Hormone shifts, confusing symptoms, and a body that suddenly feels unfamiliar can feel overwhelming. What happens during perimenopause and menopause, common symptoms, and support options beyond quick fixes.
Perimenopause the phase of hormone fluctuations and eventual decline of estrogen and progesterone lasting up to a decade. I can begin as early as late 30s for women and really can pick up steam with symptoms ramping up as a woman goes through her 40s with the average of menopause being 51.
Menopause is the time when it has been precisely one year after your last period. If you get a period even ten or eleven months after your last one, the clock restarts. This time when periods have ceased for a full calendar year is a moment in time and from then on you are post menopausal. Menopause occurs when the ovaries are no longer releasing any eggs or making higher levels of estrogen and progesterone, fertility has come to an end OR if you’ve had a complete hysterectomy (removal of uterus and ovaries) or an oophorectomy (removal of ovaries).
If you are postmenopausal because your ovaries have been removed this is referred to as surgical menopause and it can happen at any age your ovaries are removed. It’s a more abrupt transition vs. the ups and downs over up to a decade that happens with perimenopause and the natural decline in estrogen and progesterone until menopause.
However, this is all highly variable for women so it’s difficult to put a firm timeline on it – or compare yourself to your girlfriends! So many things can impact the severity or onset of your perimenopausal symptoms and all too often hormone imbalances or changes are ignored by our doctors or chalked up to other things unrelated to perimenopause – more on that below.
Menopause is easily diagnosed by lack of a period for 12 months and can be seen in lab work as well with rising levels of pituitary hormones (those signals that come from the brain telling the ovaries to make estrogen and progesterone) such as FSH. An FSH value of greater than 30 IU/L is indicative of menopause.
On the other hand, there is not a specific diagnostic test for perimenopause. Testing hormones during this phase is tricky as they vary wildly day to day and cycle to cycle. Testing is still useful, but it’s not diagnostic. See this article for more info on helpful testing during perimenopause.
Perimenopause is determined based on symptoms a woman is having and while it can look different from one woman to the next, there are some commonalities. Most commonly for women in their 40s, as estrogen becomes erratic and eventually declines and progesterone follows its more slow and steady decline during perimenopause a number of signs and symptoms can arise including:
What’s perhaps the most concerning symptom for women is that they simply feel so far from themselves, like a stranger living in someone else’s body. The changes come on slowly and nuanced for most women like PMS feels a little extra lately or they feel more anxious or irritable in general.
Women also may notice their libido is waning or they are gaining more easily and feel that frustration but chalk it up to being busy, stressed and are quick to blame themselves for not doing better – particularly when it comes to the weight gain.
Menopause was not something commonly talked about in the past and wow has that changed!
You can’t check out at the Whole Foods checkout without a magazine cover touting the best diet for the “menopause muffin top”. Our social media feeds are now filled with ads for estrogen face creams, telehealth HRT platforms and ads for must-have midlife supplements. It’s hard to know if all this new info on hormone replacement is exaggerated or a flat out money grab.
And if you are more of the functional medicine mind or you’re following the so called “menoposse” on instagram you’re probably overwhelmed with information or you’re confused and frustrated that your doc doesn’t have the same take on hormones that you’re seeing online.
Women are so confused about this phase of life and the internet is both overwhelming and rife with misinformation.
What’s perhaps the most frustrating for women though is their OBGYN whom they’ve trusted with their most intimate and significant health issues throughout their life often give advice very counter to what their own research is showing them. These docs have delivered our babies, talked us through an abnormal pap smear and held our hand through so many things, they seem the obvious choice to handle your perimenopause transitions yet many of them are not up to date on current best practices in menopause medicine, the latest research on HRT and certainly not able to thoroughly advice you on how to lift weights, how much protein you need or provide a nuanced supplement plan to support your ever changing midlife physiology.
And they may have been less than helpful when you asked them if they could investigate what you feel might be hormonal issues.
When women start to undergo hormone changes most wonder if it might just be their hormones and generally ask their primary doc or their OBGYN for some testing or at least inquire: could these symptoms be due to something going on with my hormones?
Because of our fragmented medical system where if you as your GYN about your bloating or your skin is that they will send you to the GI doc or the derm cuz “they don’t do that” and because women’s health and well-being are sadly so drastically overlooked, here’s how it usually goes:
I’m gaining weight and I can’t seem to lose it:
This is just what midlife is like for women.
If you want to lose weight stop drinking wine and get on Weight Watchers.
Gaining weight? You need to workout more and eat less.
We have great new meds for that, let’s get you on some Ozempic.
I can’t sleep through the night, I’m utterly exhausted.
