Recognizing perimenopause requires more than a blood test
By Jenny Peterson
Nicole, 43, knew something was off.
Irritability, brain fog, selective anger and mood swings — it was a first in her normally even-keeled existence and had become a regular occurrance.
Then she experienced the more mainstream symptoms often depicted among women of a certain age: hot flashes, especially at night, trouble sleeping and stubborn weight despite regular exercise.
She did the logical first step and booked an appointment with her gynecologist.
Nicole, who asked to use a pseudonym, explained to her doctor that she was still getting regular periods, but something just didn’t feel right with her moods.
The practitioner did what many consider the logical first step to find an answer: A blood test that measures hormone levels of estrogen, progesterone and testosterone.
Surely, they thought, that would find some answers.
But to her surprise, the levels came back normal, so perimenopause was ruled out by the provider.
From a diagnostic perspective, there was nothing to “fix.”
Normally, medical blood testing creates a tangible snapshot — diagnoses, deficiencies, diseases and how our organs are functioning.
But perimenopause specialists now say hormone level testing, surprisingly, provides very little, if any, information.
“Too many women get a, ‘you’re too young’ or ‘your labs are too normal. This simply can’t be perimenopause,’ And we know that that’s not the case,” said Dr. Maggie Evans, a longtime Charleston-area gynecologist who opened Novant Health Menopause Care and Sexual Wellness Center – Daniel Island in August.
Dr. Evans said throughout a woman’s life, her hormone levels are on a constant roller coaster throughout the month — and can even fluctuate day-to-day — in peaks and valleys unique to each person.
A hormone level test won’t determine what a person’s “normal” is, or even whether a result is “normal” for that particular day, she said.
“You could go months feeling the same and then have four months where you feel ‘off,’ and then you’re back to feeling completely normal again,” Dr. Evans said. “A lot of women come in and ask, ‘Can you tell me where I am in perimenopause?’ which would suggest that the ovaries ‘peter out’ over time. And it doesn’t really work that way at all.”
What experts do know is that perimenopause symptoms come from these natural hormonal peaks and valleys.
When a woman is in a valley “dip” in estrogen, her body doesn’t compensate as it once did, and she can experience a literal “crash” that manifests in physical and emotional changes.
One of the most common treatments is hormone replacement therapy.
“Hormone replacement therapy is to give you a little bit of a ‘floor,’ so that when your estrogen starts crashing down, you’re not left with nothing,” said Dr. Kate White, a gynecologist and menopause and metabolic health specialist who opened Recalibrate Health, a boutique membership Midlife Women’s Health Clinic in downtown Charleston this past August.
As Dr. White explains to her patients — and on her podcast Heads & Tails that she co-hosts with her husband, a therapist — these symptoms are not just in a woman’s head, even if her lab results look fine on paper.
Estrogen dips can affect everything from subtle changes in mood to forgetting words.
“Women can notice that executive functions aren’t firing exactly the same way as in the past, like ‘brain fog,’” she said. “And at this point in our lives, we are at the top of our careers and can’t afford to be distracted. Because hormones are fluctuating so widely, you may be able to do great on Tuesday, and then on Thursday, your brain is unreliable. And that can lead to tremendous anxiety.”
A New Dawn
It’s a new generation of perimenopause exploration and a new era of experts recognizing that women are often the first to sense a shift in their bodies.
Instead of relying solely on hormone testing, women’s health experts are employing a new approach: listening to women about their symptoms.
“Just like no woman’s puberty is the same and no pregnancy is the same, no menopause and perimenopausal journey is the same,” Dr. Evans said. “It’s really about looking at the individual and saying, ‘how do you feel and how can we make you feel better? What’s your ‘normal?’”
Symptoms can begin years before a woman has tangible changes in her menstrual cycle — in as little as two months, or as much as 10 plus years before her final menstrual cycle, Dr. Evans said.
Dr. Evans says her focus on menopause and sexual health began early in her career, when she realized medical training had not adequately prepared her to treat these concerns.
“I read a statistic that said under 10 percent of medical residents that come out of training feel prepared to do this. It is undertaught to medical providers, so we know we’ve got a big task ahead of changing our curriculum for teaching,” she said.
Dr. White said her residency training was similarly limited, which inspired her to open her boutique practice.
