that food is not working the way it used to, the belly that appeared without explanation: these are insulin-mediated effects of oestrogen decline. The cause is oestrogen decline. The calendar and lifestyle choices are not the explanation here. Hormones are.
AMH (Anti-Mullerian Hormone)
AMH measures how many eggs are left. It declines as perimenopause approaches and is used to estimate where you are in the transition. It varies significantly by ethnicity. Black and Hispanic women tend to have lower AMH levels than Caucasian women of the same age, while Chinese women tend to have higher levels before 25. These differences affect when perimenopause begins, and they are not always reflected in guidelines built on predominantly white Western populations.
You are not managing one hormone. You are managing eleven. That is not more complicated than it needed to be. It is just what a body is. And knowing the full cast of characters is, it turns out, considerably more useful than only knowing one of them.
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And then there are these ones: worth knowing about across your whole life
These play a smaller role in perimenopause specifically, but they are part of the full picture of female hormonal health.
Prolactin
Made by the pituitary, drives milk production and suppresses ovulation during breastfeeding. Also elevated in some women with irregular cycles for no breastfeeding-related reason, which can interfere with ovulation. In postmenopause, prolactin levels drop as oestrogen declines, which is the opposite of what most people expect.
Oxytocin
The bonding hormone. Released during childbirth, breastfeeding, and genuine human connection. Oestrogen promotes oxytocin release, which is part of why lower oestrogen during perimenopause can make women feel more isolated and less able to access the social support that usually helps them. The withdrawal is hormonal. The loneliness it produces is real.
Relaxin
Primarily a pregnancy hormone that loosens ligaments to allow childbirth. It interacts with oestrogen, which is why some women notice increased joint laxity or instability during hormonal shifts including perimenopause. Not widely discussed but worth knowing if unexplained joint looseness is part of your picture.
AMH revisited
Already covered above, but worth reiterating in this section: AMH is the clearest early signal that perimenopause is approaching. When it starts declining in your late 30s, the transition has already begun, even if your periods are still regular and you have no symptoms yet.
This is different for different women
The hormones are the same in every body. What varies is everything else.
African American women experience the most severe and longest-lasting vasomotor symptoms. Japanese and Chinese women report the lowest rates, partly because of lifelong soy consumption that interacts with oestrogen receptors. Hispanic women reach certain stages of the transition earlier than average. AMH levels vary by ethnicity, which affects timing. Thyroid problems are more common in some populations. Access to HRT and hormone testing varies dramatically by country, healthcare system, and socioeconomic status.
In Ayurveda, the transition is managed with herbs like Shatavari, which has a 2024 double-blind randomised controlled trial behind it showing real improvements in sleep, anxiety, and vasomotor symptoms. In Traditional Chinese Medicine, the transition is understood as a yin deficiency and treated with herbal combinations studied in multiple East Asian trials. In many parts of Africa, South Asia, and Latin America, the conversation about hormones barely happens at all because access to menopause-trained clinicians is limited and cultural silence around this transition is the norm.
The biology is universal. The experience and the access to care are not. That gap is real, it is documented, and naming it is part of what Sophora is here to do.
How to use this information practically
The goal is not to memorise eleven hormones. The goal is to arrive at your next appointment with a better question than “I think it might be my hormones.” Better questions sound like:
“My main symptoms are sleep disruption and anxiety. Could this be progesterone rather than oestrogen?”
“I have been on HRT for six months and the hot flushes are better but the fatigue and flat mood are still there. Is testosterone worth discussing?”
“Could we run a thyroid panel? I want to rule out thyroid as a cause before assuming everything is hormonal.”
Sophora’s Doctor Prep document builds a structured record of exactly what you are experiencing and when, so you arrive at that appointment with a complete picture rather than trying to reconstruct months of symptoms in ten minutes while someone is already reaching for the door handle.
The individual hormone pages
The Big Three, in full
Everything oestrogen is running and why the instability matters more than the level.
Oestrogen in perimenopause and menopause
Why progesterone declines first and what that means for your sleep and mood right now.
Progesterone in perimenopause and menopause
What testosterone does in women, why it matters beyond libido, and how to raise it with your doctor.
Questions you are probably asking
How many hormones are involved in perimenopause?
At least eleven that are clinically relevant. Oestrogen, progesterone, and testosterone drive most of what you feel directly. FSH, LH, DHEA, cortisol, melatonin, thyroid hormones, insulin, and AMH all interact with the transition in meaningful ways.
Why do my symptoms seem unrelated to each other?
Because they are being driven by different hormones. Hot flushes and oestrogen instability. Sleep and progesterone decline. Anxiety at 2am and cortisol dysregulation. Weight changes and insulin sensitivity shifting. They are all happening simultaneously and they are all connected to the same transition, but they have different hormonal drivers and sometimes need different responses.
Should I get all my hormones tested?
Not necessarily. A single set of readings during perimenopause is often misleading because everything is fluctuating. The most useful tests are thyroid function and iron levels to rule out other causes of symptoms. Hormone testing is most useful for monitoring HRT once you are on it, not for diagnosing where you are in the transition. Your symptom pattern tells you more than most blood tests will during this period.
Does this ever settle down?
Yes. The volatility is the hard part. Postmenopause is not symptom-free, but it is hormonally more stable than perimenopause. Most of what makes perimenopause disruptive is the unpredictability, not the destination.
You now know: There are eleven hormones involved in this transition. The Big Three drive most of your symptoms. The rest complicate things. All of them are worth knowing about.
One thing to do: Identify the cluster of symptoms affecting you most right now. Then find out which hormone is most likely driving that cluster, and ask about that one specifically.
Hold onto this: You are not managing one hormone. You are managing eleven, that’s nature’s design.. It is just what a body is.
Someone important to you needs this too.
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The next step
Sophora’s Hormone Map builds a plain-language picture of what is happening in your hormonal system from what you share. Not lab values. A map. The kind you should have been given at the start of this. Private. Account-bound. Never sold, never used for advertising, never used to train public AI models.
mysophora.com · One payment. Twelve months. No subscription.
You are not managing one hormone. You are managing eleven, all shifting at the same time, none operating in isolation from the others. That is not more complicated than it needed to be. It is just what a body is.
Last reviewed: July 2026 · Review due: September 2026 · Not therapy. Not medical advice. For your own use and understanding only. · mysophora.com