What No One Tells Women About Perimenopause, Hormones, and Midlife Health

Hi, welcome to the podcast. I’m really glad you’re here. And for those of you who don’t know me, I’m Dr. Tracy Page. I’m a functional medicine physician, and I’m passionate about helping women expand their education and knowledge and really understand how to age well. So today’s topic is what no one tells women about perimenopause, hormones, and midlife health.

So we’re really going to focus on perimenopause today, because it leads to menopause, and a lot of symptoms happen that people don’t recognize. You know, perimenopause doesn’t start with a missed period or not having a period — it starts with symptoms that doctors often dismiss. I hate to say it, but it’s true. Up to 90% of women experience symptoms during perimenopause, yet most receive little to no guidance. And a lot of times, if your labs are normal but you feel terrible, I want you to know you’re not broken — it’s usually the testing model that’s broken, or the person who’s interpreting the test, you know, isn’t looking for optimal, and they’re just dismissing your symptoms. And that’s not okay.

And we’re going to talk today about what those symptoms are, and how you can combat some of those symptoms, and really what you should be looking for to help you understand this stage of your life. So welcome back to the podcast — we’re going to talk about hormones, metabolism, strength, and all the good things. I want you to know that the most misunderstood phase of a woman’s life is actually perimenopause. And if you don’t get the answers that you need, everyone goes into menopause. So we’re not talking about menopause today; we’re not talking about aging, because perimenopause happens as we age, and it starts early. The years leading up to menopause, they can quietly reshape your body, your brain, your sleep, your mood, and even your metabolism, long before your period stops — and so you don’t even recognize what’s going on. A lot of women are frustrated because no one tells women that this phase often begins much earlier than expected, and feels nothing like we’re taught. It can start as early as your 30s. So I want you to know your symptoms are real, they are biological, and most importantly, they’re treatable — and I want you to hear that. Your symptoms are treatable. It doesn’t mean you’re going to get cancer; it doesn’t mean that you have to take a bunch of pills; it doesn’t mean that there’s something just wrong with you. These are treatable symptoms that we’re just not getting an education on. And today, I want to create some clarity around perimenopause.

So what is actually perimenopause? It often begins, like I said, in the late 30s or early 40s. It can last 8 to 10 years. It’s defined by hormonal fluctuation, not just decline. So when I first was learning about it, I used to think, oh, the hormones start declining, and your ovaries are slowing down, and therefore you’re in perimenopause. And some of that is true, but really the big take-home message during perimenopause is the fluctuation of hormones, which is what makes us feel so not like ourselves. And perimenopause ends 12 months after your final period, which is when you then enter menopause — and we’ll have lots to talk about, about that.

So most women are shocked to learn that they can be perimenopausal while they’re still having a cycle — they just think everything is going well. I think there’s a lot more education now in the world about hormones and perimenopause, so some of this stuff I might be telling you, you may already know. But I’d encourage you to keep listening, because there are some good action items you can take, and maybe some symptoms you didn’t even recognize as part of your hormonal fluctuations.

So let’s just talk about the biology. We have estrogen, which is our main female hormone, and we also have progesterone — those are probably the two biggest ones in perimenopause. Testosterone comes into play later on. All three of those hormones are made in your ovaries; they’re also made in your adrenal glands. And estrogen and progesterone are the ones that become so erratic during perimenopause: some months they’re both high, some months they’re both low, some months one of them’s high, and one of them’s low. So you just don’t really know what you’re going to get, and this hormonal chaos really can drive symptoms. Think of perimenopause less as a slow fade of your hormones — kind of like I was saying, that’s how I thought about it in the beginning — it’s more like a hormonal roller coaster. So imagine being on a roller coaster every day, going up and down, and up and down — as you can imagine, you’re not going to feel too good. And that’s what I see in my clinic every day.

We’re just going to talk about some of the things I hear and some of the things I see. So many symptoms — I want you to know — are neurological and metabolic, so they’re not just reproductive. And that’s why I think women get kind of caught, because they don’t recognize that these neurological and metabolic symptoms are actually perimenopause. They’re going to think, “Oh, I have a gut problem,” or “I have a brain problem,” or they think maybe they have anxiety, or they’ll think, “I have diabetes,” or “my thyroid’s off,” or “my iron’s off.” They associate all these symptoms with different things, not realizing that these are all signs and symptoms of perimenopause. So let’s talk about some of those.

