Perimenopause: An Undertreated Phase in Women’s Reproductive Lives
LISA BRENT, ND, LAc
Perimenopause is the time period in which women transition from premenopause (the reproductive years) into menopause. Typically, these changes occur between the ages of 40 and 51 and usually last about 4 years. Perimenopause ends 1 year after a woman’s last menstrual period, at which point she is officially in menopause.1 Symptoms of perimenopause can be mild, such as slight changes to the menstrual cycle, or much more severe, including heavy periods and debilitating mood swings.
I love treating women in this phase of their lives, as they are so often misunderstood and undertreated by the conventional medical community. Most women do not realize that, due to the extreme hormonal fluctuations of perimenopause, the experience can be rockier and more challenging than menopause itself.
Women who do seek help from their primary-care provider or OB-GYN are often prescribed an antidepressant or oral contraceptives to manage their symptoms. Some women will not even mention their symptoms to their doctors because they believe they have to “tough it out” or that there is nothing that can safely help. That is absolutely not true. Naturopathic medicine has many tools for supporting this patient population. A thorough evaluation of the thyroid, adrenal, and reproductive hormones, as well as an assessment of the gastrointestinal system and the influence of environmental toxins, can be very helpful in determining a course of treatment that will help bring vitality and optimum health into the lives of these women.
Onset & Symptoms
Perimenopause can begin anytime between a woman’s late 30s and early 40s. Many women are caught by surprise when these changes start to occur, as they assume they are too young to be having hormonal issues. In the San Francisco Bay Area, where I live, women tend to have children at an older age. In this demographic, it is thus not uncommon to have young children and be in perimenopause at the same time. Many women in this age group are busy – raising children, building careers, caring for aging parents – so when they start to experience changes to their health, they will often overlook them, assuming they are due to inevitable age-related decline.
Perimenopause is highly symptomatic for about 20% of women; however, almost all women experience symptoms to some degree.2 The complaint I most often hear in my office is, “I don’t feel like myself anymore.” The details of this statement can include any or all of the following:
- Weight gain (especially around the middle) in spite of good diet and exercise
- Insomnia and sleep disturbances
- Loss of libido and sexual function
- Hot flashes and night sweats
- Heavy and frequent periods
- Breast tenderness and enlargement
- Headaches and migraine
- Inability to tolerate alcohol
- Insulin resistance
- Mood changes, including anxiety, depression, and irritability
- Dry and thinning hair
- Dry skin, loss of elasticity of facial skin
- Onset or worsening of “estrogen dominance” symptoms, such as uterine fibroids, fibrocystic breast disease, ovarian cysts, and endometriosis
Blood testing is useful for determining ovarian reserve, thyroid function, iron deficiency, and vitamin D status. If the menstrual cycle has started to become irregular, then a cycle day-3 blood panel including follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol can provide valuable data on menopausal status. A fasting panel for lipids, insulin, and HbA1c can highlight risk factors for cardiovascular and metabolic diseases that increase for women at menopause. Specialized blood tests can rule out chronic infections, food allergies, leaky gut, and other potential contributors to the symptom picture. (I will include these in an initial work-up if history and clinical presentation indicate that symptoms may be due to factors outside of age-appropriate hormonal shifts.)
We use salivary testing to assess cortisol rhythm and bioavailable levels of the reproductive hormones. Because of the variability of hormone levels throughout the day, a 4-point collection allows for a more accurate average of daily production. Laboratory testing will often reveal a decline in progesterone, due to intermittent ovulation. But because the ovaries are still producing estrogen, a relative “estrogen dominance” can result. This can lead to many of the most common symptoms, in addition to an increased risk of endometrial hyperplasia and cancer.3 During the 2-10 years before true menopause, estrogen levels can fluctuate wildly. Most women in perimenopause have higher estrogen levels than women in their 20s and 30s.4 The most symptomatic women have both higher estrogen and lower progesterone.5
Functional stool testing allows us to evaluate levels of beneficial vs pathogenic bacteria, intestinal immune function, overall intestinal health, and inflammation. Since many chronic disorders stem from digestive imbalances and inadequate nutrient absorption, assessing the microbiome can be very helpful in clearing the path to successful hormonal treatments.
