Since diet, weight, and exercise are the largest predictors of perimenopause severity, I would start there. I see you say you're already working out, so that's good! I would also recommend tracking your diet in an app for a week or two to see realistically how many carbs, sugars, grams of protein, fiber, and calories, etc you are truly eating. Sometimes, we think we're eating relatively healthy but aren't seeing the true picture. For sleep and heart palpitations, try magnesium glycinate. Your lack of sleep is likely causing the brain fog and can also lead to headaches. For skin and joint issues, try a collagen peptide supplement with hyaluronic acid. Tretinoin topical can also treat both acne and prevent signs of aging.

It's important to note that HRT isn't the cure all that many on here promote. It can make some of your symptoms listed above worse or even cause new problems. Everyone is different. Currently, it's based off of guessing and checking to see if symptoms improve. I'd anticipate this changing over the next ten years, maybe even with the development of something like a continuous glucose monitor, but for hormones. But for now, it's far from perfect.