Are You in Perimenopause? Take the Quiz to Find Out

Perimenopause refers to the years of hormonal upheaval before your final menstrual period. While perimenopause can begin in your thirties or forties, it’s a complex transition of body, mind, and spirit, not a chronological destination. Kicking off with declining progesterone levels which can affect the timing and flow of your menstruation, perimenopause ends with waning estrogen levels, culminating in your final menstrual period. For some women, perimenopause is a time when mood becomes unpredictable, fat deposits increase, and energy wanes—and most commonly, women experience a conflation of all three or one of the other 100-plus symptoms. Other women may feel free of the hormonal veil of the fertile years and start speaking the truth about what they want and need. Which camp you join may be determined by how you prepare to navigate these subtle, and at times wildly fluctuating, hormonal changes. 

What you’re going through is real, and you need real solutions that are as natural and safe as possible. As a board-certified gynecologist and hormone expert for 30 years, I have written six books on the topic, including the New York Times bestseller, The Hormone Cure¹. In the book, I offer a 3-Step Protocol for women that allows you to personalize what you most need and when you need it. The first step is lifestyle medicine. The second step is plant medicine. If these steps do not resolve symptoms, we recommend that you get evaluated for whether bioidentical hormone therapy is right for you. The third step is to take bioidentical hormones, at the lowest doses and shortest duration to resolve symptoms and improve quality of life. Bioidentical hormones can usually be provided by prescription as estradiol patches and progesterone pills. Many of the bioidentical hormone prescriptions are FDA approved and often covered by insurance plans, whereas others may be compounded by specialized pharmacies.²

The Knowledge Gap

Unfortunately, most women are uninformed or have very limited knowledge about perimenopause and menopause before the age of 40³. Why don’t we teach about it in school? Most physicians feel ill equipped to counsel women about perimenopause and menopause because of the Women’s Health Initiative published in 2002, which showed increased risk associated with hormone therapy—and scared clinicians and women away from treating menopause. Now the fears from the study appear to be largely overblown⁴.

It's not just that women lack information and past studies scared us off unnecessarily. Why has the research agenda in the United States largely ignored the needs of women over forty who are experiencing perimenopause, leading to massive gender health gap? One recent analysis from the prestigious journal Nature found that for many of the conditions associated with decreased longevity, female patients have more problems and are more likely to have adverse effects from treatments compared to male patients. While 70 percent of the most common age-related diseases are caused by loss of reproductive hormones, when the authors reviewed the preclinical studies of longevity, they found that less than 1 percent of published studies considered the role of menopause⁵. That’s shameful and no longer acceptable.

The net result of the knowledge gap and gender health gap is that women are left to wonder what’s occurring in their bodies, desperate for reliable information, and meanwhile most physicians are as uninformed as the women they are meant to serve.

Given that perimenopause is not well understood by most women and certainly not by their doctors, more trustworthy information is needed. Most women don’t realize that perimenopause is much rockier and more difficult than menopause, because hormones fluctuate month to month, sometimes mildly and sometimes wildly. In my thirties, I figured menopause was some future cliff I’d fall from, around age fifty or so, in the distant future. Not true. Your body has been preparing for this cliff for years, and it will pay future dividends for you to understand the “perfect storm” of perimenopausal hormone imbalances. I had signs of imbalance already—and my more frequent periods, premenstrual syndrome (PMS), deteriorating libido, rising glucose, and growing waistline were the clues. You may find that previous methods of coping (occasional exercise, yoga a few days per week, dark chocolate, a cocktail most nights) don’t seem to work as well. Metabolism becomes less forgiving. You may feel more stressed out. Sleep erodes. Amygdala hijack can occur almost daily—meaning your “reptilian,” or lower, brain, not your rational being, takes over, and overreaction may become the norm. Sometimes your spouse or partner feels like the enemy. 

The ongoing state of perimenopause reflects multiple changes in the hormonal symphony—progesterone, estrogen, testosterone, and insulin. Part of what you may be experiencing is the interplay of your major hormones at a time of great neuroendocrine fluctuation. This life stage need not be a death march through middle age; perimenopause is a period of biological rough waters that can be navigated optimally with a smart captain at the helm of the ship. That means you, maybe with the help of a trusted clinician. (If you’re having trouble finding the right doctor, check out our new Mentorship program.)When you’re 35 to 50 and wonder if your anxiety, sleep issues, and increased feeling of nervous system dysregulation make you wonder if you are in perimenopause, take the updated quiz from The Hormone Cure, which might indicate whether your symptoms are related to perimenopausal hormonal changes.

The Perimenopause Quiz

Do you have, or have you experienced, in the past six months . . .