Endocrine disruptors, such as toxic chemicals, mycotoxins, tick-borne illnesses, heavy metals, and chronic infections, can influence hormonal function and exacerbate imbalances. A thorough intake and possibly a specialized questionnaire will help clarify whether these factors should be investigated. It is increasingly common to see hormonal disruption in females of all ages as a result of, or at least influenced by, environmentally acquired illnesses.
Diet, Lifestyle & Exercise
To be honest, poor diet is not often an issue with the women in my demographic, as these women are usually well versed in healthy eating and exercise regimens. Ironically, these are patients who sometimes need to be counseled to relax their dietary restrictions and to decrease intensive exercise that is worsening cortisol elevations.
Even if the daily diet is well balanced, though, guidance can be given to increase foods high in phytoestrogens, to decrease exposure to xenoestrogens, and to emphasize clean, organic, whole foods, and plenty of healthy fats. Most women I see have already tried ketogenic diets, intermittent fasting, and various cleansing programs in order to lose weight. They often need to be counseled on the importance of maintaining stable blood sugar, eating a variety of whole foods, and reducing alcohol intake. Wine is particularly popular among my demographic. While it is a tempting means to ease anxiety and stress, alcohol almost always leads to sleep interruption, worse hot flashes, and weight gain.
Dietary counseling can also play an important role in decreasing the excess estrogens in a typical perimenopause. Increasing fiber from vegetables and gluten-free grains and eating cruciferous vegetables such as broccoli, cauliflower, kale, bok choy and Brussels sprouts, as well as using supplements such as diindolylmethane (DIM) and calcium D-glucarate, will contribute to a healthy microbiome and effective estrogen clearance.6
Liver-supportive foods, such as dark leafy greens, turmeric, green tea, and olive oil, are highly recommended as well. Herbs such as Silymarin (milk thistle), Taraxacum (dandelion) and Arctium lappa (burdock) root can be used as a tea or in a lipotropic supplement blend to assist the liver with the synthesis and detoxification of hormones. Castor oil packs are also wonderfully supportive during this time of hormonal fluctuation.
The Hormonal Triad: Thyroid, Adrenal, & Ovary
A thorough thyroid panel can reveal subclinical hypothyroidism, autoimmune thyroiditis, or a poorly functioning gland.7. Treatment should be appropriate to the lab findings and also based on the clinician’s skill in using various thyroid treatment tools. Nutrients such as iodine, zinc/copper, Coleus forskohlii, L-tyrosine, as well as glandular products, can help normalize thyroid function. Where appropriate, desiccated thyroid medications can be a temporary support or part of a long-term bioidentical hormone approach that provides welcome symptom management.
We do not necessarily need an adrenal test panel to demonstrate that women in their 40s are stressed (though some patients like to see the data to prove that how they are feeling is real). But removing the stressors is not always an option. Our most effective approach is to provide tools to help modulate the stress response and shore up patients’ resilience so they can navigate this time in their lives without becoming completely depleted. Counseling around healthy boundaries, meditation, exercise, and diet are always helpful. If a woman has a history of trauma, this might be a time in her life when she is ready to do some deeper healing work with a therapist or somatic healer. Our adaptogen herbs, such as Withania (ashwagandha), Eleutherococcus root, Ocimum (holy basil) and Rhodiola8 can create a supportive infrastructure underneath the reproductive hormone fluctuations.
In my experience, perimenopause is the time for progesterone. The proper use of bioidentical progesterone can be incredibly effective in mitigating many troublesome symptoms during this time. Used as a transdermal cream or in the oral micronized form, progesterone decreases vasomotor symptoms, improves sleep, breast tenderness, irritability and heavy menses. Oral micronized progesterone (OMP) can increase bone formation and has cardiovascular benefits. OMP does not increase breast proliferation or cancer risk5; in fact, it can help to mitigate the effects of excess estrogens on the breasts and uterus.9
One inaccurate assumption about perimenopause is that the estrogen levels are dropping or deficient. Accordingly, I often see estrogen therapy prescribed while a woman is still having fairly regular menses. This can contribute to (or exacerbate) an estrogen dominance and elevated cortisol.4
Testosterone can also be a player in perimenopause treatment. Physiological levels of testosterone are important for maintaining the strength of muscles, bones, and connective tissues.10 Testosterone also plays a key role in the brain to increase neurotransmitters, such as dopamine, which are crucial for mood elevation and sex drive. These findings support the protective role of bioavailable testosterone in counteracting the proliferative effects of estrogens on mammary tissue.11
Herbal medicine has a long-standing record of success for supporting women through hormonal changes. Herbs such as Actaea racemosa (black cohosh), Trifolium (red clover), Dioscorea (wild yam), Panax ginseng, and many more can provide effective, non-hormonal, symptomatic support during perimenopause. Many of the women who come to my office have already tried some western or Chinese herbal protocols, often finding some relief but not enough to mitigate their symptoms entirely. Bioidentical hormone therapy (bHRT) is a specialty of my practice, so many women choose to see me because they are interested in this option. When it is appropriate, bHRT can be a game changer.