Let’s try a sleeping medication, here’s your RX for Ambien.
I can’t remember why I walked in a room and my brain is so foggy, I am struggling to do my job and take care of my family.
You’re stressed and busy, it’s normal.
You may have ADHD here’s a referral to a neurologist
I’m not coping well, I feel more anxious all the time.
Here’s a script for Xanax.
I feel so overwhelmed right now, like life is so hard. I feel like I might be depressed.
I’ll write you a script for Lexapro
My period is all over the place all of a sudden OR My periods are getting really heavy.
You need an IUD, let’s get that scheduled.
Don’t want an IUD? Here the birth control pill.
My cholesterol is all of a sudden high and what’s up with my fasting glucose creeping up on those labs we just did?
Here’s a stain for the cholesterol and metformin for the blood sugar. Oh and “you need to lose weight”. (As if it were that easy!)
I’m really bloated all of a sudden and I feel like more foods upset my stomach recently.
I can refer you to a gastro, I don’t do digestion.
I have no sex drive and it’s really impacting my relationship, nevermind the fact that I’m just not ready for that part of my life to be over.
I can write you a referral for a therapist.
There is some merit in these recommendations of course and sometimes these referrals are warranted and medications for things like depression or ADHD or GLP-1 medications might be part of the equation for addressing a midlife women’s concerns.
However, the root cause of all of these things is the waning hormones and it needs to at least be part of the conversation and the treatment.
And honestly many of these above responses are still an upgrade from: “All women feel that way, it’s just the way it goes.” This “suck it up” attitude is sadly still part of too many women’s experience. You won’t find any of that here, welcome.
As menopause and perimenopause have their moment here in the 2020s with such a big focus on hormone replacement and the experience women are having, there is push back (of course) saying menopause is now benign overly medicalized and women do not really need more support or better access to hormone therapy.
Women are having children later, working longer and rightfully so have an expectation that they should not only be alive but be living WELL for their second act. Women need to understand the risks to our heart, our brain and our bones to live close to as many years after menopause without hormones on board as we did during our fertile years where hormones were high.
Supporting women with all tools including accurate nutrition info, how to exercise for midlife, how to cope with stress, what supplements are worth their hard earned dollars and how hormone therapy can help when appropriate is how we do better.
We are not exaggerating or overmedicalization anything. Women in midlife have simply been largely ignored in both clinical and research settings and now that I am actually squarely in midlife myself, like you I’m not ready to be told my life is over.
Women in midlife still want to contribute to the world whether that is in their chosen career fields, their communities, their families – or all of the above. We want to thrive, not survive. We want to enjoy where we are now and where we have yet to go. We are not ready to be put out to pasture as they say.
We are not done living and we need support to optimize the have more life in our coming years, to experience wellness not merely managing a hot flash or two.
We want to be mentally sharp, physically agile, creative, positive, strong and able to show up to our life for the long haul. When we don’t address womens’ hormonal health during midlife and beyond we are putting them at risk for all cause mortality. That right: all causes of death for women can be related to the waning hormones that happens as a natural progression through midlife.
Women with lower levels of their sex hormones are not just uninterested in sex, feeling tired and frumpy they are at increased risk for heart attacks and stroke, fractures and dementia. Knowing this means we have to give better information and more options for women during midlife and beyond. Better than “just lose some weight” and certainly better than “suck it up, that’s just how it goes”.
Women deserve better. You deserve better.
We’ve moved away from fear around utilizing hormones for symptom management in midlife or to enhance longevity, putting more life in our upcoming years. This is a good thing, a great thing.
But even our upgraded, modern midlife medicine misses the mark when we simply prescribe hormones and call it a day. There is now at least a conversation about strength training and eating enough protein (can I get an amen??) but there is still very much an “HRT is all you need” mentality and women walk away from these appointments breathing a sigh of relief and then going about their life thinking their care is safe, effective and going to provide all the benefits HRT is touted for: brain, heart, bone, metabolic health, etc.
Testing is rarely done to ensure absorption and efficacy of your HRT as well as a harmonized balance between estrogen and progesterone. Go ahead, ask a girlfriend how much progesterone she’s taking. 100mg at bedtime right? Is this the best dose for every woman? While modern menopause medicine is a huge improvement from where we were even a few years ago, we are still opting for protocol and not nuance.
When a woman’s symptoms return, her doses are increased. If she struggles with side effects, doses are decreased or HRT is stopped and shes’ told, “You just don’t seem to be a good candidate for hormones”.
As an example: many women who struggle with using progesterone as it impacts their mood (sometimes in an extreme way, see this article for more on progesterone intolerance), increases water retention, increases cravings or they feel groggy the next day.
