What is Perimenopause?

What is perimenopause? Why is it so confusing? And why is there so much misinformation about it?

These are all questions I think really need to be answered. And, we are going to get to what perimenopause is. But let’s start with why so many of us don’t know much about it.

In this article, we’ll talk about…

Why is perimenopause so confusing?
Why don’t our practitioners know much about perimenopause? And misinformation.
What is perimenopause?
What is menopause?
What is postmenopause?
Symptoms of perimenopause?
Why are there so many symptoms of perimenopause?
Review of why there is so much confusion.
What we can do to feel like ourselves again?

Why is Perimenopause so Confusing?

Perimenopause can be a very confusing time of life for women. It often comes with an incredibly long list of symptoms that are not only perplexing. But also very uncomfortable. AND… often these symptoms are normalized by our practitioners, or even our culture.

The testing around perimenopause is inconsistent.  Some practitioners don’t test at all. Some practitioners do test, but not always at the correct time. Often the most accessible testing options are not always reliable. And the most accurate testing that I prefer like the DUTCH test, Cortisol testing, and looking at FSH are not commonly looked at by most practitioners and may not be covered by insurance (or the sick care model).

This can make things even more confounding. I can’t tell you how many women have said to me “I had my hormone levels checked and they are all normal.” Yet, their symptoms and intuition say otherwise.

There is also a ton of misinformation around perimenopause. What is safe, what helps, what doesn’t help. And there can be a fair amount of straight up medical gas lighting around it too.

And maybe the biggest issue of all, is that oftentimes our doctors or practitioners don’t know much at all about it. Their knowledge is based on fear. They give very confusing, and conflicting advice around it. Or are just flat out unsupportive.

The good news is, perimenopause is getting a moment. But this doesn’t really mean that the misinformation and confusion around perimenopause has gone away. It still exists and in spades unfortunately. 

Let’s touch on why there is so much confusion.

Why don’t our practitioners know much about perimenopause?

• For decades, most studies were done only on men.
  And women’s bodies were not studied at all. In part because of male dominance in the medical field. In part because in 1977 the FDA put a ban on studying women that were pregnant, single, those using contraception, or those whose husbands had vasectomies. 
  
  Finally in the late ’80’s clinical studies started being done on women. But it wasn’t until 1993 that the FDA reversed the 1977 ban, and the inclusion of women in clinical studies became law in the US. But still to this day, women are not studied nearly as much. So when it comes to health information around women, especially midlife women, we are still really lacking. 
  
  
• Perimenopause and menopause education are barely touched on in medical school.
  Which means our practitioners are vastly undereducated around this stage of life. Even OB/GYN’s are lucky to have an hour of study on perimenopause and menopause. Yes, one hour! Additionally, what they have learned is often outdated information or misinformation based on the ‘91 WHI debunked study (see more on this below).
  
  
• There have been very few clinical studies around perimenopause and menopause.
  And the studies that have been done, have often been sub-optimal studies. The studies looked at the wrong age groups, used synthetic hormones, had people with pre-existing conditions, the subjects were much older than should have been included in the study, and in many cases people were self-reporting the findings.
  
  
• One of the most “well known” studies called the Women’s Health Initiative was horribly done, and horribly interpreted.
  Unfortunately this horribly interpreted study set the “standard” of care for women’s HRT for decades. This study was done in ‘91, and in 2002 the FDA added a black box warning to all hormone replacement therapy because of the misinterpretations of this extremely flawed study.
  
  This study used synthetic hormones (not bioidentical), tested a group of women primarily in the 62-79 range (10-20 years post menopause). These women had pre-existing conditions like heart disease, bone loss, insulin resistance, prediabetes, and diabetes. And some were even smokers. The study was vastly misinterpreted by the press. And those findings then bulldozed their way into the medical community. The claims were that HRT caused breast cancer, strokes, and created a greater risk of cardiac disease.
  
  The truth of the study was that a very very small group of women in this study that had a rise in breast cancer. Some were more susceptible to stroke. But these women had not used hormone replacement prior (it’s currently recommended to use hormone replacement within 10 years of menopause- most were beyond this stage), had disease state preexisting conditions, and were using synthetic hormones (not bioidentical hormones). This was a junk study that set the stage for 25 years of misinformation.
  
  This study has since been debunked and redacted. And yet, many practitioners still to this day base their perimenopause, menopause and postmenopause knowledge and standard of care on this study. Essentially the care has been based on fear and misinformation.
  