• Your period is coming more often—maybe it was once every 28 days and now it’s every 22 to 25 days?
• Emotional dysregulation—for the first time in your life, you feel anxiety or burst into tears at a moment’s notice, (even at work!)?
• Muscle or joint changes: loss of muscle mass, joint pain, less response to exercise despite hours at the gym?
• An unpredictable menstrual period—spotting or flooding or some weird combination of the two?
• Poor sleep (indiscriminant debates and ruminations awakening you in the middle of the night)?
• Waking up so sweaty that you need to change your pj’s and sheets, and perhaps even your husband (or partner)?
• Feeling less interested in daily chores (e.g., grocery shopping, laundry, dishes, and cooking)?
• A preference for introversion combined with wardrobe malfunction (reluctant to wear anything other than your yoga pants if you have to leave the house)?
• A need to wear stretchy pants (yoga leggings win again!) to make room for the roll around your waist, which seemed to arrive overnight?
• Dissatisfaction with exercise (it doesn’t seem to affect your weight anyway) or more fatigue post-workout?
• Feeling blah or reclusive; you can’t wait to extricate yourself from normal activities and retire for the evening?
• Crow’s feet and/or a permanently furrowed brow?
• Apathy for personal grooming (you really don’t care how attractive you look, unless forced by your job or seeing friends)?
• Sudden forgetfulness when walking into a room (knowing you had a purpose but searching for clues as to what it was)?
• Doubting your own instincts and insights?
• More frequent announcements to the family that “I’m going to take a nap now” or “Mom needs a time-out”?
• A preference for chocolate or a glass of wine over sex?
• A notion that Xanax or a little Lexapro, maybe an Ambien, sounds increasingly appealing?
• An opinion that addressing your mood issues by giving up sugar, alcohol, and carbs, taking various supplements, beginning a heavy strength-training protocol, and other lifestyle medicine sounds like way too much work?

If you answered “Yes” to five or more of those questions and you’re aged thirty-five to fifty-five, welcome to perimenopause. This means your ovaries have started to sputter and are no longer manufacturing the same, predictable, and consistent levels of the sex hormones—estrogen and progesterone—that they used to. To make matters worse, your brain is less responsive to the hormones your ovaries still do produce and the happy brain chemicals such as serotonin may head south. Some women sail through perimenopause without a worry; others need increased support. Both are a normal reaction to the midlife hormonal flux. If you answered “Yes” to fewer than five questions, you may want to track your menstrual cycles with a wearable or an app, and consider blood testing.

Blood Testing for Perimenopause and Diminished Ovarian Reserve

You can run blood tests to check on your hormones, though there is not a single diagnostic test. The interpretation of hormonal blood testing is best done in collaboration with a knowledgeable clinician. For women who are still cycling, you can request a Day 3 estradiol and FSH test. Some women find a measure of Anti-Mullerian Hormone to be helpful (normal AMH in reproductive years is 1.5-4.0 ng/mL, and as it drops lower in your forties to 0.01 ng/mL. AMH can predict the likelihood of menopause in the year or so to come, though it is less precise than you may hope and may require multiple measurements⁶. For women who have stopped cycling or have had a hysterectomy, you can check for an FSH > 25 IU/L⁷. FSH can indicate menopause when it is elevated—but may be normal in perimenopause. That’s why a more nuanced approach to diagnosis of perimenopause with a trusted clinician can be helpful.

Given most physician’s uninformed and negative bias toward the menopause, women commonly feel unprepared to cope with the physical, mental, and emotional changes associated with perimenopause and menopause. If you want more support for the transition through perimenopause and menopause, check out our Mentorship program, called Rise. Dr. Sara guides a small group of women through the initiation process of bodily changes and how small, targeted, safe, and proven shifts can create transformational changes.

Footnotes

¹Sara (formerly Gottfried) Szal, The Hormone Cure (New York, Scribner, 2014). https://a.co/d/6uwk7I5

²National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Sciences Policy; Committee on the Clinical Utility of Treating Patients with Compounded Bioidentical Hormone Replacement Therapy. The Clinical Utility of Compounded Bioidentical Hormone Therapy: A Review of Safety, Effectiveness, and Use. Jackson LM, Parker RM, Mattison DR, editors. Washington (DC): National Academies Press (US); 2020 Jul 1. PMID: 33048485. https://pubmed.ncbi.nlm.nih.gov/33048485/

³Tariq B, et al. Women's Knowledge and Attitudes to the Menopause: A Comparison of Women over 40 Who Were in the Perimenopause, Post Menopause and Those not in the Peri or Post Menopause. BMC Womens Health. 2023 Aug 30;23(1):460. doi: 10.1186/s12905-023-02424-x. PMID: 37648988; PMCID: PMC10469514. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10469514/

⁴Manson JE, et al. The Women's Health Initiative Randomized Trials and Clinical Practice: A Review. JAMA. 2024 May 28;331(20):1748-1760. doi: 10.1001/jama.2024.6542. PMID: 38691368. https://pubmed.ncbi.nlm.nih.gov/38691368/

⁵Gilmer G, et al. Female Aging: When Translational Models Don't Translate. Nature Aging. 2023 Dec;3(12):1500-1508. doi: 10.1038/s43587-023-00509-8. Epub 2023 Dec 5. Erratum in: Nat Aging. 2024 Jan;4(1):164. doi: 10.1038/s43587-023-00561-4. PMID: 38052933; PMCID: PMC11099540. https://pubmed.ncbi.nlm.nih.gov/38052933/

⁶de Kat AC, et al. Role of AMH in Prediction of Menopause. Front Endocrinol (Lausanne). 2021 Sep 14;12:733731. doi: 10.3389/fendo.2021.733731. PMID: 34594304; PMCID: PMC8476919. https://pubmed.ncbi.nlm.nih.gov/34594304/

⁷Ramezani Tehrani F, et al. Improving Prediction of Age at Menopause Using Multiple Anti-Müllerian Hormone Measurements: the Tehran Lipid-Glucose Study. J Clin Endocrinol Metab. 2020 May 1;105(5):dgaa083. doi: 10.1210/clinem/dgaa083. PMID: 32109280. https://pubmed.ncbi.nlm.nih.gov/32109280/