Perimenopause vs. Menopause: What Most Women Never Get Told

drop in estrogen. It is a profound, decades-long neurological remodeling process, and you cannot navigate the terrain effectively if you're using the wrong map. So imagine waking up at 3 AM, your heart's racing, you have an inability to go back to sleep for hours, only to fall asleep when the alarm is getting ready to go off. Your brain the next day feels like mush, but you chalk it up to poor sleep. Let's say you're 44 years old. You haven't skipped a period, you haven't had a hot flash, but your mood feels completely unmoored and you can't think through the day. And exercise routine that worked for decades and the diet that worked for decades suddenly seem to yield no results. And you get weight loss resistance and profound fatigue. So like most women, you probably talk to your doctor, you go online, you browse social media, and then you're hit with the wall of confusing and flatly contradictory terminology. One expert or social media influencer tells you that you're in menopause because of your age. Another says you can't be because you're, you're, you're not, you know, having an end to your periods. And then another one says that you're completely normal. And then a third tells you menopause is natural and you should just raw dog it. And then another one tells you that once you hit the mark of no periods, And then you're officially done and everything goes back to baseline. And so, you're stuck trying to figure this out. What I promise by the end of this episode is we're gonna completely clear the fog. You're gonna understand exactly where you are on that midlife continuum. What is perimenopause? What is menopause? And what is postmenopause? They distinctly are different and have distinct different hallmarks. We're gonna break down the precise scientific and clinical definitions, and we're gonna separate them. More importantly, we're gonna look at the neuroendocrine changes that are happening under each hood during each phase. And so you can stop chasing the generic symptoms and start actually tracking and commanding and taking control of your health. So let's look at this. So the current landscape of women's health is saturated with generic wellness advice that treats midlife as a monolith. In reality, the female body goes undergoes distinct metabolic and cardiovascular shifts during this transition. We get shifts in cholesterol production, we get changes to bone, and yet women have historically been left out of all the clinical cohorts, you know, or data from male physiology, and it has been lazily applied to women. And understanding where you are and where you sit on this Straw-10 scale, which is the gold standard of reproductive aging, is crucial because the cardiovascular and bone health interventions that work in post-menopause are fundamentally different than the therapeutic strategies needed during the volatile shift of perimenopause. So let me say that very, very succinctly. Where you are on this continuum of hormonal transition means you need to respond to it differently according to the— where you are in that continuum. So the truth is, is we need to understand where we are and how to figure it out. So mainstream advice tells women you're in menopause when you get hot flashes and your period stops. So if you listen to me, you know, that's complete and utter bullshit. This completely misses the boat and it misleads women into thinking that the years leading up to this moment where we're experiencing sleep disruption, anxiety, depression, body composition changes, and things like irritability and mood instability and a brain that feels like mush because you have extraordinary brain fog. Of, despite having normal cycles, are all in your head. The symptoms of perimenopause are largely neurological in the beginning. And mainstream clinical practice also over-relies on static blood panels in a di— you know, in a dynamic moving target. So they don't even look at your hormones. So therefore you get told we can't look at 'em because they're changing too much. So let's look at the physiology. Let's start with perimenopause. This is the transitional state. And according to the STRAW-10 framework, this is divided into early stage and late stage transition. Now, the mechanism is when it, it begins with a persistent 7-day or greater deviation in consecutive cycle length, right? So, so how long your, your 7-day or your greater deviation in the length of your period. Your ovaries are running low on eggs and it causes a drop in a, in a, in a mechanism called inhibin B and anti-Müllerian hormones or AMH. Anybody that's gone through fertility, we look at that all the time. Without that negative feedback loop, your brain's pituitary gland pumps out more follicular stimulating hormone to try and wake up the ovaries, right? So, a drop in inhibin B and AMH causes a feedback loop that tells the brain, "Hey, there's not much going. So, get some FSH on board and wake the ovaries up." This leads to wild surges where estrogen can actually be higher than normal, followed by steep crashes. Now that's phase 1. Late transition, late transition is marked by a cycle of 60 days or more with no periods where FSH levels cross the threshold, often greater than 25 IU per IL, and anovulatory cycles become standard. So what this means is your FSH starts to climb and stay steadily elevated, and you no longer are shooting eggs out. But you could actually still have something that remotely looks like a period. Now, phase 2, menopause. This is not a long phase. It's a single marker in time. It's clinically defined as 12 consecutive months of spontaneous lack of period, or, you know, and with no surgical or medical intervention. So we're talking about natural menopause, and it is the boundary line, the final menstrual period. And then phase 3 is defined by the STRAW-10 as post-menopause. Once you cross that 12-month