IV nutrient therapy, intramuscular B-vitamin injections, and acupuncture are tools used in my clinic to support women in various stages of perimenopause, and can be tailored to the individual symptom picture. After the hormonal landscape has been stabilized, peptide therapy to help with weight loss and healthy aging can be very effective. Acupuncture is also a welcome modality for a myriad of symptoms, especially sleep disturbances.12
A.C. is a 49-year-old woman with 2 grown children who presented with weight gain, joint aches, temperature fluctuations, decreased libido, irritability, and sleep issues. She stated that she was very active, ate a healthy diet, and had been struggling with these symptoms for several months, during which she had gained 20 pounds, mostly around her breasts and belly. “I feel like I am wearing a layer of fluff all over my body.” Her menstrual cycle had been irregular and light ever since an ablation procedure to curb heavy menstrual bleeding 1 year earlier. A.C. had always had heavy and painful periods. Stress was high but was managed with regular exercise. Family history was significant for uterine cancer (maternal grandmother) and a later menopause (mother).
A.C.’s personal and family history suggested a pattern of estrogen dominance. As she approached her own menopause, A.C.’s estrogen was increasingly exerting its influence on her adipose cells, her breast tissue, and uterine lining, as it was unchallenged by adequate levels of progesterone.
Some basic lab testing to assess thyroid function (which can be altered by excess estrogens13), iron status, and vitamin D were part of our first evaluation. Salivary hormone testing was deemed unnecessary, as her clinical picture of estrogen dominance was clear and adrenal dysregulation was not a concern. Significant lab results included the following: TSH = 2.79 mU/L; Free T3 = 2.6 pg/mL; Free T4 = 89 ng/dL; Anti-TPO antibodies = <10 IU/mL; Free Testosterone = 1.05 pg/mL; 25-OH-Vitamin D = 26.2 ng/mL.
Estrogen dominance; Subclinical hypothyroidism; Vitamin D deficiency; Androgen deficiency. A.C. presented with a fairly typical perimenopausal picture, which often includes some degree of thyroid hypofunction. Her low vitamin D was a likely contributor to a number of her symptoms and a reminder that not everything at this stage of life is purely about the reproductive hormones.
- Natural dessicated thyroid (NDT): 32.5 mg daily in the AM. Purpose: A short-term course of NDT can be a simple and safe way to improve symptoms, kick-start metabolism, and provide synergy to the treatment protocol. While there are a number of effective herbal strategies for improving thyroid function, many of my patients are frustrated by their previous efforts and are eager to see results.
- Progesterone SR (sustained release) 100 mg: 1 capsule at bedtime on all non-menstruation days. Purpose: To help clear the excess estrogen from her tissues and to “balance” estrogen stimulation
- Testosterone 1.5 mg compounded cream: To be applied to the labia daily in the AM. Purpose: To improve libido, lean muscle mass, and cognition10
- DIM 100 mg: 1 capsule in the AM. Purpose: To clear excess estrogens
- Stress B-Complex: 2 capsules with breakfast. Purpose: To support nervous system function and detoxification14
- Magnesium glycinate 110 mg: 2 tablets at bedtime. Purpose: Relaxation and sleep support15
- Vitamin D3: 5000 IU/day in a complex with vitamins A, E, and K. Purpose: To act as a pre-hormone for multiple pathways, and to support mood, immune function, and bones16
- Add daily fiber to the diet in the form of flax, chia, and hemp seeds, and increase intake of cruciferous vegetables: always cooked and eaten at least 2 hours away from thyroid medication. Purpose: To further support the clearance of excess estrogens
At our next visit 1 month later, A.C. reported feeling better. She had lost 13 pounds since starting the regimen, was sleeping through the night, and her mood was more even.