“The only thing we were told about perimenopause in residency is that it’s when women’s periods start getting irregular. That’s all. There was no treatment,” Dr. White said.
Both Dr. Evans and Dr. White received additional training in perimenopause and menopause health and best practices through the International Society for the Study of Women’s Sexual Health, a multidisciplinary nonprofit organization focused on advancing research, education and clinical practice in women’s sexual health.
Treatment Options Abound
Today, there isn’t just more awareness of perimenopause and its symptoms; there are many ways to tackle them, with hormone therapy available in many shapes, forms and dosages.
There are oral pills, patches, gels, creams and sprays. There are FDA-approved bioidentical forms of estrogen and progesterone, as well as testosterone treatment.
“If you want it through the skin — what we call transdermal — that comes in a patch you change once a week. There’s a gel you can rub on your thigh, a gel/cream you can rub on your arm, a spray you can spray on your arm, and also a longer-acting vaginal ring,” Dr. Evans said. “Many people don’t realize it’s not a cookie cutter treatment.”
The variety of options matters, as doctors often employ a trial-and-error methodology to see what helps manage symptoms.
“I can have five women who are all 43 years old and give them the same doses and they all will have different responses and we’ll make tweaks,” Dr. Evans said. “Rather than the answer being, ‘we just have to go higher and higher and higher in dosing,’ I ask, ‘could there be something else going on? Do we need to regroup and revamp?’”
Even testosterone, the hormone more dominant in men, can be dosed specially for women.
“We have roughly one tenth of the testosterone that men have. And since there is not an FDA approved version for us, the recommendation is to use an FDA approved version for men, but in one tenth of the dose,” Dr. Evans said.
The good news is that hormone replacement therapies tend to work quickly, Dr. Evans said.
“If I start progesterone on a woman, within a few weeks, she is feeling better, sleeping better, and then we know we’re in the right direction,” Dr. Evans said. “No lab result would have told us that.”
Below the Belt
Women during perimenopause are also facing another challenge exacerbated by changing hormones: pelvic floor dysfunction.
About one in three women suffer from some form of pelvic floor dysfunction, according to the Mayo Clinic.
Whether it’s a physiological issue or a condition following childbirth, pelvic floor concerns can be exacerbated during perimenopause when hormones shift.
Again, experts say treatment is not one-size-fits-all. It comes down to listening to what’s changed, even small shifts, from unexepcted drops of urine to discomfort during intimacy.
“There’s some thought that certain pelvic floor issues are heightened during perimenopause when women have a loss of estrogen and progesterone,” said Caitlin McCurdy-Robinson, owner and physical therapist at Inner Strength Physical Therapy, LLC in Charleston. Hormonal changes can affect muscle tone, blood flow, lubrication and elasticity.
Symptoms can include unwanted leakage, increased urinary frequency, urgency, pelvic pressure and pain with intimacy.
“Even though these things are happening to lots of women, it doesn’t mean that this has to be a consequence for aging,” McCurdy-Robinson said. “They are common, but not normal.”
Similarly to how perimenopause treatments have evolved, so have pelvic floor therapies, said McCurdy-Robinson.
“Previously, Kegels had been the answer to everything, but not everybody does well with Kegels,” she said.
A pelvic floor assessment can help determine whether someone needs more strengthening, flexibility or coordination.
More Than Perimenopause
Providers who have taken the time to understand perimenopause know that treating symptoms like hot flashes and brain fog matters, but so does looking and treating the bigger picture — from weight gain and hair loss to sleep, exercise and mental health.
It also means not automatically chalking every change up to perimenopause.
“What we don’t want to do is either dismiss something or focus on perimenopause so hard that we miss parallel lanes of things that could be coming at this time,” Dr. Evans said. “Midlife is such a big time for women to also develop autoimmune disorders or other health changes.”
Dr. White said her practice builds a broader look at women’s health into its approach, incorporating lifestyle, exercise, nutrition and bone density as women navigate the many changes coming at them “like a freight train.”
The empowering takeaway is that women don’t have to just “survive” perimenopause. The more we talk — and listen — to our bodies in an honest and real way, and the more access women have to experts and treatments, the stronger we will all be.
“Quality of life matters so much to our long-term health,” Dr. Evans said. “I tell women, the only ‘wrong answer’ when you think you are in perimenopause or approaching menopause is to feel miserable and to do nothing about it.”
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