mark, you are now in post-menopause. Now, the mechanism here is estrogen has dropped permanently, and it stabilizes at a much lower baseline. Mind you, that baseline is lower than the average man of the same age, and it's primarily converted from androgens in peripheral tissue like your adrenals or your fat cells rather than the ovaries. And your FSH, follicular stimulating hormone, is continuously elevated. This is the stage where rapid bone loss has always been assumed to be happening, especially in the longitudinal study called the SWAN study. And the SWAN study understood that it's in this period that we see significant changes, although newer research point to an acceleration of bone loss that happens in that perimenopausal period stage where you're still having periods, you might be symptomatic,, but the acceleration of bone loss has already occurred because of the wild fluctuation of estrogen and the increased loss or the loss of progesterone. So definitely the SWAN study showed there was an acceleration. And we also see metabolic profiles like lipids, your cholesterol, and insulin sensitivity that now have changed significantly. Now in the clinic, Living Well Dallas and Minerva, the telemedicine, When we look at the research frameworks, right, the single biggest red flag we see in women in their forties who present with intense brain fog, newfound insulin resistance, waking up at 2:00 AM with severe sleep disruption. Often her primary care provider runs a standard lab panel, CBC, CMP, and says, hey, you're fine. And also if they tend to run your sex hormones, they'll see a normal FSH level. And they'll tell her, "Oh, you're too young. Your labs are fine. Let's just put you on antidepressant and sleep medication," right? This is a classical case-style example of missing early perimenopause because hormones levels fluctuate daily, even hourly. A single snapshot, especially done at the wrong time, is going to miss the dynamic neuroendocrine remodeling that is taking place. And we have to look at the symptom architecture to understand the pattern Right? So here's some practical translation, testing reality. Understand that the testing of FSH or estradiol in early perimenopause is highly variable. Instead of tracking cycle length variation, that 7-day rule, and monitoring biomarkers related to metabolic health actually provide a much better solution to what's really going on and much more actionable data. Now, we can also do an early FSH in the first, 5 days to 7 days of someone's cycle. So count day 1 as the day of your cycle. If you check an early FSH there, if it is higher than normal, that is a sign that you're in that perimenopausal transitional period. That's a good way to check and see kind of what's going on. Now, if we're looking for symptom management and trying to understand the disparity between progesterone and estrogen, you're actually gonna look in the second half of your cycle, which is about 19 to 21 days after your period started. If your cycle length is about 28 to 30 days,. So it's very, very important if you're looking at lab work to check for perimenopause, we have to understand what we're looking for. Is it the signal of perimenopause? Then that would be an FSH early on in that follicular phase of your cycle. If we're looking for hormone relationships to each other, we do it in that day 19, 21 of your cycle. If your cycle happens to be the average 28 to 30 days, those biomarkers will start to shift even before those other symptoms show up. And so it's real important to understand that. And when we look at perimenopause, some of the lifestyle things that we can do in this time period is focus on stabilizing our nervous system. And this is where things get lost. Cortisol is your stress hormone along with adrenaline. And for most of us, this time period, perimenopause, is when all of this stuff is an all-time high. We're probably at the top of our career. We're probably managing children who are teens or going off to college, meaning somebody's on our checkbook. We might be managing ailing parents. We already have stress response that's already high. Now, the simple fact is reducing systemic inflammation and supporting sleep and stress tolerance and exercising appropriately and not too much and eating adequately, not starving ourselves to lose weight, all of those things make the the psychological stress we might be under better. And this is often where managing with progesterone at the right time during the cycle in early stage 1 perimenopause, which is the second half of the cycle after you should ovulate. And then in, in the second stage of perimenopause, for a lot of women, progesterone might need to be done every night for sleep. And in that second phase of perimenopause, this is also where you might use some therapeutic use of estradiol. And estriol and/or BiEst to support the body and keep the fluctuations less wild during that perimenopausal transition. And then when we look at post-menopause, the transition strategies to combat the decline in bone density, you know, observed in the SWAN data and looking at resistance training, adequate protein intake, hormone replacement therapy, and direct cardiovascular support is where those things should be solidly in your history and currently being done on a regular basis. So when we look at the emotional residence— resonance of this, like, have you felt frustrated, dismissed, or felt like your body's operating on a different operating manual than what it was before? I want to normalize this for you because you're not losing your mind and you absolutely are not broken. The body is going through a highly orchestrated biological evolution that affects every system, and the frustration you feel is completely rational response to a medical system that hasn't given you the right tools. And true empowerment does not come from a trendy supplement or somebody shaming you and