  What the data actually shows, is that Bioidentical Hormone Therapy is safe (for most women) and protective of the most common women’s health issues today. HRT improves women’s lives. It can prevent cancer, cardiac disease and osteoporosis.
  
  
• The care of perimenopause has been based on fear.
  Because of the WHI study in the last point, perimenopause care has been based on fear, because of course practitioners don’t want to hurt clients. But also… the WHI effect truly left practitioners without tools, a ton of fear, and the inability to support women and no where to learn.
  
  However, just this week 11/10/25, the FDA removed the Black Box Label on Women’s Hormone Replacement Therapy, and admitted to the harm and fear that it has caused millions of women over the last 25 years. This is hopeful. 
  
  
• Midlife women are not often seen nor heard in our culture.
  Need I say more? This is really a whole blog post in itself, but it is really accurate, and frustrating too. I think we are starting to turn the corner on this being that Perimenopause is having a moment. So my fingers are crossed. 

Are Midlife Women Seen and Heard?

So, if midlife women are not seen nor heard.  And haven’t been studied. Or the studies that have been done are completely sub-optimal, or like the WHI completely inaccurate! That leaves us with very little information on perimenopause and menopause. Practitioners that are either vastly undereducated or miseducated. And ultimately practitioners that are not able to support us well.

I’m not trying to throw all of our practitioners under the bus, as I know there are good ones… I now have a good one. And… I know, they are much much harder to find. 

I had to do a lot of research, and really dig to find someone supportive that listened, addressed my concerns, and supported my hormone replacement in a way that would support my brain, bone and cardiac health.

I also did two mentorships so I could understand how to support myself in perimenopause and beyond. Which is why this became a big part of my practice. 

Without that research though, I wouldn’t have known! And I see women every day that are vastly under-supported with this transition. 

You may even think you are getting decent support, but still feel terrible! 

This happened to me! 

I went to a highly recommended practitioner in my area. She didn’t test my hormones. She did listen to me talk about how I felt. But she didn’t help support my biggest issues and symptoms. One of my most embarrassing issues was a leaky bladder (which so many of us deal with and it’s so humiliating!). I talked to her about it for 1 1/2 years and she never addressed it. 

When I asked her questions, she would shame me for the questions I was asking. I went to multiple appointments where this happened. And every time, she shamed me. 

I am a big thinker…and I wanted to explore and understand, and EVERY TIME, she shamed me for it. That felt horrible! 

When I sat down to write this article, I really wondered to myself why I stayed with this practitioner as long as I did, especially when she was shaming me.

Here’s why…

• She came highly recommended. 
• I felt insecure with where I was at, and confused about what was happening in my body.
• I was worried I wouldn’t find someone else to support me with my HRT, as I know how hard it can be to find a practitioner. 
• I was having a hard time finding a practitioner I could get in to. 
• I thought I needed all of this care to be covered by my insurance. 
• I was in the middle of a divorce and my sense of self had been shattered. 

I stayed too long, even though I didn’t feel like an equal partner in my care.

Sometimes we do this. We stay with a practitioner, even though it’s not the right fit, because we think it is all we have. However, I strongly believe we should ALWAYS feel like we have an equal partner in our healthcare. 

What is Perimenopause?

Perimenopause is a time period in a woman’s life when our hormones are in their most rapid decline. And essentially our reproductive years are winding down. It can last anywhere from 4-10 years. Some women are very symptomatic, and others are less so. 

Perimenopause generally starts in our mid 40’s and continues until hitting menopause.

Estrogen and progesterone lower fairly rapidly during this time period. Testosterone may lower as well, but usually at a much slower rate than estrogen and progesterone. Ultimately estrogen and progesterone lower to the point of being at their bare minimums.

This time of hormone deficiency is often called estrogen dominance. However, this term has really been misused. Yes, estrogen may be higher and out of balance from progesterone. But the symptoms that typically show up are not because we have too much estrogen, but because we have too little estrogen and progesterone. And their usual ratios are off. This contributes greatly to the misinformation around the perimenopause stage of life. 

So let’s do the math… perimenopause starts typically in the mid 40’s, and can last 4-10 years. And most women hit Menopause on average at age 51. However, It can happen earlier, or later.