Two months later, she had lost a total of 24 pounds, and reported, “I’m feeling like myself.” Her cycle was still irregular and periods were coming farther apart.
Follow-up lab testing showed the following: TSH = 1.89 mU/L; Free Testosterone = 2.95 pg/mL; 25-OH-Vitamin D = 41.3 ng/mL. A.C. was advised to continue with our treatment plan until she began to skip periods more frequently or her symptoms changed.
Providing effective treatment options to women in perimenopause is crucial to their quality of life and the prevention of chronic diseases later in menopause. Naturopathic modalities are perfectly suited to treating this population due to our wide variety of tools and the individual variations in this phase of a woman’s life. It is extremely satisfying to see a woman regain her sense of vitality and confidence as her hormonal health is restored.
- Nicula R, Costin N. Management of endometrial modifications in perimenopausal women. Clujul Med. 2015;88(2):101-110.
- Prior JC. Progesterone for Symptomatic Perimenopause Treatment – Progesterone politics, physiology and potential for perimenopause. Facts Views Vis Obgyn. 2011;3(2):109-120.
- Duckitt K. Medical management of perimenopausal menorrhagia: an evidence-based approach. Menopause Int. 2007;13(1):14-18.
- Seifert-Klauss V, Fillenberg S, Schneider H, et al. Bone loss in premenopausal, perimenopausal and postmenopausal women: results of a prospective observational study over 9 years. Climacteric. 2012;15(5):433-440.
- Prior JC. Progesterone for treatment of symptomatic menopausal women. Climacteric. 2018;21(4):358-365.
- Zeligs MA. The Cruciferous Choice: DIM or 13C? Phytonutrient Supplements for Cancer Prevention and Health Promotion. Townsend Letter for Doctors and Patients. 2001;218:47.
- Pearce EN. Thyroid dysfunction in perimenopausal and postmenopausal women. Menopause Int. 2007;13(1):8-13.
- Stansbury J, Saunders P, Winston D. Supporting Adrenal Function with Adaptogenic Herbs. Journal of Restorative Medicine. 2012;1(1):76-77.
- Sitruk-Ware R, Bricaire C, De Lignieres B, et al. Oral micronized progesterone: Bioavailability pharmacokinetics, pharmacological and therapeutic implications – a review. Contraception. 1987;36(4):373-402.
- Davis SR, Wahlin-Jacobsen S. Testosterone in women – the clinical significance. Lancet Diabetes Endocrinol. 2015;3(12):980-992.
- Dimitrakakis C, Zava D, Marinopoulos S, et al. Low salivary testosterone levels in patients with breast cancer. BMC Cancer. 2010;10:547.
- Chiu HY, Hsieh YJ, Tsai PS. Acupuncture to Reduce Sleep Disturbances in Perimenopausal and Postmenopausal Women: A Systematic Review and Meta-analysis. Obstet Gynecol. 2016;127(3):507-515.
- Mazer NA. Interaction of estrogen therapy and thyroid hormone replacement in postmenopausal women. Thyroid. 2004;14 Suppl 1:S27-S34.
- McCabe D, Lisy K, Lockwood C, Colbeck M. The impact of essential fatty acid, B vitamins, vitamin C, magnesium and zinc supplementation on stress levels in women: a systematic review. JBI Database System Rev Implement Rep. 2017;15(2):402-453.
- Boyle NB, Lawton C, Dye L. The Effects of Magnesium Supplementation on Subjective Anxiety and Stress – A Systematic Review. Nutrients. 2017;9(5):429.
- DeLuca HF. Overview of general physiologic features and functions of vitamin D. The Am J Clin Nutr. 2004;80(6 Suppl):1689S-1696S.
Lisa Brent, ND, LAc graduated from the combined program in naturopathic medicine and classical Chinese medicine at NCNM in 2000. She is the founder and medical director of Be Well Natural Medicine in Mill Valley, CA, where she specializes in women’s health and, specifically, the safe and effective use of bioidentical hormone therapy. Dr Brent also has a special interest in environmentally acquired illnesses and their impact on the hormonal health of women in all stages of their reproductive lives. She lives in Marin County, CA, with her husband, dog, and 3 teenage children, all of whom keep her busy and happy.