telling you that you need to work your lifestyle a little bit better to get, you know, to basically replace a hormone imbalance that is actual, basically castration of a woman, right? We lose so much of the production of estrogen and progesterone, and testosterone is on its decline too. It just doesn't wildly vary in menopause, but relative to where it was in your 20s, it's often lower, but we have basically gone through a chemical castration at that point. And we have to understand that that affects everything, right? It's why we don't castrate men, cuz they recognize that the impact was extraordinary on men's physiology. The truth is, is it's physiologically the same to women as well, right? So, so let's look at what can we do to sort of look at this transitional phase. So I talked about the perimenopause ladder. All right. So the, the stage 1 and stage 2 perimenopause lab work helps us catch where you are, either that first 7 days for FSH to say, am I in the early throws? Or the second half of the cycle to catch the disparity between hormones. Now, when you get to menopause, remember that's 1 day, 12 months from the last time you had your cycle. Now, the situation of postmenopause means that menopause and postmenopause are the exact same thing. And so, when we look at hormones and hormone testing and laboratory testing, we have to understand that this is where all the metabolic and body changes happen. So, this is where it's absolutely, absolutely required that you get a DEXA scan. And also, I would recommend a body composition scan to see where the shifts are happening in your body. Now, understand, in the US, it is not in the cookbook of conventional medicine to even examine a woman for potential risk of bone mass loss until 65. What's a guarantee at that point? The truth is, is it's highly likely that you've lost enough bone to have an osteopenia or osteoporosis diagnosis if you did not actively try and reduce the risk by taking hormones, by lifting weights, eating protein, and all those other things. So women, if you are in your forties and you're listening to me, this is where you wanna get a DEXA scan. And many of the DEXA devices today can also look at your body composition. Right. So not just weight, but what we're talking about is where the distribution of fat is, because in that menopause transition from perimenopause to menopause, we see a shift of body weight concentration and fat concentration around the abdomen, which is your visceral fat. The DEXA scans and bioimpedance to some— to a little bit lesser degree can capture that visceral fat level because that's that inflammatory fat. So when we're looking at this menopause transition, if you haven't had a bone density done, while you were in perimenopause or prior to that, this is where you must get it. Bone mass and strength and density is easier kept than rebuilt. And especially if you want to do things naturally, it is easier to keep it than it is to regain it. So, so DEXA is one of the things that we highly recommend if you're in menopause and you haven't had a full set of labs. So when we look at the distinguishing marks, we can easily check your estradiol, your progesterone, your testosterone, your DHT, because often those two will be high relative to everything else. And we see— we see estrogenic, you know, female pattern baldness, not because your testosterone and androgens are necessarily high, it's because they are higher relative to your estrogens. But it's important to get DHT because that's often the culprit that's active. Also DHEA sulfate, which is kind kind of your body's measure of your recovery capacity. And those are a minimum to look at your sex hormones. Also, you want to get a full panel of thyroid hormones, TSH, T4, T3, free T4, free T3, antithyroglobulin antibodies, antithyroid peroxidase antibodies, and reverse T3 if you can get it, because that tells you if the shift is also occurring Dr. Betty Murray, with your hormones at the same time. Hypothyroidism and alterations to your ability to convert T4, which is roughly inactive, to T3, the active hormone for thyroid, also can be affected by the changes in your hormones. And especially if your stress is high and your cortisol is high. And so you want a full picture. So if you're in that late perimenopause to menopause stage, you need a baseline. You need to understand if we're just dealing with hormone changes from sex hormones or thyroid or ability to recover. And then it becomes very important to start watching metabolic changes in your body, in your blood work. Like I said, a lot of times it's, it's harder if your doctor isn't aware of when to test for the hormones. But what is almost universally true is we do start to see lipid changes, particularly if you're somebody that has familial hypercholesterolemia or you have greater risk for high cholesterol because estrogen has an effect on the liver's capacity to clear cholesterol and also produce cholesterol. So when it declines, what we see is an general increase in your LDL cholesterol, your total cholesterol, and can even impact triglycerides if we're also insulin resistant. And then the apolipoprotein B, which is the carrier protein that's in that family that carries LDL and is responsible for the plaquing of arteries. That is something you want to watch and be aware of. We want those numbers to be as low as possible, but they automatically creep. So if you're in the perimenopause transition or menopause transition, this should be something you're looking at at least annually. We recommend it, you know, at least every 6 months to just be able to understand, number 1, if things are changing, and number 2, if you're taking action on it, that we're actually seeing changes in the lab work. And so when you're looking at all of the transitional time period, we need to have those addressed all the time. So let's talk a little bit about the research and what, what