Here is a little time line showing these ages and terms:

PREmenopause / also known as Reproductive Years – Teens- Early 40’s – (I think this term is super confusing!)
Perimenopause – Mid to late 40’s – Early 50’s
Menopause – Average age 51 in the US
Postmenopause – Average age 51 – Rest of Life  

To know Perimenopause is to know Menopause.

Menopause occurs after the cessation of cycles for 1 year. And in medical terms, it’s only 1 day. I know, it’s a little mind blowing, but yep, it’s true, it’s one day.

Let’s break that out into a time table for ease:

Perimenopause – is anywhere from 4-10 years.
Yes, this is 4-10 YEARS of feeling weird, funky and not ourselves. (I know, I know)

Menopause – is 1 day, after a year of not cycling. So technically it’s day 366.

Postmenopause – is day 367 and beyond. To clarify further, one year of no-cycles, plus a day for menopause, and then we are post menopause the rest of our lives.

The average woman in the US goes through menopause at age 51. However, not everyone goes through it at that time, and it can be earlier than 51.

There are different terms for when menopause happens earlier. 

Premature Menopause – is prior to age 40
Early Menopause – is prior to age age 45
Menopause – is on average age 51

Symptoms of Perimenopause

The decline in hormones puts us in a state of Hormone Deficiency. We are deficient in the hormones we once had. This can cause a huge list of symptoms, because the decline is hard on every cell in the body. Think of our hormones as protections for our cells and organs. When we no longer have those protections, this is when the symptoms get louder. 

Let’s take a look at the perimenopause symptoms that rise up, as symptoms lower. 

Symptoms:

• Breast tenderness
• Irregular cycles
• Painful cycles
• Sleep disruption
• Insomnia
• Fatigue
• Bloating
• Constipation
• Diarrhea
• Cramps
• Spotting
• Night sweats
• Brain fog
• Impaired memory
• Anxiety
• Depression
• Headaches
• Migraines
• Short cycles
• Long cycles
• No cycles
• Missed ovulation
• No ovulation
• PMS
• Belly fat
• Hard to lose weight
• Insulin resistance
• Changing body shape
• Low sex drive
• Painful sex
• Vaginal dryness
• UTI’s
• Urinary urgency
• Urinary frequency
• Urinary leakage
• Bacterial vaginosis
• Hair loss
• Joint pain
• Muscle pain
• Back pain
• Frozen shoulder
• Cracked or broken teeth
• Acne
• Melasma
• Histamine intolerance
• Tinnitus

This is an incredibly long list of symptoms. No wonder perimenopause is so confusing! 

So why are so many things going haywire at this time? 

And why are we experiencing so many symptoms?

And why do I not feel like myself?

Let’s dig into this further…

Why are there so many symptoms that come with perimenopause?

Our hormones touch every cell and every tissue in the body. 

Think of it like this. When we are moving through the perimenopause stage (and beyond), our body is starved for the hormones it once had. It doesn’t function the same because the hormones are not there to support the usual functions of the body. 

This is all due to loss of estrogen, progesterone and maybe even testosterone. Since estrogen touches every cell and functions in the body when our hormone levels drop to deficient states, it’s like there is no gas in the tank. 

And really frankly, we can feel like shit.

Because there is so little education around this time of life, it also can be a really big shock to the system. It can be a lot like hitting a brick wall without warning. Which then causes a lot of confusion!

I hear things like this all the time:

• No one told me! 
• What the fuck is happening?!
• Why do I feel so terrible?!
• What is going on with my periods?
• OMG this is humiliating?
• Why am I gaining so much weight?
• Where did my memory go?
• Why can’t I think straight?
• Why can’t I sleep?

Because also, let’s face it, a lot of these symptoms are no walk in the park. And, they can really be embarrassing too! 

Can you imagine if this happened to men? They hit a certain age and lost all of their hormones? (men do have all the same hormones we do, just in different ratios) 

Our medical system would look so different if it did! 

Research shows that when we get to our 6th decade of life as women, chronic conditions are much more prevalent and our health begins to degrade. This is in large part due to the lack of hormones that previously protected our health previously. Estrogen is protective, and actually helps to prevent inflammation in our bodies. 

Without hormones we are much more susceptible for these disease states. 

• Cardiac health issues
• Cancer
• Dementia
• Bone health issues like Osteoporosis and Osteopenia
• Urinary Tract health issues
• High cholesterol
• Insulin Resistance / Metabolic disorders which have to do with:
  • High blood pressure 
  • Weight gain
  • Struggle to balance blood sugar
  • Prediabetes
  • Type 2 diabetes

Let’s review why there is so much confusion.

