9781785045790 by Smakprov Media AB

Make Sense of Your Symptoms and Build Your Personalised Treatment Plan

THE PERI MENOPAUSE SURVIVAL GUIDE

DR HEATHER HIRSCH

‘A compassionate, science-backed road map’ Tamsen Fadal, New York Times bestselling author

The Perimenopause Survival Guide

MAKE SENSE OF YOUR SYMPTOMS AND BUILD YOUR PERSONALISED TREATMENT PLAN

Dr Heather Hirsch

Dr AVRUM BLUMING

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To my daughter, DeMille Margaret Hirsch, and all future generations of women.

May we all receive the care we need throughout our lives.

FOREWORD

I fi rst met Dr. Heather Hirsch through an organization called Advancing Health After Hysterectomy, founded in 2014 at Yale University, where a group primarily of gynecologists had been convened to discuss the medical symptoms and concerns of women going through perimenopause and menopause. We all knew that training in this area was grossly deficient in programs around the world. Indeed, the word “menopause” was barely mentioned in most medical schools— and why would it be, given that the male body was (and often still is) the “normal” body that medical students were taught? Our task was to educate physicians in training and in practice through lectures, published papers, and online educational sessions, bringing peer-reviewed research and information to the frontline physicians working with patients going through the maelstrom of menopause.

As a medical oncologist who has spent decades doing research on the benefits of estrogen for my patients, even those who have survived breast cancer, I was delighted and reassured to fi nd myself in a group of like-minded physicians who, like me, had been frustrated by our profession’s silence about menopause. All of us had stories to tell of how it felt to be lone voices in the wilderness, urging the rethinking of the establishment paradigm that “estrogen causes breast cancer,” trying to raise awareness of perimenopause as its own pre-menopausal phase, and combatting sexist attitudes that women complaining of severe menopausal symptoms were likely “hysterical” or exaggerating. Even in such a collegial atmosphere, Dr. Hirsch’s participation brought an added energy and enthusiasm to the program. She had founded and was coordinating The

Menopause Clinic at Brigham and Women’s Hospital while serving on the faculty at Harvard Medical School. As I became aware of the extent of her knowledge, her professional experience, and her tutorial skills, as well as her passion to educate health care professionals, I became a fan.

And then I read this book, which confi rmed for me the esteem in which she is held by her peers and patients.

This is one of the rare books that seamlessly blend the author’s personal experience, keen observation, and careful scholarship with illustrative examples from women’s lives. It is both easy to read— for those wanting the basic information— and extensively referenced— for those wanting to learn more or to use in discussions with their physicians. Dr. Hirsch’s recommendations are practical and doable, but they are not cookie- cutter advice guides; rather, she allows readers to customize her suggestions according to their own circumstances and needs. Thus, in the chapter called “Assess Your Symptoms; Set Your Priorities” she candidly writes: “The next part of this book is a bit of a choose-your- own adventure.”

Dr. Hirsch fulfi lls the responsibility of both the physician, whose task is to counsel and heal, and the scientist, whose task is to determine the best available evidence to guide diagnosis and treatment. And she does both in the spirit of partnership with the patient, rather than dominance. That is why she is equally comfortable offering readers ways to help themselves as well as other solutions that require working with a medical professional. She offers advice without fi nding fault or inducing guilt. As you read this book, you feel as if Dr. Hirsch is holding your hand and looking directly into your eyes. And her concern, fi rst and foremost, is well-being and autonomy— crucial matters for the many midlife women who feel squeezed between the demands of their partners, children, parents, and employers. As she writes, “Whenever a patient tells me, ‘I’d like my sex life to get better,’ I always ask, ‘For you, or for your partner, or both?’ If the answer is ‘For my partner,’ I suggest moving libido down the priority list, because nothing we do will be significantly effective if you’re doing it for someone else. I’d rather see you prioritize

sleep or address brain fog, because those will make you feel better— and when you do, you may genuinely feel more interested in tending to your sex life.”