we do have and what we don't have. The STRAW-10 consensus, this is all the way back from 2012, has been considered the gold standard clinical framework that mapped out 7 distinct stages of reproductive aging using cycle characteristics and endocrine markers. Rather than age alone. Now, the SWAN study, which is longitudinal data, followed a cohort of multiethnic women. So it had a pretty good diversity and it definitively demonstrated when vasomotor symptoms in the last median, about 7.4 years. So what was really important about the SWAN study is they showed that hot flashes and night sweats. And of course, this was a study, you know, looking at the kind of very, very simplistic expression of what they thought menopause really was. But this was the first study that showed that the vasomotor symptoms of hot flashes, night sweats, temperature change lasted 7.4 years, not the idea that hot flashes were only 1 to 2 years. So the SWAN study was, it was valuable in that. Now, obviously we have the historical underrepresentation of women and, and we know that. Now, when we look at more recent studies, the emerging evidence, timeline of bone density loss relative to the final menstrual period is highly established. However, however, more recent research shows that that acceleration of bone loss happens in 3 to 4 years before the actual day of menopause. So here's the question. We don't have verifiable ways in which to understand where you are in that last 3 to 4 years. Labs don't necessarily define it. Symptoms don't necessarily define it. So how are we supposed to understand and treat for bone loss before bone loss occurs? It's glaringly obvious that we have incredible differences between what the older studies show and what we probably need to use to actually help women. And we can't use a cookie cutter template to say, well, we won't dexa you until you're significantly past menopause. And we don't bother to do anything until menopause. That's actually categorically untrue at this point. So when you, you know, when you start thinking about this, when do you notice shifts in your energy? So this is the first reflection question. When do you notice shifts in your energy, your sleep, or your mood? And if you're looking at them as isolated issues, this is when you're looking at connecting them in a broader hormonal transition. So When do you notice those? Because those are the early hallmarks of early perimenopause, and that can affect women all the way down into their late thirties. Here's another question. How many times have you accepted a clinical explanation of everything is normal when your lived daily experience tells you otherwise? Most women have gone through this again and again and again and again. Your gut instinct is almost always right. If not always right. And it's just that the medical community and your care provider is not educated enough to meet you where you're at, or they're dismissing and not actually listening to what's going on. Now, here's the other question. Are your current exercise, nutrition, lifestyle habits designed to support the body you have, or are you trying to get back to the body you used to have? We are working with a different playbook in perimenopause. Early stage, end stage, menopause, and post-menopause than what you did in your 20s and 30s. And I would argue we actually have different playbooks for perimenopause and menopause, and they're similar, but there's slight variations. Are you trying to get back to the body you had in your 20s? Are you trying to work with the body and the biology you have today and learn the new way to do things? This is free from judgment. It's, it's just understanding we have to understand that this transition is a total neuro— brain and endocrine hormone related change. And we have to address it doing the things that our body expects us to do. And I've done many, many, particularly many, many podcasts talking about why we gain weight in menopause and what are the mechanisms behind it, and especially the dietary changes. So you can definitely go back and listen to those. But I want you to think, about where you are on this continuum. I know a lot of the, a lot of my listeners are probably women in menopause and then officially post-menopause. But if we aren't looking at those exact labs to understand what's going on on a regular basis and addressing the hormone deficiency that we have, we are fighting a biological situation where our body is accelerating the aging process. We know that we have Current research shows that aging sort of stays stable, and then we have a significant spike in our 40s, men and women, but especially women. Well, it's very easy to understand what's driving that because it's got a lot to do with our hormones. And so, if we're looking at this transitional time period, perimenopause to menopause, we have to go, go first and say, where do I need to advocate for myself? You know, so if you're in the early perimenopause transition, you're still cycling. This is where tracking your cycle can help. This is where devices like Mira— Mira is a urinary testing device that you actually— it's kind of like a glucose monitor. You pee on a little strip, you put it in the device, and it tests your hormones to see kind of where you're at, because that can help you understand, are you actually ovulating? You know, on a daily basis, it can show you throughout the entire month. Because true, yes, lab work is a single day when you go to the blood draw facility and get your labs done. So newer devices like Mira are great for perimenopause. It's great to understand where you are and tracking for the cycles, and especially identifying, even though you may still be having a cycle, whether you're actually ovulating. This is something that wasn't really clear to me. Like, I did not realize, and I would say most practitioners would also agree with this, that you could have a cycle, and