The Perimenopause Puzzle: Where Do I Begin?!

LTM: How do I know if I’m in perimenopause?

Dr. Flagg: That’s a great question and one that does not have a clear answer. Perimenopause is an individual journey. Just as puberty and pregnancy look different for everyone, your perimenopause journey will be unique to you. The beginning of perimenopause can also be difficult to determine because it can last 4 to 10 years, often making it difficult to pinpoint when things begin changing.

I always thought the first hint of perimenopause would be period changes, but it turns out that one of the first signs of perimenopause is often fatigue. Life is exhausting—women are raising children, caring for aging parents, at the height of their career—so fatigue can often get overlooked as a symptom.

Fatigue can also be tricky as it’s a common symptom of many things. Is it anemia? Low thyroid levels? In medicine, we say common things are common. In other words, yes, anemia and low thyroid levels are common, but what’s the most common? Menopause. We don’t ever say anything is 100% in medicine, except perimenopause. I can say with 100% certainty that perimenopause is going to happen to every woman if they are lucky enough to live through that time period. So, perimenopause should actually be the first thing that comes to a clinician’s mind! I also check in with my patients to make sure they have had a full slew of bloodwork done with their primary care provider, so that we can make sure we’re not seeing any other causes for concern.

Unfortunately, there is no lab work that can confirm perimenopause. Your hormones may be one thing in the morning and another thing a few hours later. Listening to the patient, hearing their symptoms, and potentially ruling out other issues, that’s how we assess for perimenopause.

LTM: Now I’m thinking I may be in perimenopause… How do I get connected to care?

Dr. Flagg: The hope is that you can go to your gynecologist or primary care provider and discuss it with them. It’s become clear that we have done a pretty poor job of educating our clinicians, so we’re playing catch up. What we are doing better at, though, is getting information out there (via organizations like Let’s Talk Menopause, for example!) so that you can arm yourself with information about perimenopause and advocate for yourself when you speak with your provider. We unfortunately often don’t have enough time during an annual visit to dive into menopause. If possible, schedule a separate appointment with your doctor to discuss your symptoms and treatment options. Find a menopause informed provider locally or virtually. If you can’t find a menopause specialist, educate yourself as best as possible, and prepare a couple of questions before your visit!

LTM: What is your first conversation like with patients who come to you with symptoms of perimenopause?

Dr. Flagg: The conversation is so individual based on who is sitting in front of me. There is such a spectrum of how people are affected by menopause. I tailor the conversation based on the patient’s priorities, how severe their symptoms are, and how the symptoms are impacting their daily lives. To talk about everything all at once is too overwhelming, so I focus on what matters most to you. What are your priorities? What are you most concerned about? I often talk about the six pillars of lifestyle medicine:

  1. Sleep
  2. Nutrition
  3. Physical Activity
  4. Stress Management
  5. Social Connection
  6. Substance Use

We often try to move the needle on one or two things. Often the downstream effects of a couple of small changes will make you feel a little better and then we can attack other areas. Sleep is a great example of that. A lot of perimenopausal women aren’t sleeping well. I spend a lot of my day talking about sleep hygiene because if people are sleeping better the downstream effects are huge. I personally feel that hormone replacement therapy (HRT) is one of the best starting points because women often feel so much better with HRT that they are then able to attack the other pillars of lifestyle medicine.

I always remind my patients that menopause is the biggest transition a woman will make. You have to say goodbye to one version of yourself and welcome a new one. That’s going to be a different process for everyone. I'm so grateful to my patients that they’ve felt comfortable talking to me about their symptoms. It takes a lot of courage to say, “I need help.”

Dr. Heidi Snyder Flagg is a founder and managing partner of Spring ObGyn, a private practice in New York City.  Since completing her ObGyn residency at Brown’s Woman & Infants Hospital in 1999, Dr. Flagg’s clinical interests have spanned the spectrum of the woman’s reproductive cycle with a focus on peri menopausal and menopausal issues, challenges and treatments.  She is a certified menopausal specialist.  She is a part of the Every Mother Counts Founder’s circle and holds positions on the HL Snyder Medical Foundation and The Experimental Science Now boards. In addition, Dr. Flagg is a medical advisor to Flow Health. Dr. Flagg lives in New York City with her husband, Chris, and two kids.