Not seeing yourself in those happy, life has never been better midlife faces on Instagram? This guide is for you.
GET MY COPYEnsure their HRT is being absorbed and utilized optimally, to levels that will actually provide the benefits they are taking hormones for in the first place.
Testing that both ensures levels are adequate and her entire regimen is well balanced as well as testing to ensure she is metabolizing those hormones effectively, thoroughly and safely. This approach enhances efficacy, avoids side effects and lowers risks associated with HRT.
Ensure that estrogen and progesterone (and maybe testosterone) are not the ONLY hormones we are addressing in midlife. Thyroid can take a turn and needs to be monitored closely. Insulin sensitivity lowers and inflammation rises we need more than an estrogen patch to fix it. Sources of inflammation and a lifestyle and nutrition plan to balance blood sugar must be set up. And cortisol needs to be supported.
It is often assumed women in midlife have high cortisol, but the truth is they can have
normal, high, or low cortisol either overall or at varying times throughout the day. It’s easy to test and treatment can be easily tailored to what each of our own stress responses rather than a generic cortisol supplement being recommended and you’re sent on your way.
The truth is nutrition, circadian rhythm, inflammation, nutrient deficiencies, how you exercise, and how you approach the many stresses that women in midlife inevitably face need to be addressed. This is what I do, because midlife is about more than HRT.
The good news is we can resolve all of this with a more holistic plan, well beyond your estrogen patch.
HRT is awesome, but it’s not everything. Women deserve everything. And perhaps what HRT misses entirely, is how midlife FEELS.
All over social media we are seeing women stepping into midlife like a true star. They are owning themselves, stepping into a new power armed with experience and wisdom and with their HRT in hand, they are tackling the next chapter with wisdom, strength and serenity they didn’t have in their 20s. They seemed to know who they were and what they wanted.
It looked good, real good. The problem was that I didn’t see myself in those women.
These shiny faces on Instagram looked like they had arrived somehow, and I felt like I didn’t even know where I was going anymore.
As I felt the overwhelm my future, the regret of roads less traveled and certain choices made, the weight of aging parents and the heartbreak of my kids growing up and moving on, and my marriage on shaky ground…well it began to look a little midlife crisis-y and that really freaked me out.
Turning the corner of midlife can really bring us face to face with unhealed wounds, past trauma, work we haven’t yet done, work we didn’t know we needed to do, relationships that are broken or at least badly battered. This phase of life didn’t feel like a “pause” but rather a reckoning where so many things I’d managed to ignore or put in the “I’ll deal with that later” pile suddenly felt urgent.
And then there’s the shift in our face when we look in the mirror. Deeper lines, rougher texture, droops where we used to feel bright and perky. There’s a new squish around the middle, whatever that is that’s happening to our necks, the backs of our upper arms that continue to “wave” long after our hand has stopped. Feeling frumpy more often than feeling sexy. Everything just “feels” different about our bodies.
Aging gracefully is beautiful in theory, but I couldn’t access that feeling when age was staring back at me.
Perimenopause has been described as a “reverse puberty” as during this time your hormones decline when in puberty, they rise. But remember puberty? It was disorienting, embarrassing and just like perimenopause, left us often wondering “what exactly is happening to my body??”
There was some excitement and some hesitance with these physical changes. The new batch of hormones changed our sense of self and how we interacted in relationships – we remember middle school right? It was a bumpy emotional ride too with our friends, parents and teachers.
In our early teens though we felt energetic, excited and with our whole life ahead of us. We knew we had time to make some mistakes, start over, have adventures. We felt we had nothing but time. Midlife doesn’t always feel as hopeful or exciting. Actually it can feel really stressful and at least a little sad. Time might feel like it’s running out or at least moving too fast.
They have much in common but in any event, puberty certainly didn’t feel like a non-event – and perimenopause doesn’t either except that this time our hormones are leaving the building vs. coming in. It can feel like we are ushering in a new chapter on empty vs. in our teens when we felt we had a full tank.
The truth is that midlife and perimenopause is hard. So much harder than I ever expected. We need to talk about that because women are expected to just go through this with stamina and a smile.
HRT is great, it really helps so many things. It can make coping with these changes easier, but we still have to traverse this time and it can feel sad, disappointing and even scary.
I wrote this for you. It’s what got me through and the exact process I use to coach the women in my practice.
Whether you want to listen or read or get some help directly from me, I’ve got something for you!
The best way I can help you is one on one. Together we can create a customized, comprehensive plan to ensure you’re optimizing your hormones, longevity and experience of midlife and beyond. Reach out for more info or to get started.