even a regular cycle, and still have low relative estrogen over the course of an entire month compared to where you were when you were cy— when you were actually ovulating. Yes, you might still have spikes that go up and down, but the overall level of estrogen can be sufficiently lower than what it was and you're still having a cycle. And I think I missed the boat. Like, I think I missed the boat on early estrogen intervention because I kept thinking I was high cuz I had all this hallmarks of estrogen dominance, but it was that I had receptors that were highly sensitized. This was my hypothesis to estrogen, but my overall estrogen effect was low, right? So you wanna, you wanna look at it. So if you're in perimenopause, Mira's great. It's relatively inexpensive once you've bought the device if you really wanna watch it. But even if you're looking at the cycle tracking apps, you can track your cycle for 3 times just to see what they're really doing. Just track the days that you actually have a cycle. And especially if that cycle fluctuates in length. Now, some women may be estru— really estrogen dominant during this early perimenopause and menopausal state. And you may actually have heavier periods. Fibroids, fibroids are really common in perimenopause, even into menopause, but they often start to go away in menopause because progesterone has declined and estrogen is unopposed. Compared to where it was when your progesterone was, was normal. So crime scene periods, heavy periods, fibroids are all signs that something's out of balance, but tracking your cycle can help you do that. And then you can also look at things like sleep quality, baseline resting heart rate, because we see changes in baseline resting heart rate. It often accelerates a little bit as you go from early perimenopause to menopause. I remember that I would wake up in the middle of the night. Now, some of this was airway, but I wore an Oura ring and it wasn't— Oura wasn't catching it for me, cuz I had an Oura ring for like 9 years. And I remember that all of a sudden, kind of gradually, my heart rate went higher, but I would get these spikes where my heart rate would go to like 100 in the middle of the night. I may or may not be awake for it. And I remember talking to my husband who's a firefighter and paramedic for the city of Dallas. And he said, uh, Betty, to have your heart rate go up to 100, 120 while you're sleeping, doing nothing, would warrant a ride in our ambulance, right? Now, I was lucky enough to see that because I had a ring on that would catch it. But the question is, why was it doing it, right? And it's— and the hormones, specifically estrogen, has a lot to do with the mechanics and the electronics of the heart. And we get a lot of heart palpitations too. And so we can see that in our day-to-day life, but we can also see it at night. So it might be also using a device like an Oura Ring to track your sleep quality, heart rate, and especially baseline resting heart rate to see, are you getting abnormality or just an overall increase in your heart rate? And then that's how you know you're entering stage 2 in perimenopause. And then what I'd like to do is collapse. Once you're in menopause, you're always in menopause. There's no reason to call it post-menopause. You are menopausal. And even in that time period, as you get further and further out from perimenopause, the other thing that I see a lot is women might get into that first couple years of menopause.. And then the hormone replacement therapy that, that they're doing doesn't seem to work as well, or the dose needs to shift. So the other thing is it's not a static time period. Once you're in menopause, it's not like other things aren't changing. And so I still think it's valuable to get your labs done at least once a year, if not twice a year, including your sex hormones, including your thyroid, always looking at your lipids, your ApoB, your insulin, your glucose. Because I have seen over the last 22 years in my own experience and then in the clinical experience of all the patients that have come to our clinic and also the women that our team helps at Minerva, there is some change that happens as we enter our 50s, late 50s, early 60s, early 70s. Stuff shifts. So you're not in menopause and all of a sudden everything's static and you don't have to do anything else and you don't need to look at it. It does change. So remember, menopause isn't a cliff you suddenly fall off of. It's predictable, it's navigable, and it's a biological evolution. And we have to understand that the distinct physiology shifts between perimenopause and menopause milestones and take you— take the power out of the hands of the confusing internet by understanding the distinct physiological shifts between perimenopause and menopause, and even postmenopause. You can take the power out of the hands of the confusing internet trends, the social media influencers, and quite frankly, the people who are selling stuff online, right? And you can be your own best advocate. You can look at the data. You can also trust what your body's telling you. You can deep dive into your own biology in these transitional periods. And understand how it is uniquely affecting you. The throwing the hands up in the air that conventional medicine does with women today is no longer something we should tolerate. And I hope that this, that this episode helped you understand where you are on that continuum and some of the things that you can do to understand that transitional phase. On the next episode of Menopause Mastery, we're going to dive into a little bit more about the science of matching your, your diet and lifestyle to the metabolic changes in body composition specifically. So I've talked a lot about this, but I'm going to come back to it because I, I know that's, that's what's on your mind. So join me on the next episode of Menopause Mastery, and we'll dig in.