Navigating Perimenopause: A Personal and Professional Journey

navigating perimenopauseAs a nutritionist and herbalist with nearly two decades of experience, I’ve accompanied hundreds of clients through the challenges, mysteries, and upsides of perimenopause and menopause. And recently, as my interest in the topic becomes more personal, I am struck by a few things. One, women are still being made to feel terrible about their bodies. It is f*ing relentless. Two, navigating this transition is fraught with a peculiar mix of scant information, dismissive health care providers, and overwhelming media narratives (hello targeted Instagram ads by celebrity-owned wellness brands), leaving many of us in a state of cognitive dissonance. But somehow, we’re still supposed to be doing and having it all, “gracefully,” which was the word A.I. used most frequently when I asked it about menopause.

“Welcome to the Perimenopause Hotline, where wait times are completely unpredictable”    

 ~ Kathryn Baecht, McSweeney’s

My mission is to chart a course through this complex terrain, and leave you with some information that you might find useful or empowering.  Perimenopause (PM) is not monolithic; the same process manifests in different people with a vast array of experiences. For some, the transition is a subtle shift barely noticed, while for others, it dramatically alters the fabric of their daily lives, contributing to chaos, overwhelm and serious health challenges.  Still others may feel at peak physical strength and mental resilience. This variance speaks volumes about our bio individuality and the societal and environmental factors that shape our health—culminating in a unique physiological makeup that dictates everything from how we metabolize food to how we experience emotions and memory. It's a reminder that hormones, those pluripotent chemical messengers, play a pivotal role in shaping our existence, influencing everything from our mood, body composition, and sleep patterns to our sexual drive and cognitive functions.

This intricacy makes perimenopause a deeply personal experience, and is why there can never be a "one-size-fits-all" approach. Given this range of experiences, I encourage you to embrace what resonates with you and leave behind what does not. 

Note:  Not all people who go through menopause identify as women.  Or have uteruses, for that matter.  While I do think “women'' as a category is still necessary and important for advocacy, I speak about menopause in a non-gendered way when possible. 

What the HECK is actually going on?

Let's begin by demystifying this big hormonal shift.  The precursor to “true” menopause (in which there is no period for 12 consecutive months), perimenopause is a gradual shift in hormone production, typically beginning in one’s 40’s, lasting anywhere from a few months to 10 years, and is marked by hormonal fluctuations that can more more extreme, and less reliably cyclic than during one’s 20’s or 30’s.  For a long time perimenopause was equated with hot flashes and irregular periods (and if you didn’t have those things, you weren’t “in it”), but now a range of experiences, including “feeling not oneself,” fatigue, sleep disturbance, overwhelm and a decreased ability to cope, are recognized as common features of PM.

Estrogen Fluctuations

Estrogen is a key hormone, responsible for regulating the menstrual cycle and affecting various parts of the body, including the brain, heart, and bones, tendons and skin. As we approach menopause, the number of follicles (a fluid-filled sack containing an immature egg) in the ovaries decreases, leading to less consistent ovulation. This change disrupts the normal patterns of estrogen production in two main ways:

  • Erratic Highs and Lows: The ovaries may sometimes produce normal levels of estrogen, but at other times, the levels can swing unpredictably high or drop significantly low. High estrogen levels can cause symptoms such as heavy bleeding, fibroid growth or increased PMS symptoms, while dropping levels are associated with hot flashes, night sweats, and vaginal dryness.
  • Overall Drop: Despite these fluctuations, the general trend for estrogen during perimenopause is a gradual decline. This reduction becomes more pronounced closer to menopause, eventually leading to very low estrogen levels typical of postmenopause. Throughout perimenopause, a potent form of estrogen known as estradiol is replaced with a much weaker form called estrone, leading to signs of estrogen withdrawal, such as body pain, hot flashes and dry eyes/skin/vagina.