Let’s start with emotional and cognitive symptoms that you can develop during perimenopause. So, anxiety day one, or panic attacks — often it’s new onset. All of a sudden, my patients are feeling anxious; you might be feeling it too — like, all of a sudden, you’re like, “oh, these are really bothering me,” or “I had my first panic attack; I never had panic attacks.” My patients have told me this: all of a sudden, it just comes on. And that’s usually because their progesterone is dropping quite a bit—it’s our calming hormone —and they might lose it for a little while, and then it might come up, and they might feel better. And when you’re on a hormonal roller coaster, irritability is a big one I see. I also see low mood, loss of confidence — that’s a big one, and that has a lot to do with testosterone as well. All of a sudden, women lose their confidence, and they’re like, “I don’t know who I am, I don’t feel as strong, my motivation’s in the tank, my drive to get things done is nowhere to be found, and my libido is gone.” They’ll have brain fog, and they’ll also have memory lapses. So those are all kind of the emotional, cognitive things I see, because estrogen plays a huge role in serotonin, which is a neurotransmitter — it’s inhibitory; it’s a relaxing neurotransmitter. Estrogen plays a huge role in dopamine, which helps with our memory and our brain function and makes us happy — kind of like that dopamine hit we’ve heard of. And in our cognitive function, estrogen plays a huge role too.

The other symptoms I see patients come in with in perimenopause that they don’t always recognize are related to their hormonal shifts, and fluctuations include sleep disturbance. It’s actually one of the earliest signs. They have trouble falling asleep — waking at 2 or 4 a.m. is very common when your hormones are fluctuating, especially estrogen. Night sweats, but not always; that’s more of an estrogen thing, and it can happen when progesterone starts to drop. And non-restorative sleep — so they might go to bed on time and be in bed for eight hours, but they don’t feel rested when they get out of bed. Progesterone decline really does reduce natural calming — so that anxiety we were talking about earlier — and progesterone really helps with sleep promotion. And that early-morning awakening? You can see changes when estrogen starts to change and fluctuate too.

Now, this one usually gets women into my office: they start gaining weight. So they see metabolic changes, even with unchanged habits — this is a hard one; I experienced it myself, especially weight gain around the abdomen. I remember the first time I reached down to pick something up — I was sitting — and I felt something on my thigh, and I was like, “What is that?” It was my tummy. I had never really held weight in my tummy, but it just came on so quickly that I didn’t even realize it until I did. And especially as a physician, you know, at that time I was wearing scrubs quite a bit, and scrubs are very forgiving, so you don’t even realize that you’re putting on weight until you actually put on regular clothes or something, and you’re kind of forced to identify the fact that you’ve gained weight. Increased hunger, cravings for things, happen during this hormonal fluctuation; reduced energy; and a lot of blood sugar instability, which really affects energy and brain function — so one minute you’re feeling really great, and the next minute you crash and burn. And I see that a lot, because estrogen affects insulin sensitivity, fat distribution, and blood sugar regulation, and we don’t realize that these are actually signs of perimenopause.

The other thing my patients a lot of times will come in with is physical symptoms like headaches or migraines, joint pain. And this one is really interesting — I can’t tell you how many women have come to me with body pain, and I put them on progesterone because their levels are low (not every woman needs progesterone), but I put them on progesterone and all their aches and pains go away, the majority of them, if not all — because we have a receptor in every joint for progesterone, and without that, we actually hurt worse. And then also, too, if they’re really low in testosterone, they’ll have body aches and muscle aches and pains, because testosterone plays a huge role in pain in the body. We’re going to talk more about testosterone’s role in women, but I will tell you, when your hormones are fluctuating, definitely body pain and joint pain are big ones.

I also have patients complaining of, and seeing, breast tenderness, bloating — and that’s where they think they have GI problems, or something they ate, but it really is just hormonal fluctuation. They’ll have cycle irregularity, so all of a sudden their cycles will start changing — there will be more time between their periods, there will be less time, sometimes they’ll have two periods in a month. And then they’ll also notice a change in their bleeding — it will get heavier or lighter depending on their hormonal fluctuation.

So I want to share an important statistic with you: research has been done about this time in our lives, and up to 90% of women experience symptoms of perimenopause, yet they don’t connect them to hormones — like, 90%. And what’s even worse is they’re not identified — not just by the patient, but more importantly, by the physician treating them. So today, I want to arm you with the education you need to talk to your physician about and ask to have your hormones checked.

