Perimenopause Dizziness and Vertigo: Causes, Types, and What to Do

Dizziness During Perimenopause: More Varied Than You Might Think

Dizziness is a word that covers several very different sensations. There is the spinning sensation of true vertigo, where the room seems to rotate even when you're still. There is the lightheadedness of nearly fainting, a sudden graying at the edges of vision when you stand up too quickly. There is the wooziness and disconnected feeling that can accompany anxiety. And there is the subtle off-balance sensation that makes you feel like you're walking on a boat. All of these can occur in perimenopause, sometimes in the same person at different times.

This variety is part of why perimenopause dizziness can be difficult to investigate and manage. The word dizziness is not specific enough to immediately point toward a cause or a treatment. When you're describing your symptoms to a doctor, being as specific as possible about what the sensation actually feels like, what makes it better or worse, how long it lasts, and what you were doing when it started, gives much more useful diagnostic information than the single word dizziness.

Several distinct mechanisms can produce dizziness in perimenopause, and they often coexist. Working through them systematically reveals which ones are contributing to your experience and what can be done about each.

Inner Ear Changes and BPPV

Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of true spinning vertigo and is more prevalent in women, particularly in midlife. BPPV occurs when small calcium carbonate crystals (called otoconia) that normally sit in specific chambers of the inner ear become displaced into the fluid-filled canals that sense head movement. When you move your head in certain directions, these misplaced crystals create abnormal signals that tell the brain you're spinning when you're not.

BPPV typically presents as brief, intense episodes of spinning that last less than a minute and are triggered by specific head positions: lying down, rolling over in bed, tilting the head back to look up, or bending forward. If this description matches your dizziness experience precisely, BPPV is the most likely cause. It is highly treatable with a repositioning maneuver called the Epley maneuver, which a doctor, physical therapist, or vestibular specialist can perform in the office. The crystals are guided back to their correct location, and symptoms typically resolve within one to three treatments. The maneuver can also be learned and performed at home with proper instruction.

Estrogen may play a role in the stability of otoconia. Some research suggests that the protein matrix that holds these crystals in place is hormonally influenced, and lower estrogen during perimenopause may increase the likelihood of crystal displacement. Women are significantly more likely than men to develop BPPV, and rates increase in the decade around menopause, suggesting a hormonal connection, though the exact mechanism is still being studied.

Meniere's Disease and Hormonal Fluctuation

Meniere's disease is a condition of the inner ear characterized by episodes of intense vertigo lasting twenty minutes to several hours, often accompanied by fluctuating hearing loss, ringing or roaring in one ear (tinnitus), and a sensation of fullness or pressure in the ear. It is significantly more common in women, and many women with Meniere's report that their episodes correlate with hormonal changes, particularly the days before menstruation or during the hormonal fluctuations of perimenopause.

The proposed mechanism involves hormonal effects on fluid regulation in the inner ear. The inner ear maintains a precise balance of specialized fluids (endolymph and perilymph), and disruptions to this balance produce the symptoms of Meniere's. Estrogen and progesterone influence fluid regulation in many systems, including the inner ear, which may explain why hormonal fluctuations trigger episodes in susceptible individuals. Women with Meniere's often notice a pattern of worsening during perimenopause as hormonal swings become more dramatic.

Meniere's disease requires diagnosis by an ENT (ear, nose, and throat specialist) or a neurologist with expertise in vestibular disorders. Management includes dietary strategies (low sodium diet to reduce fluid retention), diuretics in some cases, and vestibular rehabilitation therapy for the balance impairment that can develop over time. If your vertigo episodes are prolonged, accompanied by hearing changes, and associated with ear pressure, an ENT evaluation is the right first step.

Orthostatic Hypotension: Dizziness When You Stand

Orthostatic hypotension is a temporary drop in blood pressure that occurs when you move from lying or sitting to standing. The autonomic nervous system, which controls blood pressure regulation, normally triggers rapid adjustments to maintain blood flow to the brain when you stand up. When these adjustments are delayed or insufficient, blood momentarily pools in the legs and away from the brain, producing a sensation of lightheadedness, graying vision, or near-fainting that typically resolves within a few seconds.

During perimenopause, the autonomic nervous system is less stable due to the loss of estrogen's regulatory influence. This means that the cardiovascular reflexes that compensate for positional changes can become sluggish or exaggerated. Women who are also not drinking enough water, who are taking medications that lower blood pressure, or who have hot flashes that cause sudden vasodilation are particularly susceptible to orthostatic hypotension during perimenopause.

The key distinguishing feature of orthostatic hypotension is its timing: the dizziness comes specifically when you rise from a lying or seated position and improves within a minute of standing still. If this matches your experience, practical management includes rising slowly from bed or chairs, sitting on the edge of the bed for thirty seconds before standing, staying well hydrated, and consuming adequate sodium. Compression stockings can help by reducing blood pooling in the legs. If the episodes are frequent, severe, or causing falls, a cardiovascular evaluation to check blood pressure in different positions is appropriate.

Blood Sugar Dips and Hormonal Connections

Reactive hypoglycemia, a drop in blood sugar that occurs a few hours after eating, can produce dizziness, shakiness, difficulty concentrating, and irritability. This pattern can be mistaken for other types of perimenopause dizziness, and it's worth considering if your dizziness tends to occur a predictable time after meals, particularly after high-carbohydrate or sugary meals.