• Ban on studying women.
• Very few studies still to this day on women.
• Very little education around perimenopause, menopause and postmenopause
• The deeply flawed, and misinterpreted WHI study that led to a halt on HRT.
• Deep fear around supporting women in Perimenopause.
• A medical system that hasn’t properly educated practitioners about how to support women in Perimenopause.
• Misinformation on what happens to our hormones when we age.

It’s been a snowball effect of mistakes or what I am calling the “miseducation of menopause”. 

I know that information can make us feel a bit hopeless, but I am writing this to put into context what happened, so we can move forward with hope. We do have options. We just have to be our own advocates. And find the right partners to support us.

What can we do to feel like ourselves again?

I often hear women in this perimenopause stage say, “I just want to balance my hormones”, so I feel like myself again. And I TOTALLY get this desire. AND that is what the miseducation of peri menopause has taught us we can do! 

But unfortunately, this isn’t how the body works. We don’t get those hormones from our 20s and 30s back. And we can’t help our bodies to produce them once again.

Our hormones are based on the cycle of reproduction, and when we get to our mid 40s our bodies are moving into a different season of life, and reproduction is coming to a close. 

So although we can’t make our bodies reproduce our hormones once again,
we can replenish our hormones and nourish our bodies in different ways, to feel like ourselves again. Lifestyle, nutrition and stress management truly make a difference.

Optimize Your Sleep

Sleep with intention. Sleep is key to keeping our cortisol in check, keeping extra weight off, and helps everything in our body restore and replenish. 

• Create a consistent bedtime routine. Have your last bites of food by around 7pm to optimize your digestion, and create about a 12 hour fast which helps with sleep.
• Aim for 7-9 hours of sleep per night.
• Instead of using your phone as your alarm clock, use an old school alarm clock. The EMF’s from phones can disrupt sleep, and so can notifications! Keep your phone at least 6 feet away from your bed. 
• Reduce Blue Light Exposure – The blue light in phones, ipads and laptops keeps us awake. It disrupts our melatonin, and can even cause us to wake in the middle of the night too. Stop using your devices at least an hour before bed. 

Nutrition Matters & Get Ample Protein

When estrogen tanks, it is much more difficult to balance our blood sugar. We don’t have the same ability to process simple carbs the way we used to. So getting in ample protein helps to keep our metabolic health in balance, which in turn keeps our blood sugar imbalance, which in turn fights off diseases of aging. 

• Shoot for 100-130 grams of protein per day. If this is a very new number for you, then start slow, and work your way up. This is easier than all-in right away.For example, if breakfast does not include protein right now, start by adding in a couple eggs – this will give you 12 grams of protein, then slowly work your way up with each meal. If you make each meal average about 30-40 grams of protein per day, you will be in that range. 
• Cut out sugar and simple sugars

Heal Your Gut

Healing your gut is paramount to hormone balance. Sugar, antibiotics, medications, the Standard American Diet, stress, heavy metals, toxins, parasites, mold exposure, age, loss of estrogen and even viruses/illness can be disruptive to our gut health. 

When our gut health has been disrupted it affects our microbiome and causes us to clear toxins less efficiently, and leaves them to circulate around the body.

• Start with a gut health test like the GI-Map to see what the health of your gut looks like.
• You might try an Elimination Diet and remove Gluten, sugar, maybe dairy, and any foods you know are creating sensitivity issues to your gut. This will give your gut a deep rest, and allow it to heal in a big way. 
• Start your day with a full glass of water, and drink 8 ounces of water. Then get in half your weight in ounces each day to help flush and hydrate your system. 

Move Your Body

Movement matters. Movement improves our microbiome, our digestion, reduces inflammation, helps with anxiety and mood. It also keeps us strong, and supports our longevity. When we hit midlife it’s much harder to maintain muscle with our lowering hormones. And we actually lose muscle mass as well as bone density.

Key tip – start where you are, and work up to all of these things. This doesn’t have to be your schedule from day one. Give yourself months to work up to this schedule. Start small, build success, and add on when you’re ready. 

