Navigating Perimenopause

Posted: Jun 5, 2021 By: Comment: 0

While trying to get this post going, I spent a good few minutes taking my brain back almost 20 years ago. I was trying to remember what exactly I was taught in medical school about menopause. I came up with nothing, other than its when estrogen decline, things dry up and a woman stop menstruating. But even then, we had to wait another 5 years to actually classify the patient as menopausal according to the textbook definition (back then). We were taught to simply medicate this with a oral synthetic hormone replacement tablet and that was it.

I am so glad things have changed in the 20 years since I started medical school.

So let’s get to it – what happens to our hormones as we age?

Perimenopause is the period in a woman’s life when the hormonal equilibrium starts disrupting itself due the aging process closely influenced by our lifestyle, diet, genetics and environment. Science says this starts at the median age of 51 years, yet we have seen these changes in ladies as early as in their 30’s. In reality, most of my patients are in their 40s when these typical symptoms start presenting themselves and they find themselves in my office.

It is a tumultuous time for a woman and for treating physician. Typically, conventional medicine focuses on the waning estrogen levels when in fact, progesterone as well as testosterone changes all play a role in the typical symptoms seen in the perimenopause. Symptoms include:

  • shortening of your menstrual cycle
  • heavier bleeding
  • anxiety
  • mood disturbances
  • insomnia
  • loss of libido
  • vaginal dryness and pain with intimacy
  • weight changes
  • hair loss
  • dry and aging skin
  • breast tenderness
  • expanding waistline
  • hot flashes

These symptoms often persist for years until they are adequately managed or even brought to a doctors attention.

The 3 sex hormones take front center in this menopausal drama. Their action is so intimately linked to what’s happening with our adrenal glands and the stress response with their sibling hormone, cortisol. Cortisol, also known as the stress hormone, gradually increases as we get older. Cortisol dysregulation wreaks havoc on the hormonal balance in perimenopause. You cannot address hormonal disturbances, without addressing cortisol. To make things even more complicated, thyroid dysfunction in females also tends to present itself in the menopausal years. There is a symbiosis with ovaries, adrenals and thyroid – you cannot manage one without addressing the other.

How do we manage this?

Conventional medicine falls short in managing women in this time of their life. In 2001, a clinical trial known as the Women’s Health Initiative, was halted prematurely into 2002. The otherwise healthy substrate of the trial had an increase in breast cancer diagnoses and thrombotic events such as strokes, heart attacks and DVT. This trial investigated the effects of a synthetic estrogen (derived from urine of pregnant equines) and a synthetic progesterone, or progestin.

It is this trial which created the universal fear of HRT in general. However, that was 20 years ago and science has advanced for the better. Safer treatment options are available – both conventional and in orthomolecular (integrative) medicine.

The answer to menopausal management lies in integrative medicine… not in the “one sized fits all” approach we were taught many years ago. Perimenopause is difficult to manage – both as a patient and for us as doctors. Post-menopausal on the other hand, much easier to manage once you get over the hurdle.

The answer to improvement in symptoms lies with how you eat, how you move, how you think, your environment, easing symptoms and only then, replacing hormones and only if needed. HRT is never the first line approach.

Hormone replacement can be prescribed in bioidentical form or synthetic form. I personally stick to bioidentical HRT for my patients. These hormones are derived from plant origin and more identical in structure to those hormones found in the human body. We use smaller doses, individualise them according to the patient’s symptoms and most will be administered via the transdermal route – via the skin with patches or creams. No woman’s symptoms is the same as the other, the BiHRT caters to just this – tailoring your dose for you. Assisting the way to metabolise and detoxify your hormones, is just as important.

No HRT – synthetic or bioidentical – is without risk. Regular follow ups, surveillance and keeping to screening programs is essential.

Perimenopause is manageable and relief of symptoms is safely achievable with integrative medicine.


Dr Allison Blair.




Allison Blair

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