Perimenopause (aka Reverse Puberty)

There are all sorts of nice euphemisms for the transition to menopause, such as “the change before the change.” But I prefer to call it what it is: reverse puberty. Just like puberty, our hormonal peeks are higher and the valleys are lower, leading to unpredictable emotions, changes in metabolism, and the dreaded hot flashes. (No, I will not be cutesy and call them “power surges.”)

There are few things in medicine that are more esoteric than the perimenopause, and we doctors typically avoid esoteric diagnoses. We like things to be black and white: is that bone broken or not? Does the patient have diabetes or not? Unfortunately, there is no good test in conventional Western medicine to determine if a woman is in perimenopause.

(This is an untouched photo of my patient after stopping hormones. She is 42.)

In my opinion, this is one area where a functional medicine approach is superior. What is functional medicine? There are lots of definitions but the most accepted is that it is medicine that looks at root causes of conditions and does not just try to treat symptoms.

Hormones are complicated, but we can simplify a little by dividing them into three main categories, and all categories come into play when describing the Perimenopause.

  • Sex hormones include estrogen, testosterone and progesterone.
  • Stress hormones include cortisol and DHEA.
  • Metabolic hormones include thyroid, glucagon and insulin.

To be honest, this is all one big ven diagram and every hormone directly or indirectly affects every other hormone. Example: if you are a female with high cortisol, you will likely have higher insulin and lower thyroid function. 

Despite this complexity, there are a few key points that women should understand.

Progesterone deficiency is a major factor in the perimenopause.
Progesterone is made by the ovaries when a woman ovulates. Women who are transitioning into menopause will sometimes skip ovulation and thus not make progesterone. This is the main reason for irregular and sometimes heavy bleeding.

Progesterone and estrogen are the yin and yang of hormones. Progesterone deficiency leads to estrogen dominance. In my experience, most women with heavy bleeding will benefit from progesterone replacement.

So why don’t we just draw blood to determine progesterone levels? Because like most hormones, it is constantly fluctuating. It also cannot be measured in isolation. One must evaluate other hormones to get the full picture.

When I was a youngster in residency, I was taught that all progesterones were the same and that bio-identical hormones were a bunch of BS and BTW, which medical school did Suzanne Somers* attend? Although I still do not rely on Ms. Somers for medical advice, I have changed my mind and I truly believe that bio-identical progesterone is safer and superior to synthetic progesterones.

Hypothyroidism is wayyy underdiagnosed. The symptoms of a low-functioning thyroid can mimic symptoms of perimenopause, such as fatigue, hair loss and weight gain. Thyroid labs, specifically TSH, have “normal” ranges that are far too broad and miss many cases of hypothyroidism.

Functional medicine has long recognized that a normal TSH should be closer to 2.0 instead of under 5, and main stream endocrinology organizations are beginning to agree. However, a lot of primary care providers are still using old data and missing this.

Hormone replacement is not poison. Not every women going through the transition needs extra hormones, but many will and they will feel better and function better. There are risks with any hormone replacement, but these risks have been greatly exaggerated.

Do not forget the stress hormones. Stress and the adrenal glands play a huge role in the symptoms of perimenopause. These are best evaluated with saliva or urine testing. A lot of mainstream doctors will dismiss this as bogus without looking at the data. Again, I feel that functional medicine addresses this more thoroughly than conventional Western medicine.

The Women’s Health Initiative (WHI) caused millions of women (and their providers) to fear hormones . It is important to note that the women who were studied in the WHI were considerably older than the average woman going through menopause, and the hormones they were given were at higher dose and almost exclusively synthetic. Apples to oranges.

I am not sure if I totally embrace the existance of “adrenal fatigue,” but I think there is some validity. A family practice doctor whom I respect explained it this way: we know that there are disorders of excess cortisol (Cushing’s Disease) and deficiency of cortisol (Addison’s), but isn’t there a spectrum of adrenal function? This is a very controversial subject and volumes of books have been written about this, so I will stop here.

Take home points:

  1. Perimenopause is often a time of progesterone deficiency and replacing progesterone can ease the transition and help many symptoms.
  2. Thyroid is under-diagnosed. If you have symptoms of hypothyroidism that are not fully addressed or are dismissed, get a second opinion.
  3. Do not fear hormones. They might do you some good.
  4. Do not only focus on the sex hormones. Appreciate the complexity of our hormonal milieu, including stress hormones like cortisol, and seek providers with expertise in this.

*For those of you who were not addicted to 80s sitcoms, Suzanne Somers starred on “Three’s Company” and later became a proponent of bio-identical hormone replacement. She is loathed by much of the mainstream medical community.

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