• Stretch – Yoga, stretches, pilates get this in a few times a week, as stretching helps to create suppleness in the muscles, helps our strength and recovery, helps reduce stress and supports all the other activities we are doing.  
• Balance  – Do tree pose, half moon, pick a balancing pose. A great way to do this is brush your teeth on one foot in tree pose. Or cook while standing on one foot. (safely of course!)
• Walk – work up to a minimum of 4000 steps a day, then add more as you have the time. There is new evidence from the British Journal of Sports Medicine that shows us 4000 steps at least 3x per week reduces cause of death by 40%. The benefit increases with additional steps, so if we make 4000 our minimum and add as we have more time and energy we will gain further benefit. 
• Jump – at least 20 jumps a day to support your bone health. 
• Strength Train – 2 – 4x a week Lift the heavy ones, not the 2-3 pounders. Get into the gym and lift heavy. Work up to the weight where you can do 4-6 reps per exercise. If your budget affords it, use a trainer to help you get there. 
• Sprint – 2x a week. Sprint for 30 seconds. Then fully recover for 2-3 minutes and do this 4x. This helps to build a strong heart muscle. This is a tip I learned from Dr. Vonda Wright, MD, and I really love it. She is a great follow on Insta by the way. Just make sure you work up to this, and stretch beforehand. I got a little too excited and pulled a hamstring early on when I started this. 

Avoid Xenoestrogens

This is so important. Xenoestrogens are hormone disruptors. They mimic our own hormones, and confuse the body… not to mention they are toxic. And xenoestrogens disrupt our own healthy estrogens. Follow these tips to eliminate xenoestrogens.

• Clean up your makeup, skin care, health and beauty products. Look for non-toxic, and organic options. 
• Buy organic foods whenever your budget allows you to avoid pesticides… which disrupt the reproductive cycle of the pest… (guess what they do to humans?)
• Ditch plastic and start storing your leftover food in glass containers. 
• Use a glass or stainless steel water bottle and not plastic. 
• Work on gentle detoxes to help your body clear toxins. Toxin build up in the body can lead to other bigger issues. 

When you have all of the above dialed in… then… 

Explore Bioidentical Hormone Replacement

Bioidentical Hormone Replacement Therapy does not have to be feared. Bioidentical hormone replacement is preventative and restorative support. It helps to prevent cancer, cardiac disease, osteoporosis and osteopenia, prevents dementia, and prevents metabolic issues (which prevents prediabetes and type 2 diabetes). It supports our sleep and our vaginal health too.

Here are some tips on what to look for with HRT. 

• Systemic estrogen (Estradiol) supports the whole body. This helps support bone health, heart health, brain health, our skin, hair and nails, our cholesterol levels, our energy and 
• Vaginal estrogen supports the vaginal tissues, not the whole body. It helps prevent urinary tract infections, urinary urgency, lubrication, may help with sexual function, orgasm, and may help with leakage as well. 
• Support Estrogen with Estradiol first. Estradiol opens the receptor for progesterone and testosterone so they can be received. Not everyone needs testosterone, but most women need both estrogen and progesterone (not one or the other). 
• Testosterone is often the last hormone to lower. If a practitioner wants to start you here, this is a red flag. Starting with estrogen first is important so that estrogen can open the receptor so other hormones will be received. Additionally when we start on testosterone, it does not all convert to estrogen. AND.. there are some bigger side effects with testosterone as well as body changes like an enlarged vulva or clitoris that can’t be reversed when we go on T and don’t optimize estrogen.  
• If you have a hormone positive cancer, you would want to speak to your practitioner about your options. 
• We do still want to avoid synthetic hormone replacement like oral estrogen, often called Premarin which is linked to a higher risk of stroke (topical is not associated with stroke). And the synthetic progesterone called Progestin. 

Ok, so this is a lot of information! For a quick overview you can come back to, see my Perimenopause guide.

And remember, you don’t have to make all the changes at once. Small steps are what create success. Take it one step at a time.

Lastly, I created this “How to Find a Supportive Midlife Provider” guide for women like you. Click the image below to grab it!

**The information provided is for educational purposes only and is not intended as medical advice, diagnosis, or treatment. It should not be used as a substitute for professional medical advice from a qualified physician or other licensed healthcare provider. Always seek the guidance of your doctor or other qualified health professional with any questions you may have regarding a medical condition, symptoms, or treatment options. Never disregard professional medical advice or delay seeking it because of information you have read here. If you believe you are experiencing a medical emergency, contact your doctor or emergency services immediately.