Progesterone Changes

Progesterone, another critical hormone, works in concert with estrogen to regulate the menstrual cycle. Its levels rise in the second half of the menstrual cycle, prompting the uterine lining to thicken in preparation for a possible pregnancy. If pregnancy does not occur, progesterone levels fall, triggering the shedding of the lining.

During perimenopause, the irregularity of ovulation leads to decreased progesterone production for several reasons:

  • Anovulatory Cycles: Cycles where ovulation does not occur (anovulatory cycles) become more common in perimenopause. During these cycles, progesterone is not produced in significant amounts, leading to estrogen dominance. Less frequent ovulation means lower overall levels of progesterone. This imbalance can cause symptoms such as heavy periods, short cycles, mood swings, bloating, sleep disturbances and increased premenstrual symptoms.
  • Chronic High Stress Levels:  Let’s face it, many of us are arriving at perimenopause in an exhausted or stressed state, and in this case, the body will preferentially make cortisol (a long-acting stress hormone that can wreak havoc in our systems over time) rather than progesterone.  This is such an important aspect of the perimenopause experience that it has its own upcoming article.  

Other Hormonal Players

Perimenopause involves a complex interaction of many regulatory hormones.  Other major impacts include:

Testosterone

  • Testosterone is also produced in smaller amounts by cycling people and plays a role in muscle mass, bone density, and sexual desire.
  • Testosterone levels gradually decline with age, but the decrease is more subtle compared to estrogen and progesterone. Some studies suggest that this decline can contribute to reduced libido, fatigue, and low mood, but that a relative higher level of testosterone to other sex hormones can lead to changes in body odor and facial hair growth.  Fun times!

Insulin

  • Insulin, produced by the pancreas, helps to regulate blood sugar levels and fat storage. It allows cells to take in glucose to be used for energy.
  • Hormonal fluctuations during perimenopause can affect insulin sensitivity, making it more difficult for the body to manage blood sugar levels. This can lead to an increase in cravings, weight gain, and an increased risk of developing insulin resistance and type 2 diabetes.

Cortisol

  • Cortisol, one of the body’s long-acting stress hormones is produced by the adrenal glands. It plays a vital role in the body's stress response, regulating metabolism, inflammation, and immune response.
  • Our world is crazy-making, and societal factors like systemic racism, socioeconomic hardship, and trauma can lead to very high cortisol levels over time and a much more challenging–and early–menopause.  The SWAN study of 2022 highlighted the fact that Black women are 3 times more likely to experience early menopause (before age 40), dramatically increasing lifetime risk of cardiovascular disease.  Not to mention that stress of dealing with the symptoms of perimenopause can lead to increased cortisol levels, which may exacerbate symptoms such as weight gain, sleep disturbances, and anxiety.

Thyroid Hormone

  • Thyroid hormones (including T3 and T4) are crucial for regulating cellular metabolism, energy production, and overall bodily functions.
  • Hormonal fluctuations during perimenopause can affect thyroid function, potentially leading to symptoms like fatigue, brain fog, weight changes, constipation, dry skin and mood disturbances. It is not uncommon for hypothyroidism to develop during PM. 

Impact of Hormonal Fluctuations

The fluctuations of estrogen and progesterone, along with the complex interplay of other key hormones during perimenopause, can have a profound impact on body and mind. The symptoms experienced are often directly tied to these hormonal changes. For instance:

  • Menstrual Irregularities including irregular periods, heavier or lighter bleeding, and longer or shorter cycles.
  • Mood Fluctuations: mood swings, anxiety, irritability and depression.
  • Vasomotor Symptoms: Hot flashes and night sweats/night heat 
  • Increased systemic inflammation 
  • Bloating
  • Musculoskeletal pain
  • Body composition changes, weight gain especially around the middle
  • Cognitive changes, overwhelm
  • Memory impairment 
  • Low energy/loss of vitaility 
  • Thyroid fluctuations
  • Palpitations, blood pressure increases
  • Sleep difficulties, especially nighttime wakings
  • Achy joints and body pain 
  • Dry skin/eyes 
  • Hair loss
  • Inflammatory skin conditions, eg, rosacea and acne breakouts
  • Low sex drive 
  • Existential dread 
  • Vaginal dryness and painful sex 
  • “Feeling not oneself”