If you want to have access to the best answers available now for the symptoms and experiences of perimenopause; if you want to know the best alternatives (prescription and non-prescription) that are available to you as you navigate through this often diﬃcult period; and if you want to partner with your physicians to choose the best options available to you, this book will be a cherished guide as you travel along this phase of life’s journey.

Avrum Z. Bluming, MD, MACP emeritus clinical professor of medicine, University of Southern California coauthor, with Dr. Carol Tavris, of Estrogen Matters

INTRODUCTION

Hope for the Biggest Transition of Your Adult

Life

Drew Barrymore sat onstage between Oprah Winfrey and me and was spilling her guts to the crowd of women in the audience. Drew, who was forty- eight at the time, admitted that lately she’d been feeling “dead inside.” She’d recently experienced her fi rst hot flash— on TV while interviewing Jennifer Aniston, no less. She knew she was perimenopausal— that period of time during which a woman transitions toward, but is not yet in, menopause— but still, her experience felt really bewildering. “I’ve heard different answers from different doctors,” she said. Things like: You’re not a candidate for hormone therapy if you’re still getting your period; Oh, just reduce your stress; or, The only thing I can o er you is an antidepressant. “I’m incredibly confused and I don’t know what I’m supposed to do,” she confessed.

Drew was sharing so openly because we, along with Maria Shriver and Dr. Sharon Malone, were taping a segment for Oprah’s “Life You Want” series on the topic of menopause. The majority of women in the audience were nodding their heads in recognition and some of them even silently wept. My heart broke in that moment, as it does whenever I hear similar stories from my patients, friends, and family, as well as the women who comment on my social media posts.

Drew Barrymore is just one of the millions of women between the

ages of thirty-five and fi fty (the average age range of women whose ovaries have begun the transition to menopause) whose health, life, and work are derailed by the symptoms caused by the decline of their sex hormones—which, despite their name, have a major impact throughout the body, not just the reproductive organs.

The result is that women grapple with all kinds of symptoms. Jane, for example, was a high-powered real estate lawyer in her early forties who’d recently become very anxious and couldn’t seem to sleep through the night. Her job was stressful, yes, but she’d never had trouble with anxiety. At age forty-seven, Lucy was having a hard time remembering things— constantly leaving the house without her purse; she was unable to easily recall words, and she forgot to send important emails. She worried, Could this be early- onset Alzheimer’s?, fearing the same thing that happened to her father might happen to her. Her primary care physician referred her to a neurologist, who told her she was fi ne, but still—why couldn’t she remember things? At age forty-six, Cherise began having incredibly heavy periods— so much so that she had to wear super-maxi tampons and period underwear and still sometimes bled through her pants. When she called her ob-gyn, he terrified her by suggesting she might have uterine cancer, saying she needed an ultrasound immediately. The test results were normal, and though her heavy bleeding continued, she never got a good answer as to why this was happening.

The reality: Jane, Lucy, and Cherise were all exhibiting symptoms of perimenopause. Yet because so many of these symptoms can seem completely disconnected to reproductive health, few women— or even clinicians for reasons I’ll go through in just a moment— make the link between those symptoms and ﬂuctuating hormones.

And here is the harsh reality: Too many women are left to wonder what in the world is going on with them, completely in the dark about the very normal changes their bodies go through in their late thirties, forties, and early fi fties, and feeling dismissed and unheard by their healthcare providers.

The Long Tentacles of Perimenopause

There’s something else too many of us don’t know about perimenopause: As we go through the menopausal transition, the very underpinnings of our long-term health can become more vulnerable, too. The decline in reproductive hormones has clear and important ramifications that aﬀect our gastrointestinal (GI) system, musculoskeletal system, pelvic ﬂoor, mental health, cardiovascular system, and even our brain.

