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In the recent weeks I have met some amazingly strong and determined women whose stories will forever stick with me and forever change my practice. Time and time again, I hear stories of women who have been dismissed by conventional medicine with lines such as "your labs look fine," or "you are too young to be starting perimenopause," "you should just start birth control," or "your symptoms are because you are fat." Yes, you read that last one correct, a doctor told a 37 year old woman that she was losing her period because she was fat – no, this is not a thing; rather this woman should have had a work-up at the time to rule out polycystic ovarian syndrome or primary ovarian insufficiency (POI).
Unfortunately this was not done, and her cycles never returned. She was entering premature menopause which is now called primary ovarian insufficiency. Now at age 52, per the Menopause Society's guidelines, she is no longer a candidate for hormone therapy because she has been without hormones for more than 10 years. If she were to start now, it may increase her risk for heart disease.
POI is defined as amenorrhea (loss of menstrual cycles) prior to the age of 40. In this circumstance, it is a medical imperative to start HRT (hormone replacement therapy) as it is known to prevent risk for dementia, osteoporosis and heart disease. Sadly, she is now struggling with severe osteoporosis at 52 years old at midlife.
So what about the women who start to have symptoms of perimenopause earlier than expected. Well, first we have to define when "expected" is. The average age of menopause is 52 (this is when you have not had a period for one full year). The average age of perimenopause is 45. Early perimenopause is defined as symptoms starting between 40-45.
Progesterone starts to decline first, typically between 40-45, but for some women, may be as early as 35. The earliest symptoms we see of progesterone decreasing are increased anxiety (maybe subtle or not) and sleep issues – difficulty falling asleep, staying asleep, trouble going back to sleep and/or frequent night time awakenings. It is so easy to write these symptoms off as something else, namely stress.
Testosterone also starts to decrease in a woman's 30s. The symptoms here may be even more insidious and easy to write off as something else, but look for a constellation of symptoms to give you some clues: fatigue, low motivation, irritability, decrease in muscle mass, difficulty putting on muscle when exercising, poor recovery after workouts, low libido/sex drive, and a decrease in body hair, notably on upper thighs and arms.
When in doubt, do a work up. Labs can help, but yes, it is not a perfect science, I describe it as an art, a skill I have developed from years of looking at thousands of luteal phase labs – yes, sometimes they can be misleading, but often, we can get a general idea of what is going on, and if it clearly is menopause, we can typically see this in labs. So what does the Menopause Society say?
Don't use labs to diagnose perimenopause, rely on symptoms. So if a woman has all symptoms of perimenopause and other conditions have been ruled out, like hypothyroidism/Hashimoto's, adrenal dysfunction, secondary amenorrhea (malnutrition, gut dysbiosis, chronic health conditions like autoimmunity) and pituitary adenomas), then treat; treat based on symptoms.
So then what if a woman's symptoms start earlier than 40? What a gray area. What an underrecognized/under treated group of women. Yes, this is young, but not impossible. The most beneficent clinical course, in this situation, is to try to optimize your hormones; it does not hurt to try. As mentioned, in our post on "do hormones cause breast cancer" the answer is, no, not with the modalities most typically used today: transdermal estradiol and oral micronized progesterone (Prometrium). Hormones are some of the safest medications we can prescribe; complicated, yes, but harmful, no. I credit Dr. Heather Hirsch for allaying any fears I have had prescribing bioidentical hormone therapy (bHRT).
So to circle back to the question on hand, when do I start bioidentical HRT, my answer is, when your body tells you it needs support and we cannot find any other clinical explanation for your symptoms.
A little personal background on me, I have had low "normal" testosterone for longer than I know, and I have seen these clinical and physical signs. Shockingly, this year, I was diagnosed with osteoporosis. I can't say it is solely due to low testosterone. Stress likely plays a large role (for both the low T and the bone loss), but I know low testosterone is a significant factor. This should not be ignored. Testosterone isn't even on an annual panel. Actually none of your hormones are!
At Liv, we provide preventative care and are looking to identify problems before they become actual problems. If you have symptoms or suspect symptoms of perimenopause or menopause, I encourage you to have your initial consultation with us, and we will do your hormone panel and any other diagnostic investigation necessary to sift through the possibilities.
I hope this information is helpful and reassuring on your health journey to and through midlife.
In wellness,
Kristen, FNP-C