Hormonal changes in perimenopause affect insulin sensitivity. As estrogen declines, insulin sensitivity tends to decrease, which can produce more pronounced blood sugar swings after meals. Women who were previously stable in their blood sugar regulation may begin to notice the symptoms of reactive hypoglycemia for the first time in perimenopause. The mechanism is that a large carbohydrate load produces a more exaggerated insulin response, which then drives blood sugar lower than intended, triggering symptoms.

Managing blood sugar swings involves eating meals that combine protein, fat, and fiber with carbohydrates to slow glucose absorption, avoiding large gaps between meals, and reducing the portion sizes of high glycemic index foods. If you notice that your dizziness consistently follows certain meals and relieves with eating something, this blood sugar pattern is worth exploring. A continuous glucose monitor (increasingly accessible without a prescription) can make these patterns visible and help you see exactly how your blood sugar responds to different foods and meal timing.

Anxiety-Related Dizziness and the Hormonal Loop

Anxiety can produce dizziness through several mechanisms. Hyperventilation from anxiety changes the carbon dioxide levels in the blood, which directly causes lightheadedness, tingling in the extremities, and a sense of unreality. Anxiety also heightens awareness of normal body sensations, meaning that minor fluctuations in balance or vestibular input that would normally go unnoticed become amplified into frightening experiences. And anxiety activates the sympathetic nervous system, which causes the heart to race and blood vessels to constrict, altering blood flow patterns in ways that can produce dizziness.

During perimenopause, anxiety increases for both hormonal and situational reasons. Estrogen has anxiolytic (anxiety-reducing) effects through its influence on GABA receptors and serotonin activity. As estrogen becomes erratic, the anxiolytic protection it provides fluctuates, making the nervous system more reactive. Hot flashes themselves trigger surges of adrenaline that activate anxiety circuitry. And the experience of unexplained dizziness can itself provoke anxiety, creating a loop where anxiety causes dizziness and dizziness causes anxiety.

Recognizing anxiety-related dizziness requires looking at the context: does it occur during or after moments of stress or worry? Does it come with other anxiety symptoms like racing heart, tight chest, or racing thoughts? Does slow, deliberate breathing reduce it? If the answer is yes to these questions, working on the anxiety itself, through mindfulness, therapy, exercise, or appropriate medical support, is likely to reduce the dizziness as well.

Vestibular Migraine: The Underrecognized Connection

Vestibular migraine is a form of migraine in which the predominant symptom is dizziness or vertigo rather than headache. Many women don't realize they're having migraines because the traditional throbbing headache is absent or mild. Vestibular migraine is more common in women, increases in prevalence during perimenopause, and can be difficult to distinguish from other causes of vertigo.

The episodes of vestibular migraine can last from minutes to days and may include spinning vertigo, rocking or swaying sensations, sensitivity to motion, light sensitivity, sound sensitivity, and cognitive fog. Some women have headache along with the vestibular symptoms; others have very mild head pain or none at all. The history of traditional migraines, a family history of migraines, and a response to migraine treatments are all clues toward this diagnosis.

Why does vestibular migraine worsen during perimenopause? The same hormonal fluctuations that drive many perimenopause symptoms also affect the brain's migraine threshold. Estrogen influences serotonin pathways and the trigeminal nerve activity that underlies migraine. The erratic estrogen swings of perimenopause lower the threshold for migraine attacks in susceptible individuals. Vestibular migraine is treated with the same strategies as other forms of migraine: identifying and avoiding triggers, lifestyle regularity (consistent sleep, regular meals, hydration), and in some cases preventive medication. A neurologist who specializes in headache disorders can diagnose and manage vestibular migraine.

When to See an ENT vs. a Neurologist

Knowing which specialist to see for dizziness in perimenopause depends on the character of your symptoms and what the initial evaluation reveals.

An ENT (otolaryngologist) is the right first specialist if your dizziness is clearly positional (BPPV pattern), involves hearing changes or ear pressure (possible Meniere's), or is accompanied by tinnitus. ENTs have audiologic and vestibular testing available in their offices and can diagnose and treat the inner ear causes of dizziness comprehensively. A vestibular physical therapist, who often works within or alongside ENT practices, can perform the Epley maneuver for BPPV and conduct vestibular rehabilitation for balance impairment.

A neurologist is the right specialist if dizziness is accompanied by neurological symptoms such as double vision, weakness, slurred speech, numbness, or difficulty walking. Neurologists can also evaluate for central causes of vertigo (arising from the brain stem or cerebellum rather than the inner ear), for vestibular migraine, and for other neurological conditions that cause balance problems. An MRI of the brain and inner ear can be ordered by either specialist when warranted. If you experience sudden severe dizziness with any neurological symptoms, seek emergency care immediately rather than waiting for a specialist appointment.

Tracking your dizziness episodes carefully before any specialist appointment, noting onset, duration, associated symptoms, position, and triggers, makes the diagnostic process much more efficient. Using PeriPlan to log dizziness alongside hot flash frequency, sleep quality, and cycle timing can reveal whether your episodes cluster around specific hormonal phases and gives your doctor actionable information rather than vague impressions.

Medical Disclaimer

This article is for general informational purposes only and does not constitute medical advice. Dizziness and vertigo can have serious causes that require prompt medical attention, including stroke. If you experience sudden severe dizziness, particularly with double vision, slurred speech, weakness in the face or limbs, or loss of coordination, seek emergency care immediately. For persistent or recurrent dizziness, consult a healthcare provider. Nothing in this article should replace professional medical evaluation of your individual symptoms.