With heart disease being the leading cause of death in women, women comprising two-thirds of all dementia patients, and more women experiencing osteoporotic bone fractures than cardiovascular events, strokes, and breast cancer combined,1 it’s vital for us to understand that the entire body feels the decline in hormones starting in perimenopause, and how we address these hormonal changes today will determine the trajectory of our health in the decades to come.

Perimenopause also impacts our work lives and pocketbooks as well as the economy at large. In 2023, researchers at the Mayo Clinic surveyed more than four thousand women who reported having moderate hormone-related symptoms. They found that 13 percent had experienced an adverse work outcome because of those symptoms, and 11 percent were missing days of work because of them. Collectively, the researchers calculated, this was costing the United States $1.8 billion in missed work and $26.6 billion in medical costs.2 And that’s just in women with average symptoms. A study by Dutch researchers found that of women whose symptoms were severe enough to get them to seek care at a clinic, 76 percent said their symptoms were impairing their ability to perform at work.3 And who could blame them? It’s tough to be your best when your sleep is impaired, your mood is all over the place, your joints ache, you have brain fog, and you have to run to the bathroom every hour or two to make sure you aren’t bleeding through your clothes.

It’s Time for Perimenopause to Have Its Moment

In the past few years, menopause has come out of the shadows. Coverage by the mainstream media has exploded and multiple books covering the topic— including my own fi rst book, Unlock Your Menopause Type — have led to thousands of women becoming more vocal about their experiences. This is great news!

The not-so-great news?

Perimenopause has not been part of this conversation— and it’s an entirely diﬀerent animal:

• In menopause, a woman’s hormone levels are low, but they are steady. In perimenopause, they ﬂuctuate wildly, spiking one week and bottoming out the next, making women confused about their cycles or, worse yet, not realizing that their symptoms are related to their hormones. This means that how I counsel women and treat symptoms of perimenopause is diﬀerent from how I treat a woman in menopause (and this is the reason I wanted to write a book devoted solely to perimenopause!).

• Menopause has a clear diagnostic criterion— one year without a period. Perimenopause is much trickier to pin down because a blood test captures hormone levels on only one day, when they are changing from week to week and month to month. The result?

Women are told, “Your blood levels are normal, so it can’t be your hormones,” which only gaslights them and reinforces the idea that their experiences aren’t valid. It also delays treatment, which then deprives women from feeling and functioning at their best through the transition, which can last as long as ten years. (Ten! Years!)

• Women are starting to acknowledge and talk openly about menopause. But perimenopause is barely part of the conversation— among women themselves or with doctors who are caring for female patients in this age group. As a result, too often women

are blindsided when their hormones start to shift. According to research published in the journal Menopause, 59 percent of women didn’t think it was possible to experience any hormone-related symptoms until age fi fty.4 Yet I see women in their late thirties in my practice regularly. The same study also found that when women experience symptoms earlier than they expected, they have a higher likelihood of holding a negative view of their overall health than women whose perimenopausal symptoms showed up “on time.”

The takeaway? The more women understand what can happen to them in their late thirties and forties, the better they’re likely to feel.

Why I Wrote This Book

My goal for this book is not only to demystify your symptoms, but also to explain how to treat them and why doing so is important to your health today and over the long term. Just as importantly— if not even more so— I want you to fi nally feel seen and get answers from a woman who is not just an experienced and credentialed clinician, but who is also in the middle of her own hormonal transition. Believe me, I know what you’re going through.

When I started wanting to throw out all my kids’ toys because I couldn’t stand the mess one second longer and began getting really irritable for about a week out of every month, I didn’t think all that much of it— just a bad case of PMS, right? Then I started experiencing the occasional hot ﬂash, but I thought I must have forgotten to turn the heat down before bed, or I was just doing too much that day and was having a hard time settling down. And because I had an IUD and I had only very light bleeding, it took me awhile to put together that my irritability and the hot ﬂashes I was denying were related to perimenopause.