Midlife is not for the faint of heart, but we’ll get through it together!
Join this group coaching program where we’ll not only empathize with each other we will:
Free resources you can access right now whether you want to listen, read or download a guide. You’ll find info on the basics of HRT like cancer risks, where the pill fits into all this, what terms like “bioidentical” mean and what types of HRT to avoid. I’ve also got a lot of info on what to eat, how to navigate not tolerating certain aspects of HRT (progesterone, I’m looking at you) and what supplements can and can’t do for you compared to HRT. I update this page constantly as I release more podcasts and write more articles to check back!
Have a question you don’t see answered here? Email me!
HRT is rightfully back in the spotlight after years of unwarranted fear around using estrogen during perimenopause and menopause BUT it’s not appropriate or mandatory for every woman. Every woman deserves to understand all her options and while HRT is an important piece of the puzzle, it is not the entire puzzle. HRT doesn’t get us out of lifting weights, figuring out how to balance our blood sugar, optimizing our gut health and all of those other things. HRT might make it easier in some ways but the conversation about midlife for women is bigger than HRT as not only are there many other facets to our health besides HRT, there are some things that simply are not fixed by an estrogen patch. Midlife is a reckoning and a time to recalibrate and refine. Like so much about being a woman: it’s complicated. This article helps you glean a framework for HRT and beyond.
With so many options available for women who want to use hormones during perimenopause and menopause, it’s important to know what’s different about an estrogen patch vs. an oral pill vs. a compounded cream. Most importantly, women need to know that there is a different risk profile for synthetic hormones vs. bioidentical hormones (those molecularly identical to your own estrogen and progesterone) as well as different risks associated with different delivery systems, i.e. transdermal estrogen doesn’t have the same risks as taking an oral estrogen pill. This article will arm you with the info to have a better conversation with your provider as well give you a big picture view of all of your options, a better understanding of common terminology (systemic vs. local, MHT vs. HRT, etc.) and what options are right for you.
Pellets inserted under the skin are a popular, though often expensive, way to get bioidentical hormone therapy in midlife. In addition to concerns about financial incentives for docs using pellets, the biggest concerns are often sky high levels in a woman’s system with this delivery method and no way to manage that once the pellet is in. While it can be a quick shot of hormones that can get you feeling better fast and it doesn’t require daily application, side effects of too much hormone are all too common – some of which are irreversible. This article covers the pros and some very real concerns with pellet therapy.
Listen to the Dr Brooke Show episode #448
Wondering if any of these seemingly miraculous midlife supplements that social media is serving up to you would help you with symptoms or issues you’re still dealing with in midlife? The answer is: maybe. This article will help you know what common ingredients in female hormone balance supplements actually do and how to know if they might be the right fit for your particular issues or concerns. It also covers how over the counter options compare to taking actual hormones.
Get the FREE Guide to using supplements to support your female hormones. Listen to the Dr Brooke Show episode #434
In the 1990s the Women’s Health Initiative began and it concluded in 2005 with what have now been deemed flawed conclusions about HRT causing cancer, heart disease and stroke. Nevertheless this created a panic and women everywhere stopped their HRT and we’ve been scared ever since. It’s important to understand what this initiative was intended to study, which was hormone impacts on chronic disease and NOT on how hormones can improve quality of life in perimenopausal women. The women in the study were not typical women pursuing HRT today and the hormones used are not what’s currently recommended either. This article will help you understand how hormones actually impact your health and what risks do and do not come with them.
Weight gain is among the most common concerns for women in midlife and the internet is rife with advice on this topic and while HRT is helpful, it doesn’t get us out of balancing our blood sugar or eating in a way that doesn’t exacerbate inflammation. As well there are many strategies that might work for fat loss in our 20s and 30s but we have other goals in midlife such as maintaining our strength, agility, brain and heart health as we age. This article will show you the basic principles that accomplish all these goals. As a bonus, it helps you think about using certain foods to better support hormone balance.
A quick Google of “what to eat for my hormones” will bring up a lot of strategies that might work really well before perimenopause and menopause but fall short because the midlife hormone landscape is simply delicate and ever shifting. Many of these strategies are too subtle to make much of a difference with erratic and ultimately dwindling hormone output and others are too aggressive in some ways for perimenopause. This article will save you time and effort by explaining how common “hormone balancing” strategies actually work and which ones come up short in midlife.
There are a lot of menopause experts that are very against the use of compounding pharmacies to make custom hormone replacement medicines for women during midlife. The concern is that these medications are unregulated – making it sound like these medicines are made in someone’s basement. The truth is compounding pharmacies fill an important role when women need a customized dosage or formulation that isn’t available from our local Walgreen’s and spoiler: compounding pharmacies are run by licensed pharmacists in FDA regulated facilities using FDA regulated ingredients. There is a place for these types of pharmacies and medications and this article will clear up any fear and confusion around this topic.