Now, I do know that when you get a blood test, it’s a point in time. I like the DUTCH test—it’s a great test for looking at hormone metabolism. It’s capital D-U-T-C-H; it’s by Precision Analytics. It’s a great hormone test because it looks at metabolites in urine samples over time— 24 hours—so we’re not just seeing one point in time, as we do with blood. But if you can’t get that test, just ask for a blood test, because if your levels are low, they’re low. And especially in perimenopause, we want to get them in the second half of your cycle, which is called the luteal phase. So if your period starts on day one, count out 14 days—most women on a 28-day cycle ovulate on day 14 —and then have your labs checked on day 19, 20, or 21. If you have more time between cycles than 28 days, add those days to 19, 20, or 21. For example, if your period is every 30 days, shift your timing by two days over —so instead of days 19, 20, 21, it would be days 21, 22, 23.

Okay, so it is important to try to get your labs drawn during that luteal phase, because we can see the ratio of progesterone to estrogen — it’s called the progesterone-to-estrogen ratio, and it usually should be about 150 to 250 in most women, but you want to be somewhere in the range of 100 to 500. I feel like women feel their best around 150 to 250; if they have a lot of anxiety, they feel better if that ratio is 250 to 400.

So, to talk about hormonal fluctuations — I want to talk to you about why I feel like a lot of women I see feel dismissed in this area, and it’s because these hormones fluctuate daily. So, like I was saying, a single blood test is just a snapshot — it’s not really the movie; I kind of call it the trailer. So it just tells us a little bit, but it doesn’t tell us the whole story. Labs may look very normal, especially if you don’t even get them during the luteal phase. That’s why doctors often say, “Well, your labs are normal, so I don’t know what you’re experiencing, but it’s just part of aging, or you just have to live with that.” But let me tell you: normal range doesn’t equal optimal. These are reference ranges on lab reports based on population averages, so they’re not really functional labs—they’re not for what we’re trying to achieve, which is optimal health. So they’re ranges to keep you alive, but there’s a difference between being alive and feeling optimal. You can be within range and still be symptomatic and still be functionally depleted. It’s really important — I’ll do a podcast on the 10 or 15 most important labs, the ranges, and what every woman should be looking for. But let me tell you, normal doesn’t always mean optimal.

And our healthcare system is more reactive — most conventional care responds to disease and not really early dysfunction. So a lot of times, your physician, first of all, doesn’t recognize the symptoms, and also, too, because you’re not bleeding, you don’t need surgery, and you don’t have cancer, sometimes they don’t even treat them. And this is my profession, and I would say, just like there are good doctors and bad doctors, there are good plumbers and bad plumbers — so I’m speaking in general terms; I know a lot of great physicians. I just think it’s part of education and knowing what to look for. A lot of times it’s right in front of them, but they don’t see it because they just haven’t been educated. I think we’re all trying to educate more—those of us in functional and integrative medicine and longevity medicine—to help our colleagues understand optimal health, not fear hormones, and not dismiss patients’ symptoms, because they are real. And I see a lot of patients — because we’re just not quite there yet — but I think we are definitely making progress and helping more providers help patients deal with perimenopause.

So what I do still see, though, is women are told, “you’re just stressed,” “you’re getting older,” “everything looks fine,” “you’re anxious,” “you’re just depressed,” “you need to lose weight” — that’s funny, there are a lot of things. And women feel dismissed — you may be feeling this too. And actually, sometimes being dismissed can be more distressing than the symptoms themselves. So I would say, if you recognize any of what I mentioned, be your own advocate — you don’t have to be a people-pleaser here; you can speak up for yourself and reach out if you have questions.

So let’s talk about what actually helps during this time, which can be empowering — and I’m hoping to make it not overwhelming, but to help you with some of the key things that are happening. So the key things that are happening are blood sugar dysregulation because of hormonal fluctuations, sleep being off, our body not feeling good, and often not being able to manage stress. So I’m going to talk about those four areas and what you can do to help optimize hormonal fluctuations and feel better.

So when it comes to blood sugar stabilization, it’s important to realize that blood sugar swings worsen — and when they do, you have mood instability, you’ll have anxiety, you might feel fatigued especially after eating a meal, cravings — you could eat, and then 30 minutes later you’re hungry again — weight gain, and sleep issues. And all of that can be blood sugar. I see a lot of women sometimes think that they’re having night sweats, and it’s because they might be doing early dinners, trying not to eat a lot of food before bed, and then their blood sugar drops during the night, and cortisol spikes to wake them up — and so they’ll think they’re having a hot flash during perimenopause, when it’ll actually just be blood sugar dysregulation. So to solve that, I often have patients have a small snack with protein and fat before bed—that tends to help figure out whether it’s truly a night sweat or just a blood sugar drop causing a cortisol spike.