You’d think that as a woman who has spent the past decade treating women going through hormonal transition, I’d have a clue. Well, I

didn’t. So, when I fi nally pieced it together, it only drove home the fact that most women don’t see perimenopause coming.

As bewildering as perimenopause can be, there is hope.

When you get the information you need to help you understand how this major hormonal shift is impacting you, you’ll be empowered to make choices that both relieve your symptoms and shore up your health. You’ll also be better able to advocate for yourself with your doctors to get one of the many evidence-based treatments that suits your unique symptom set, health history, and priorities. You’ll be fully equipped to navigate this yearslong transition so you no longer feel dead inside or wonder if you are losing your mind, but instead can feel like yourself again.

And you’ll be helping to fi ll the gaping hole in our collective knowledge about perimenopause, which will benefit not only you, but also your friends, sisters, doctor, and everyone who will make their way through this transition with you and after you.

And frankly, it’s far too unlikely that you’ll be able to easily fi nd a doctor who can help guide you through this transition (although I cover how to fi nd one who is knowledgeable in “Appendix B: Resources” at the back of the book).

Why? The vast majority of doctors— even ob-gyns— receive very little training in menopause and perimenopause. A survey of medical residents in the fields of internal medicine, family medicine, and obstetrics and gynecology conducted by the Mayo Clinic found that 20 percent of residents had received no lectures during their training on menopause, and only 6.8 percent felt confident that they had received enough training to help women through the menopausal transition.5

Do these stats make you angry? They make me crazy. This lack of education for medical professionals about a perfectly natural yet disruptive transition that happens to half the population is absurd.

I decided to specialize in women’s hormonal transitions when I was a fellow at the Cleveland Clinic and realized that the education about women’s health basically ended with pregnancy and childbirth. It’s not even that perimenopause and menopause were overlooked— they were

completely missing from medical school training. They simply weren’t considered important enough to be covered in medical textbooks.

A direct result of this massive gap in our doctors’ education is that the average appointment wait list for menopausal medicine doctors is out seven months. On top of that, according to the experiences of the thousands of women I’ve treated in the past decade, many perimenopausal women see five to six diﬀerent doctors before getting to the hormonal root of their issues. No wonder my posts on social media get blown up with comments and DMs every day with questions and pleas for help. They are seeking help wherever they can get it and they are hungry for information. Gen X and the older millennials are on the front lines of perimenopause, and they are not taking it lying down!

I am on a mission to do everything I can to get the information, validation, and guidance on perimenopause that women so desperately need into their hands. In fact, I have devoted my entire medical career to studying and treating women’s midlife hormonal transitions. As a certified and experienced menopausal medicine doctor, I want to bridge the information gap with clear evidence- and experience-based guidance that both women and doctors can utilize.

That’s why I wrote The Perimenopause Survival Guide — to help you develop a plan to address your symptoms and protect your long-term health that combines medical treatments— prescriptions, labs, and perhaps even procedures where appropriate—with at-home strategies— dietary changes, supplements, stress reduction tools, exercises, and lifestyle adjustments. Perimenopause is not “menopause light,” and it deserves its own road map.

How to Use This Book

The Perimenopause Survival Guide has three distinct parts that correlate to three vital steps for caring for yourself along your perimenopause journey.

Part I, “Understand the Hormonal Hijacking,” provides the background

information that will help you understand what you’re experiencing. Starting with a chapter that explains how the hormones that are waning influence much more than your reproductive organs, you’ll learn what each hormone does, how they work throughout the body, and why they have such a huge influence on physical and mental health. I also outline the thirty-four— and counting!— symptoms of perimenopause, so you can start to piece together how your particular hormonal shift may be affecting you in ways you didn’t even realize, as many symptoms are surprising. For example, many women don’t know that perimenopause can connect the dots between their back pain, their low mood, and their newly sprouted chin hairs.

