What Your Doctor isn’t telling you about perimenopause (but you really need to know)

What is Perimenopause?

Perimenopause is a neuroendocrine transition that can span years—and every woman who lives long enough will experience it. And yet, many doctors and practitioners aren't proactively screening patients for it, let alone talking to them about what to expect or how to manage their symptoms.

Because let's be real: perimenopause symptoms are taking women out every damn day. And every damn day, women are walking into doctors' offices only to hear BS like, "Your labs are normal," "We can't test your hormones," or my personal favorite: "Perimenopause is a fad." (Yes, that was said to an actual patient.)

I wish I made this stuff up.

Perimenopause isn't simply a time when your hormones "get low." It's a time of significant hormonal change, fluctuation, and eventual decline. Progesterone often begins changing as ovulation becomes less consistent, while androgens generally decline more gradually across adulthood. Estrogen? She's the twisted sister of the group—fluctuating dramatically up, down, and sideways throughout the transition.

You Don’t Need Hot Flashes To Be In Perimenopause

I talk to so many women saying “I’m not sure if I’m in perimenopause” and I know within six minutes of talking to them that they 100% are without a doubt. Why are women so uncertain? No one is educating them, and most women think no hot flashes = no perimenopause.

This couldn’t be further from the truth. In fact, the first several symptoms of perimenopause for women include the following:

“I don’t feel like myself anymore”, sleep disturbances/insomnia and new onset or worsened anxiety.

And symptoms can get as weird as burning mouth, phantom smells and itchy ears! WILD RIGHT!?!

So, periods are still regular. No not flashes. But a woman is itching her ears while wide awake every night at 3:07am wondering why she can’t sleep and her ears itch. MAAM. Congrats. You’re in perimenopause.

Can We Test Your Hormones in Perimenopause? Yes. Do Your Labs Diagnose Perimenopause? Not Necessarily.

Can You Test Hormones In Perimenopause (and why “normal” labs aren’t the whole story!)

One of the questions I hear constantly is, "How do I test my hormones?"—usually followed by, "My doctor told me you can't test hormones in perimenopause."

Let's clear this shit up.

Yes, we can test your hormones. But no, one set of hormone labs is not the holy grail of diagnosing perimenopause.

Hormones fluctuate—sometimes dramatically—throughout your menstrual cycle and throughout perimenopause itself. That means a perfectly "normal" estradiol or FSH result on one random Tuesday does not magically prove that your symptoms aren't related to the menopausal transition.

This is why I look at the entire picture: your age, menstrual cycle patterns, symptoms, health history, labs when they're clinically useful, and—if you're using HRT—how you're actually responding to treatment.

Labs are one piece of the puzzle. They are not the whole damn puzzle.

It is important to make sure you test your hormones at the correct time in your cycle. Cycle day (CD) 3-5 and 5-7 days post ovulation (DPO). CD 3-5 testing should include FSH, LH + estradiol. 5-7 DPO should include progesterone and estradiol (this is also typically when I test androgens as well).

I know more than one of you is screaming going WHAT ABOUT IRREGULAR CYCLES OR I DON’T HAVE A UTERUS.

We can still test. And accurately. While this isn’t the point of this article know that if you utilize temperature tracking + at home testing devices like Mira or Inito or even simple LH strips we can definitely get you accurate labs.

The other thing women come to me with is saying “my doctor said my labs are normal” and while there are hints at perimenopause on labs (slightly climbing estradiol and/or FSH on CD 3-5), lower progesterone, lower estrogen and testosterone etc. “Normal labs” don’t mean you aren’t in perimenopause. Complete BS.

What About Hormone Replacement Therapy (HRT)? Why Birth Control Isn’t The Same as Bioidentical Hormone Replacement.

When it comes to HRT (don’t worry there will be a whole series on HRT and tons of info in the rest of this series) I see a lot of doctors saying “just stay on your IUD or oral contraceptives. NEITHER of these options are actual hormone replacement therapy. Now, if you are looking for contraception options they work for that— but in no way shape or form are any of the synthetic chemicals in birth control hormone replacement therapy.

Lots of doctors sell the “convenience” of IUD’s in perimenopause and “just get to 50 with it”. This is not my personal approach to HRT with women. This could be hours long of a conversation. But a few important things you need to walk away knowing/understanding:

The PROGESTIN in your IUD is not the same as PROGESTERONE which is what your body makes.

Estrogen-containing birth control carries a different risk profile than menopausal hormone therapy, and those risks become increasingly important to consider as women age—particularly in the presence of smoking, migraine with aura, hypertension, or other cardiovascular and clotting risk factors.

You can utilize a progestin IUD and also utilize bioidentical progesterone.

The big picture: perimenopause is not a cute fad word. It’s a real biological process that can really put women through the ringer if they aren’t asking the right questions and working with the right practitioner.

So, What the hell are you supposed to do?

Stay tuned to check in with Part II of The Perimenopause Playbook: 7 Signs of Perimenopause That Have Nothing to Do With Your Period (and what you can do for them!!)

If this article made you go “I WANT TO WORK WITH HER”. I get it— as in why you want to work with me and also perimenopause care— I get that, too! Schedule a Consultation or if you’re ready to dive right in book your Hormone Strategy Session!