So I always tell patients, during perimenopause, you really have to prioritize protein at every meal. You should get a minimum of 30 grams, and if you’re doing three squares a day—breakfast, lunch, dinner—you should get a minimum of 30 grams at every meal. Breakfast and dinner are the most important because dinner comes before you start fasting and go to sleep at night, and breakfast matters because it’s when you break your fast. And if you’re getting 30, 60, 90, that might be enough for you depending on your weight — I would say it’s probably on the lower side, so that’s why I said it’s the minimum, but you can go up to 50 grams at breakfast and dinner, and still your body should be able to metabolize that. So, protein at every meal. If you’re a snacker, have at least 10 grams of protein with your snack; in a perfect world, even 20 would be fine.

And then, avoid starting the day with sugar-only foods. I’ll be the first to admit, I love a blueberry muffin with sugar sprinkles on top — they’re good. But do I eat them often? No, because they’re not good for you. And actually, if I’m going to have a muffin, I would have it more as a dessert than as breakfast, because you don’t want to start your day with sugary foods—it’s just going to wreak havoc on your blood sugar. You really want protein at every meal, including breakfast. And then you want to combine carbs with protein and fat. There’s a great book called Glucose Revolution, the Glucose Goddess — you may have heard of her, and you can look her up on the website. We follow many of her protocols and educate our patients on blood sugar regulation, and we use CGMs (continuous glucose monitors) to help them lose weight, stabilize their blood sugar, and understand what they’re eating and how it affects their blood sugar. Because if I ate an apple and nuts, I’m going to have a different response in my body than if you ate an apple and nuts. So it’s really important to understand how blood sugar regulation affects you, and also how the foods you eat affect your blood sugar. Because when blood sugar goes up, insulin goes up, and that’s when we have problems with weight gain. So we always say, never eat a naked carb—combining protein and fat with your carbohydrates is really important, and it will help regulate your blood sugar.

And most importantly, don’t skip meals, because you’re prone to crashing. So if you’re not eating your regular three squares a day, or even your snacks, if you’re just not eating — and I see this a lot, where some of them will eat one meal a day, or they’ll be intermittent fasting and have this really small six-hour eating window — that’s just not enough time to get proper nutrition and to feel your best. So it’s important not to skip meals. You can have time-restricted eating, where you eat maybe eight hours a day, and try not to eat before bed, as long as you don’t have blood sugar crashes at night — and that can be okay. But you really have to listen to your body.

And I really love the CGM, continuous glucose monitor. You can actually go to the Stelo website — S-T-E-L-O — it’s a Dexcom CGM, and it’s $99. We have it in our clinic for $99 as well, and you get two monitors, and we give you a four-week protocol. For the first two weeks, you want to be curious and eat everything so you can see exactly what’s happening to your blood sugar. Then, for the second two weeks, try to adjust your meals so you’re getting protein, carbs, and fat—and pay attention to the order you eat them, walking after meals, and other small changes that can help stabilize your blood sugar. And I’ve seen amazing weight loss in my patients when they keep their blood sugar between 70 and 120 — and that’s 120 with a meal. So it’s just pretty interesting how blood sugar really does affect our ability to lose weight.

Okay, let’s talk about sleep optimization. Sleep is foundational. I just giggle a little bit, because when I met my now-husband, after we started dating, we spent a lot of time together, and I noticed my sleep was getting a little bit disrupted. We did this little pyramid where we had to write down our four foundational things, and, not surprisingly, my foundational one was sleep—sleep is my foundation. He reminds me of that now when I don’t always follow my own rules — I stay up a little bit too late. But sleep is foundational, because it affects every part of our body.

So: consistent bedtimes and wake times is really important to help manage sleep. Reducing evening light exposure — if you can’t be without having light at night, light-blocking glasses really work well, so that you still produce melatonin and still feel that you need to fall asleep. Limit alcohol, because alcohol actually disrupts our sleep architecture and we don’t even realize it. Keep your room cool—when we keep our room nice and cool and get under the covers, we tend to sleep better because we can’t regulate our temperature as well when our hormones are fluctuating. And then, really, having a sleep ritual before bed — kind of think about your luggage: when you walk into the bedroom, you should really leave all your luggage at the door, and that should be a place for you to calm, rest, rejuvenate, restore, read a book, relax, listen to some music or white noise. I really don’t love TV in the bedroom, just because of the blue light and how it affects melatonin production. But really, you just want to leave everything at the door — so having some type of nighttime ritual is really helpful when you’re trying to get to sleep.