In chapter 2, I explore and bust the many widespread, hard-to-kill myths and misconceptions about perimenopause: Aren’t I too young to be experiencing symptoms? Does a skipped period mean I’m pregnant? Is hormone therapy really safe? And many more. Then in the fi nal chapter of part I, I walk you through the exact same process I take each of my patients through. When I meet my patients, I want to develop a complete picture of how perimenopause is aﬀecting them, and to prioritize which set of symptoms they want to treat fi rst— and the questions in this chapter will help you do the same thing for yourself.

Part II, “Pinpoint Your Perimenopausal Symptom Set,” guides you on how to treat the group of symptoms you have identified as your top priority, outlining all treatments and tactics that have a track record of being eﬀective at reducing symptoms and bolstering overall health. Some of these will require a prescription. After all, I’m an MD. I want to introduce you to and demystify the many FDA-approved medications that can help treat your symptoms— including hormone therapy, although there are more and more nonhormonal treatment options every year that too many women are still unaware of. I’ll also cover the many lifestyle strategies that research and my clinical experience have shown to work. You have many options available to you. Learning what they are will help you engage in shared decision-making with your clinician to personalize your treatment plan.

Then, part III, “Set Yourself Up for Smooth Menopause Sailing,” helps you set the stage for an easier menopause journey and also for your best health in the second half of your life. First, I’ll help you target some of the stranger symptoms of perimenopause that can start now and linger well into menopause, such as ringing ears and itchy skin. Then I’ll oﬀer advice and strategies for how you can confidently take the journey from perimenopause through menopause and recalibrate your lifestyle and habits to accommodate your new self as a woman in her post-reproductive years.

Finally, I’ll answer the questions I’m asked most frequently, such as “How does perimenopause aﬀect fertility?” and “When should I talk to my doctor about perimenopause?” and provide a detailed list of further resources, such as vetted apps, books, and websites that can help you understand— and manage—your symptoms.

You’ll likely notice that many symptom sets have the same or similar treatments, so as you read through you’ll notice some familiar advice. While I defi nitely don’t want to sound like a broken record, I do want you to have easy access to everything that might help you manage your symptoms without having to ﬂ ip back and forth through the book. I’ve attempted to include cross-references to other locations in the book where you can fi nd more information about whatever you’re facing.

The Perimenopause Survival Guide is designed to help you understand what’s happening with your body, fi nd and make shared decisions with a knowledgeable clinician about possible treatments, and know what you can do on your own—like taking supplements, implementing dietary strategies, and making lifestyle changes— that have a proven, scientifically tested track record of being helpful, as well as what you should avoid.

Please let these words sink in: You don’t have to suﬀer through your bothersome symptoms and just resign yourself to a life of not feeling all that great. My ultimate aim is for you to be able to walk away from reading this book with a plan that is going to address your symptoms, improve your quality of life, and help you feel educated, confident, and unstoppable in your journey to a healthy second half of life.

PART I UNDERSTAND THE HORMONAL HIJACKING

CHAPTER 1 Can It Really Be My Hormones?

Jessica was on her fi rst Zoom call with me for an initial perimenopausal medicine consultation. When I asked her how she’d been feeling, she started listing several seemingly unrelated symptoms: Most noticeably, her periods were all over the place— her cycles had started coming more like twenty- one days apart instead of her typical twenty- eight, but now it had been almost seven weeks since her last period. She’d taken three pregnancy tests, but they’d all come back negative, although she felt bloated and her breasts were so sore that she had trouble believing she wasn’t pregnant. I asked if she’d noticed anything else, and she said she’d been feeling more anxious than usual, even though nothing in her life had really changed (except for her periods). The anxiety was making it hard for her to fall asleep at night, and the next day she was irritable, snapping at her partner because she was tired. Sometimes it even felt like her heart was beating too fast and she struggled to catch her breath. Plus, her back was stiﬀ in the mornings, but she hadn’t done anything to strain it. “I don’t see how these could all be related, but they are all what I’m experiencing,” she told me. “I don’t know what’s going on with me— it’s like I’m falling apart!”