6 Things to Do for Perimenopause

Get a new perspective on your nervous system

I can say with assurance that stress makes everything worse–a LOT worse. This may seem obvious, but during perimenopause, the wheels can really fall off for people. I encourage you to understand your unique stress signature: how does stress manifest for you? You’ve heard of Love Languages? Well, what’s your Stress Language? Do you get irritable and combative, or shut down and get impassive with high stress? How can you address stress in ways that are nourishing, not numbing? Some perspectives and modalities that have helped me and countless clients include Polyvagal theory, Internal Family Systems (IFS or “parts work”), self-directed neuroplasticity, trauma therapy like EMDR or brainspotting, and codependency self-education. This is a great time to get back in therapy and focus on your mental health, and a great time to get curious about the changes your body is experiencing. (See resources)

Up your exercise 

Increasing your exercise now benefits your metabolism and helps your system process high hormone levels, and counters the cognitively depleting effects of low hormone levels. There is much to say about the benefits of exercise, but the importance of doing whatever is possible for your body NOW cannot be overstated. Building and conserving muscle mass before entering true menopause, improvements in insulin sensitivity, mood elevation, increases in libido, release of all-powerful Growth Hormone, better sleep and a decreased risk of dementia are just some of the plus sides of regular exercise.

Prioritize sleep! Specifically, leave off evening email and social media at night.  

Given that PM challenges sleep in its own right, we need to get serious about sleep hygiene and real about the fact that getting pulled into daytime stress and the gaping maw of perceived deficits that social media opens in us is NOT the path to restorative slumber. Natural sleep support can be game-changing, too. I love magnesium, B vitamins, non-synthetic GABA, plant-based melatonin, adaptogens, nervines and gentle herbal sedatives like hops and california poppy.

Eat to balance your blood sugar–and your estrogen. 

Blood sugar balance is the stage upon which hormonal balance is set, and is intricately linked to liver health, cortisol levels, and systemic inflammation. Given that systemic inflammation levels tend to gradually increase through PM and into menopause, limiting sugar and alcohol, and upping protein, fiber and healthy fat now will set you up for an easier transition. This way of eating also supports cognition, which can be severely impacted by neuroinflammation associated with fluctuating and low hormone levels. If you run estrogen-dominant (or you’re in the E-dominant phase of PM), read our “Eating for Hormonal Balance” article, and load up on the cruciferous vegetables!

Support your adrenals with adaptogens and nervines

We talked about how high cortisol levels pumped from our adrenals can come at the expense of progesterone production–but there is another crucial connection here: our adrenals pick up sex hormone production from the waning ovaries in menopause. Adaptogens are thought to work via numerous cellular mechanisms–but we know that they support adrenal health and help build our stress “buffer zones,” making them a vital support in this time. Nervines are herbs that have affinity for the nervous system, and are often fast-acting and overtly calming. 

Support your body’s progesterone levels

Hormone balancing herbs–specifically chaste tree (aka “Vitex”) can be a life saver here.  Chaste tree is thought to support progesterone production via its effects on the pituitary, which subsequently affects ovulation.  For this reason, we typically use chaste tree while there is still a cycle happening, however irregular.  We often see Adaptogen therapy to support the adrenals and nervous system, and possibly supplemental progesterone (oral or topical) can be very supportive as well, especially if your cycles run short and your sleep is impacted.  

In navigating the intricacies of perimenopause, it is paramount to honor the unique rhythms and needs of each individual's body and mind. By arming ourselves with knowledge, embracing bio-individuality, and finding supportive practices, we can transform this transitional period into a journey of empowerment and self-discovery.

Resources:

Polyvagal Theory (PVT):

Self-directed Neuroplasticity:

Internal Family Systems or “Parts Work” 

For a laugh: 

Validating:  


Balance

 

 

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