And then there are two more things that matter for this time — strength training is the third one, and it really should be non-negotiable in midlife. If you say, “Hey, I’m a walker, I love to walk,” I tell my patients to get a weighted walking vest and put those weights on, because you’ll still build muscle and strength. And that muscle benefits us in so many ways. Preserving muscle mass is so important for metabolic health and longevity — it improves insulin sensitivity, supports bone density (we’re going to have a whole discussion about bone density), boosts metabolism, and improves how you feel when you take your clothes off. If you like to strength train, having firm muscles feels much better. And as we get older, gravity is just not our friend, no matter how you slice it. So for me, muscle is metabolic armor for midlife and beyond, and there’s no better time to start than now.

So I’ve found a couple of things helpful. I make sure I have equipment at home so it’s a little more accessible. Keep it simple — I used to be one of those people who had to do everything and work out for an hour; now, sometimes it’s just 20 minutes, doing some basics — squats, lunges, some bicep curls, some push-ups, some shoulder presses. It doesn’t have to be complicated; I think sometimes we make it too complicated. Or find a really good YouTube video and follow that — Heather Robertson’s videos are really good; she has them by time, by body part, by exercise. So just find what you like. But the most important thing is you have to like it, because you won’t do it if you don’t. Just make sure it includes some resistance training.

And then, stress regulation. We’ve talked a little bit about stress throughout this whole thing, so we all have different ways to manage it. You want to get outside, do some breath work, close the office door, get in your car, find a quiet space, and just do some deep breathing — you can inhale for four, hold for five, exhale for six; four, five, six is kind of how I like to remember it. That’s really great for just calming you and getting you into that parasympathetic state, where you’re more relaxed. Finding something that feels mindful—whether it’s meditation or reading—is a way to bring you down during stressful times. And then, you know, we all need boundaries — so, like I said at the beginning of the podcast, don’t be afraid to not be a people-pleaser; don’t be afraid to speak your mind and be authentic. Creating boundaries really helps you deal with stress and reduce overload. Don’t be afraid, because stress does affect our body—and we’ll dive deep into how much it affects us more than we realize.

Okay, so when appropriate — not everyone, but some people during perimenopause are going to need hormone therapy, because it can be life-changing. I mean, I see women put on progesterone during perimenopause, and their sleep improves, their mood improves, their weight goes down, they have less brain fog, their quality of life improves, even hot flashes get better. So typically during perimenopause, progesterone is the first hormone that we tend to replace. You can take progesterone orally in a capsule, as a troche that goes under your tongue and melts, in a sustained-release capsule, or in a cream. So there are four different ways to get progesterone, and you can talk to your healthcare provider, because there’s not one size that fits all — it is important to check levels, and it requires an individual assessment. So this is not medical guidance telling you what to do, but it gives you clarity on what’s out there and what’s available to you. And you should always discuss the risks and benefits with your provider — but I feel like it’s a very good hormone to help women really feel better during perimenopause.

Most importantly, I want you to know this happens to all of us. Like I said before: death, taxes, and perimenopause — you just can’t get around it. It’s happening. Millions of women are navigating this, often silently, so you’re not alone. And a lot of times we don’t talk about it — there’s a lot of shame around it, because people make us feel like we should be able to handle this, or something’s wrong with us, or “other women are fine, so it’s just me.” But I will tell you, more women than not are experiencing the exact same thing. So please know: the symptoms you’re having are real, and you do need to talk about them with your healthcare provider, pay attention to them, and treat them, because they are treatable.

And remember, mostly, that perimenopause and menopause, again, is not decline — it’s really just a time that your body’s talking to you, your body’s shifting, and you need new strategies to help you understand this, deal with this, and treat this. This information is really here to help you and support you, and give you tools so you can feel strong and clear and vibrant through this time, and not be afraid of all those changes in the body. So I hope this helps. Again, this is just on perimenopause, and we’ll get into menopause and some other things in future episodes.

And if you have questions, please feel free to reach out to info at Wisconsin Functional Med. I’d love to hear any questions or topics that you want to talk about, so we can help you navigate this time of life with clarity and confidence. Until next time, talk to you later.