Jessica then told me how she had already seen her general practitioner, who referred her to a therapist for her anxiety (who told her to take a vacation); a cardiologist for her heart palpitations (who said

her heart was fi ne); and an orthopedist for her joint pain (who told her to go to physical therapy). Finally, her older sister pointed out that all her various symptoms could be hormone-related. Yet when Jessica raised the idea with her general practitioner, he suggested these symptoms couldn’t possibly be hormone-related because Jessica was still having her period. That’s how she wound up seeing me for a consultation.

The number of times I hear some variation on this story makes my life seem like the movie Groundhog Day. Even though every person who was born with ovaries— a full half of the worldwide population—will experience perimenopause, it’s like the transitional period is a secret, but one that is hiding in plain sight.

So Much More Than “Reproductive” Hormones

Why is it the case that so many women and their doctors don’t think of perimenopause as a possible cause of the many symptoms that can begin to appear when a woman’s hormone levels start to ﬂuctuate?

Part of the reason lies in the lack of clinical education and training, but another part is that we think of estrogen and progesterone as merely “reproductive” hormones that primarily play a role in the menstrual cycle and pregnancy. It’s minimizing at best, and harmful at worst, to think of these biochemical messengers in this limited way, because they have wide-ranging impacts throughout the entire body. In fact, we have receptors for these hormones from head to toe— and I will take you on a tour through the body to point out the multiple ways estrogen impacts whole-body health in just a moment.

So, if your perimenopause presents as low back pain, brain fog, and anxiety, you might just think you’re stressed. Or that it’s generic aging. A lot of patients tell me that they assumed they were coming down with the ﬂu, or dealing with long COVID, because they were running warm, sweating at night, and feeling tired. All of these thoughts can cause

you to either: (a) ignore your symptoms and wait for them to pass; or (b) schedule an appointment with your primary care doc, who is also unlikely to connect them to your ﬂuctuating hormones (because of the woeful lack of education they’ve received about perimenopause). Either way, you don’t get relief. However, by reading this book you’ll gain the knowledge necessary to empower yourself to correct any health impacts before they become long-lasting.

Too many of us still think that our hormones stay steady until our periods have stopped and we are fi nally in menopause. This is simply not true. In perimenopause, these hormones are all over the place— spiking one week, bottoming out the next (particularly estrogen). All the tissues and organs that have receptors for those hormones prefer a steady supply, whether it’s high or low, and they can handle the normal monthly ebbs and ﬂows that occur for most of your reproductive years. But when your levels become more erratic and unpredictable, confusion is sown at the cellular level— and your body’s response to that confusion can be equally bewildering. Since so many doctors don’t recognize the symptoms of perimenopause, however, you may be feeling as if your own physician is gaslighting you when they tell you your symptoms can’t be hormonally based since you are still getting your period. Or that these things just happen as women get older and you just have to live with it. Or that there is nothing medically wrong with you, so perhaps you should “try getting more sleep or go on a vacation.”

Perimenopause is also tricky because it’s a clinical diagnosis, one that is oﬃcially made by a well-trained clinician who can see the pattern within your seemingly random and unrelated symptoms. Just as there is no lab test to confi rm depression, there is no lab test to 100 percent confi rm that you are, or are not, in perimenopause. In many ways, menopause is less confusing because it’s clear whether or not you’re in it— no one can deny that you haven’t had a period in at least a year.

If you’ve had a doctor order lab tests to measure your hormone levels

and then given you a diagnosis based on those results, that diagnosis is likely to be false (we’ll unpack why in chapter 2).