LIsten to the Dr Brooke Show episode #436
Many women frustrated at lack of local providers who are up to date on current HRT best practices are turning to telehealth for a virtual prescriber to get their hormone prescriptions. There are some real advantages to these platforms including convenient access to experts right from your couch but there are some downsides too. This article covers pros and cons and how to make the most of telehealth if it’s the right fit for you.
HRT can be thought of as a bit of art mixed with science in that the best providers help women create a regimen that helps them feel their best. One of the topics in HRT that has the least agreement is whether a woman should take the same dose of estrogen and progesterone throughout her cycle or throughout the month or should she vary it aiming for a rhythm that is similar to what our bodies would normally do during a 28 day monthly cycle. There are certainly advantages to this but it can feel tedious as well. This article explains the advantages of cyclical HRT and why it might be worth the hassle.
LIsten to the Dr Brooke Show episode #444
If you’ve suspected your hormones are shifting and leading to your current symptoms you likely have been given a couple of typical responses including: no, hormones vary too much so we don’t’ test them during perimenopause or certain tests are better than other during midlife. It is hard to make sense of what you see on the internet as it so often conflicts with what your doctor may have told you. There are a variety of options for testing and this article will help you make sense of how to utilize them to feel your best and reduce risks and side effects from HRT.
Estrogen and progesterone have an intricate relationship that needs to be in balance whether you are cycling or taking HRT. Progesterone is the hormone of temperance, keeping estrogen in check and when it can’t, we see a host of symptoms. Utilizing testing to calculate the P:E2 (progesterone to estradiol or E2 ratio) can help you suss out exactly what the issue is so that you won’t assume it’s merely a case of needing to begin taking or increase your dose of progesterone, balance your estrogen dosage better or support the metabolism of estrogen.
If you have expressed a concern about erratic periods, hot flashes or mood changes in midlife your doc may have suggested that you take a birth control pill. If you have asked your doctor to prescribe your HRT you may have been offered birth control pills instead. While birth control pills can temper the erratic hormone landscape of midlife – and certainly provide contraception – women deserve to know that these hormones are not the same as the hormones used as part of HRT nor do they provide the same benefits. This article explains the difference so you can make an informed choice.
LIsten to the Dr Brooke Show episode #451
Progesterone generally makes women feel less anxious and sleep better. However, some women either do not feel much benefit and others feel mild to severe anxiety, irritability, insomnia or even panic from it. This can be part of the picture of PMDD (premenstrual dysphoric disorder, more on that here) or it can be an issue that arises when a woman starts HRT and feels worse rather than better. It’s tricky because if we want to utilize estrogen as part of our HRT, we need to figure out how to give a woman progesterone as well, be that via different delivery methods, lower dosages or other strategies. This podcast episode explains why progesterone isn’t tolerated by all women and what you can do about it.
Sleep issues are among the most common problems in midlife. Tossing and turning, waking frequently, often taking quite a while to go back to sleep if you do at all, or waking up 3-5AM with your body thinking it’s 6 or 7 and you are up for the day. Progesterone is the go to for sleep problems related to hormone decline, but low estrogen will shift your clock leading to early waking times and it boosts serotonin which is both relaxing and related to melatonin production. Both of these hormones are needed for adequate and restorative sleep and this episode will help you understand if it’s low progesterone or low estrogen – or both – that needs to be addressed.
Testosterone is both overprescribed and totally ignored. While an important hormone it’s often given too soon or via delivery methods that cause extremely high levels of this hormone to build up for women. What’s more there is no FDA regulated product for women so prescribers need to compound it or give a male approved product and ask women just to use a small amount. Needless to say, testosterone creates quite a bit of confusion for women while on one hand it appears to be the answer to all their problems and on the other the side effects of acne, hair loss and irritability make some women nervous.
There is so much about midlife that isn’t solved by starting HRT, making a change in dosage or dialing in the right testing or supplement regimen. It’s about facing what feels sad, overwhelming and all too real about this phase of life. Midlife can feel like a real reckoning and it’s important that we talk about this and not just how estrogen can relieve a hot flash or how progesterone can help you sleep. I cover my own personal journey in the first part of a two episode series and then my 3G +4R Process in part II. I also cover all this in a FREE downloadable guide as well.
Get the FREE guide Midlife Is More Than HRT
Listen to the Dr Brooke Show Midlife Is More Than HRT Part I and Part II
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