What if it’s Not Perimenopause?

How I helped one client avoid unnecessary HRT.

I am sharing this important case study as I want to demonstrate how important it is to test and do a full investigation before jumping straight to HRT.

I fear that now HRT is becoming so popular and easy to obtain, many women will be put on it when they turn up as 40+ with a list on symptoms associated with perimenopause, and it being totally unnecessary.

But before I go into more detail, I do want to share my view on perimenopause, and remind you all that this is not a disease or deficiency state. It is a completely natural transition. Yes, we go into menopause earlier than most other mammals, but it is not because we are living longer. When they say that historically our average life span was 45-50, this number is the average mean based on taking deaths across all ages. Many babies and children died, many women in childbirth, many men in conflict and hunting. This skewed the mean age of death to 45-50, but when you look deeper into the data, those who did escape childhood, childbirth, and conflict lived well past 70.

I also don’t believe that mother nature would mess things up that much and make us suffer. There is a reason for us ending our reproductive years early, and this was an evolutionary response, because we were and should still be an asset to our families post menopause. As a grandmother, no longer reproducing we were a crucial part of the survival of our children and their offspring. There is a wonderful book that I think all women should read, it certainly was the being in to my journey into my second girlhood, called  ‘The Slow Moon Climbs: The Science, History, and Meaning of Menopause’- by Susan Mattern.

Many women can sail through Perimenopause with very little fuss. The extreme turbulence, I believe (and I am not alone in this belief) is due to the evolutionally mismatch between our genes and our environment (food, stress, sleep, lifestyle, toxins etc). If we address these, we have a much better chance of a positive perimenopause transition. Yes, it is common that many women are struggling, but does not mean its normal. There are very few women I know who are eating well moving well, not stressed, getting enough sleep, and not exposed to loads of chemicals, do you know many?

Anna’s Story

So, let’s talk about Anna (her pseudonym for privacy), she came to see me as she suspected her symptoms were the start of perimenopause; stubborn weight gain, fatigue, menstrual headaches, low mood, PMDD. Anna does have history of depression and is taking antidepressants, and although what we discover through testing Anna will have impacted her depression, the topic of depression in her case will not be discussed, as would require a whole other article to be written.

Her goal was to assess if she was perimeno, and then to go on HRT. She her Follicle stimulating hormone (FSH) and Luteinising Hormones (LH), which btw cannot assess conclusively if a woman is perimeno, in fact no test can. Usually, one can tell by symptoms alone (see here for more on that).

 So why do I test you may ask?

I use testing when a woman comes to me with symptoms, because the symptoms are driven by hormone imbalances, so testing tells me what hormones are out of balance and by addressing them we can usually improve symptoms. This is important to remember, because turbulent symptoms in perimenopause are driven buy imbalances in hormones, and not just sex hormones (oestrogen, progesterone, testosterone), but cortisol, thyroid, and insulin. And sometimes, as we are about to see in this case study there is overlap in many perimeno symptoms with other imbalances that are not perimenopause.

Anna saw her local menopause specialist via the NHS, and it was suggested she start on HRT of body identical oestrogen, and a progestin coil- protgestin is not the same as progesterone made by the body, and I really don’t think this is a good idea to use. I suggested that before she started, we do an assessment of all her hormones to get her baseline, so that she can not only monitor her HRT, but also help her decide on the best combination. Some women only need body identical progesterone, and not oestrogen, and if oestrogen is used it is better not to use without progesterone, because of the important relationship these two hormones have with each other.

Anna was happy to go ahead and do the DUTCH test with me, which looks at urine metabolites of sex hormones, stress hormones, some vitamins, and neurotransmitters. This test is done in the privacy of your own home.

While we waited a few weeks for her results we started working on some diet and lifestyle changes, and by the time we received the results Anna reported that she was already feeling like she has her mojo back.

What Anna’s Results Revealed.

When we received her test results, we found that both her oestrogen and progesterone levels were with the normal premenopausal range, oestrogen is made up of the types of oestrogen Estrone (E1), Estradiol

(E2) and Estriol. Estradiol (E3) is out most dominant oestrogen in our reproductive years. Her progesterone which also declines in as we go into menopause is at premenopausal level. This suggests to us that it is not a sex hormone imbalance driving her symptoms and she certainly does not need HRT.

However, when we look at Anna’s adrenal hormones, we can see she has a blunted cortisol awaking response, this explains why she is so tired in the mornings, and why she would be feeling a bit low in general. And her DHEA is very elevated. This is a picture of chronic stress. We usually see this when stress has been going on for some time, and before this her cortisol would have been very elevated, which is what would have played a role in her weight gain, as this changes our metabolism.

Interestingly Anna reported that she did have burn out not so long ago and was sighed off work because of it. Anna loves her job and works hard, but now she can see how this is impacting her wellbeing and is planning to have a conversation with her manger to find ways she can have more down time.

Next Steps for Anna’s Plan

Our overall strategy with diet has been to increase protein, reduce carbohydrates, increase variety of vegetables, and go gluten free. Anna reports less bloating after going gluten free, and that her body feels so much better with more protein.

Anna loves working out, and we discussed how for the time being she needs to focus more of walks and yoga more than weights. She is to save weight training for days when she feels strong, but not to overdo it. Exercise is good, and I love that she is looking after her muscles and bones with weight training, however when the body is under stress and exhausted heavy work outs will only strain the body more and impede recovery.

I have added in some adaptogenic herbs and supplements to help Anna with her adrenal dysregulation. Based on her health history and current medications I suggested we try liquorice, lemon balm, L-theanine, and holy basil. To help with energy, and menstrual headaches a slow-release riboflavin (B2), and to continue with the mood supporting supplements I started her out on that contain saffron, and specific probiotics shown to support mood and a multivitamin.

Please do not go out and take any supplements/herbs mentioned in this article without talking to an experienced practitioner/herbalist, as many herbs interact with medications and are also contradicted in certain conditions. It’s always better to test or get properly assessed before taking anything.

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