For example, when my patient Katie came to see me, she had low libido and fatigue along with night sweats and had not had a period in six months. Because her last menstrual period was less than twelve months ago, she and I discussed how she was still perimenopausal, and could still get pregnant. (Perimenopause is a big reason for a lot of unplanned and unexpected pregnancies.) The next month, when she went to see her gynecologist for her annual appointment, he ordered labs to measure her levels of follicle-stimulating hormone (FSH— a hormone that tends to rise and stay elevated as a woman moves into menopause). Her FSH on that particular day was in the menopausal range, so the nurse called to let her know she was “oﬃcially in menopause.” The nurse made a crucial mistake in relying on just the FSH level without asking Katie about her last menstrual period (LMP). Not only was Katie left to wonder what exactly was going on with her body, but she could have also experienced an unplanned pregnancy, thinking her fertile days were behind her. Luckily, she had a menopause- certified doctor to clear up the confusion, but too many women don’t (yet).

There’s also been a systemic problem that has kept perimenopause, and menopause, for that matter, understudied: Women of reproductive age were barred from being included in clinical trials for the fi rst several decades of pharmaceutical research. The reasoning for this? The volatility of their hormones was a confounding factor, and the risk of experimenting on a woman who might be pregnant was too great to take.

The shocking truth is that women weren’t even allowed to participate in pharmaceutical research that was funded by the National Institutes of Health (NIH) until 1986, and even after that mandate, many researchers didn’t get the message. It wasn’t until 1993 that Congress passed a federal law requiring researchers to include women and minorities in their studies. Still, this law only pertains to research that is funded by the NIH— many studies don’t use government funding and

are still performed primarily on men and assumptions are made that women and people of different races would experience the same or similar results. As a consequence, we have lost out on decades of research into how a wide number of medications affect women differently than men, as well as how they affect women of different races differently than white women. This list of medications includes blood pressure medications, diabetes medications, and hormone therapy, which has been understudied since 2002, when the Women’s Health Initiative— a large controlled study that was designed to evaluate hormone therapy’s impacts on risk of disease—was ended prematurely for reasons I’ll delve into in chapter 2.

The tide is turning however. In 2023, the Biden administration launched the White House Initiative on Women’s Health Research in order to “galvaniz[e] the Federal government and the private and philanthropic sectors to spur innovation, unleash transformative investment to close research gaps, and improve women’s health.”1 In order to fi x a problem, you have to fi rst acknowledge that there is a problem. But still, the net result of our missing decades of research is that the medical community is still majorly uninformed about the unique health realities of women. Furthermore, since the WHI was stopped in 2002— an event that resulted in hormone therapy being deemed unsafe (a myth we will completely overturn in chapter 2)— decades of clinicians missed out on learning how to counsel and treat women in perimenopause and menopause with hormone therapy.

There are certain aspects of women’s health that have gotten the spotlight treatment. Breast cancer, for instance. Because one in eight women will get breast cancer, we are all prescribed a yearly mammogram to promote early detection. In contrast, every single woman— one in one—will at some point experience perimenopause if they live long enough, yet very few doctors will even raise it as a possibility when female patients in their thirties and forties come in questioning the very real symptoms they are experiencing.2 As a result, perimenopausal women are likely to be oﬀered an antidepressant or a sleep medication and told to take better

care of ourselves, sending the message that our symptoms are somehow our fault.

The reality is, if you were born with ovaries, your hormones will go through a major change that can disrupt your daily life and multiple aspects of your short- and long-term health. And that, my friend, is not your fault.

That means it’s up to each of us to educate ourselves on what’s happening with our bodies and lead the way in demanding better care to help ourselves feel better.

The Differences Between Perimenopause, Menopause, and Post-menopause

Perimenopause is the phase during which you are transitioning toward, but are not yet in, menopause. It can last between one and ten years, which is another reason you don’t want to wait for your symptoms to go away on their own—you’ll be waiting too long! Once they learn the many symptoms of perimenopause, many of my patients can look back and see that their symptoms started years ago— they just didn’t connect what they were experiencing to their hormones.

While your hormone levels are declining over time, from week to week and month to month they are spiking and then bottoming out. This variability and volatility can make perimenopause the most bothersome stage in this yearslong transformation all women go through. It is also the reason why the treatments for perimenopause and menopause aren’t the same— for example, in perimenopause you may only need to increase estrogen the week before you get your period when it is naturally at its lowest point, while in menopause you might need it all the time because there are no more monthly ﬂuctuations.

There are two phases to perimenopause: early, and late. I spell out the diﬀerences in these phases in the chart on page 10, but in general, early perimenopause is characterized by more frequent and heavier periods

due to the lowering of progesterone, and late perimenopause by cycles that become less frequent and symptoms such as hot ﬂashes and night sweats due to the bottoming out of estrogen.

It’s important to note that not all women will experience these changes in their cycles, especially if they’ve had a hysterectomy or an ablation, or if they use birth control pills or have a progesterone-releasing IUD— in these instances, you may not get a period at all. That makes it even more important to pay attention to your individual symptoms, as they are your best guide for determining which phase of perimenopause you’re in, and by identifying them, you can determine the best course of action to get some relief from them.

The menopause transition is when you have gone between nine and twelve months since your last period. The end of your cycles is near, although you can certainly still get a period— and still get pregnant (unlikely, but still possible).

Menopause, oﬃcially, is the one-year anniversary of your last period. It also marks the end of your fertility window.

Get yourself a cake and celebrate the end of your monthly bleeding! By the time you have been without a period for a year, your hormones are low, but they are stable.

Post- menopause, as its name suggests, is everything that comes after menopause, meaning you are post-menopausal the day after you celebrate menopause. Even if it’s been thirty years since your menopause birthday and your symptoms are long gone, you are always and forever post-menopausal. With our longer lifespans, women can now expect to spend at least 30 percent of their life in their post-menopause years.

This phase is also divided up into early and late phases. Early postmenopause is the fi rst two years after menopause— symptoms are more likely to be noticeable during this time. Once you’ve gone two years with no period, you are in late post-menopause, and theoretically— although it’s not guaranteed—your hot ﬂashes and night sweats may have eased. (Although some women do experience them for a decade or more.)

Stage Primary Symptoms Hormonal Hallmarks Duration

Early perimenopause

Cycles start changing— typically become shorter

Periods may start getting heavier, with more clots

Mood changes (feeling down or anxious)

Difﬁculty sleeping through the night, insomnia

Irritability and rage

Changes in memory and concentration

Progesterone is falling

Estrogen is volatile

Follicle-stimulating hormone (FSH) levels are less than 35 mIU/mL

Late perimenopause

Menopause transition

Longer cycles (every forty-ﬁ ve days, three months, or even going as long as ten or eleven months with no period, only to get it and have to start the menopause clock all over again)

Hot ﬂashes

Night sweats

Brain fog

Vaginal dryness

More impaired sleep— waking up in the middle of the night hot or cold

Going nine to twelve months with no period. Only once you have been a full calendar year with no period, are you technically “in menopause”

Progesterone is low

Estrogen is low

FSH levels are rising

Variable

Menopause

Postmenopause, early

Postmenopause, late

The day that it has been one year since your last period— unless you don’t get periods (for reasons like birth control or an ablation). Then, you might not know what that ofﬁcial day is and your doctor will look to your FSH levels to determine if you are in menopause or not

No periods in the last twenty-four months

Has been more than two years since your last period

Progesterone is low

Estrogen is low

FSH levels are around 35 mIU/mL or above (and they will remain elevated from here on out)

Progesterone is low

Estrogen is low

FSH levels are around 35 mIU/mL or above (and they will remain elevated from here on out)

Progesterone is low

Estrogen is low

FSH at 35 mIU/mL or higher

Progesterone is low

Estrogen is low

FSH at 35 mIU/mL or higher

Variable

Three months

One day

Two years

Until end of life