There's a lot of noise about perimenopause right now — some of it genuinely helpful, much of it fear-based or trying to sell you something. This piece is meant to do two things: help you feel seen in what you're experiencing, and give you clarity plus a few concrete steps.

My notes here grew out of The Peri Panel, a recent event hosted by Rachel Mark (@rachelmark.ca), where I joined Dr. Rachael Lovink, ND (@drrachaelnd), to work through what's actually happening in this stage of life and what honestly helps. It was fun to compare and contrast the approaches and knowledge that an ND and MD have.

What perimenopause actually is

The biggest misconception I hear in my office is that perimenopause is a slow, steady decline in hormones. It isn't. It's fluctuation — estrogen and progesterone swinging up and down, often unpredictably, before they eventually settle lower.

A few things worth knowing:

• It can start earlier than people expect — sometimes in the late 30s.
• The hallmark is change: shifts in your cycle, sleep, mood and body, often without an obvious reason.
• How do you know you're in it? Usually it's the pattern, not a single test — new or changing symptoms clustering together, especially alongside changes in your cycle.

The symptoms no one connects to perimenopause

Many women are living with perimenopause symptoms but never link them to hormones, because the list is far broader than hot flashes. It can include changes in sleep, mood, anxiety, memory and focus ("brain fog"), energy, joint aches, periods, libido and skin — and more.

The symptoms that surprise people most are often the mental and emotional ones, and anxiety is a big one. For a lot of women it doesn't stay as anxiety — it tips over into irritability and anger, a shorter fuse than they're used to. If scattered, seemingly unrelated symptoms have shown up together, there's a good chance they share one root.

What gets blamed on hormones — and often isn't

Here's where it gets tricky: not everything in midlife is hormonal, and the overlap runs both ways.

Take fatigue, one of the hardest symptoms to pin down. Before assuming it's "just hormones," it's worth ruling out common, treatable causes:

• Low iron — especially with heavy or changing periods. One caveat: if you're on the pill or have inflammation, ferritin can read falsely high, so a CRP helps put it in context.
• Sleep apnea
• Under-fuelling — not eating enough, sometimes unintentionally while trying to manage body changes
• Thyroid problems
• Depression
• Insulin resistance
• Plain burnout

One definition of fatigue I find useful: tiredness that persists after the usual fixes — eat more, sleep more, sleep better — have been tried.

The more useful framing isn't "hormones or not." It's that your history tells us what's likely to flare as hormones fluctuate. If you've had severe PMS, postpartum depression, insomnia — even gut issues — those are the things that can get louder now. Good treatment supports the primary issue first, sometimes alongside support for the changing hormonal landscape.

And the reverse happens too: real perimenopause gets labelled as anxiety or depression, and then it's hard to get good control. This is part of how women end up dismissed in healthcare — and "treating the anxiety" becomes one more task on their plate, especially when a medication like an SSRI isn't something they feel good about.

Capacity: your nervous system, mood and sleep

So many women say the same thing: I used to be able to handle all of this, and now I can't.

Part of why stress lands so differently now is timing. Fluctuating hormones can throw you off your usual routine — some women feel genuinely lost — and they arrive stacked on top of everything else midlife is already asking of you: parenting, kids, marriage, careers. It's a perfect storm.

Who feels it hardest? Often women with a history of PMS, PMDD, anxiety, depression or postpartum depression, which tends to come with more hormonal sensitivity. These are also the women most likely to have been dismissed before, or to have had a rough experience with hormonal treatments in the past.

It's not as simple as blaming hormones, though. A lot of what erodes capacity is that midlife demands are relentless and, honestly, many of us aren't great at boundaries. Rebuilding capacity tends to come from the small, repeatable things: micro-moments of rest, real boundaries, and connection.

The 3am wake-up

If you're awake at 3am, you're in good company. The first question is which kind of sleep problem you have, because they point in different directions:

• Trouble falling asleep is usually not hormonal.
• Waking at 3am is the one that's more typical in perimenopause.

The next question is what's waking you. Hot flashes and night sweats are vasomotor symptoms — a sign estrogen is falling and fluctuating — and this is a situation where hormone therapy is often indicated. If there are no hot flashes or night sweats, your age and cycle help guide what's going on, and it's worth looking more broadly.

Progesterone deserves a mention here. Even when hormones are fluctuating and you don't yet have the full picture of symptoms, progesterone can be a gentle stabiliser for some women — and it can really help with sleep (more on treatment below). Non-hormonal supports matter too: sleep hygiene, a pre-bed "brain dump," and CBT-I, a structured, evidence-based program for insomnia.

Gut and body changes

The gut. Hormone shifts genuinely change digestion, and stress and poor sleep make it worse. The foundations come first: regular meals, enough fibre, how you eat, movement and sleep. If those are solid and symptoms persist, that's when more focused support makes sense. One important caveat: new gut symptoms at this age still deserve proper screening. Not everything is hormones.

The body. Many women feel their body changed overnight even though nothing in their routine did. Some of this is age rather than menopause itself — testosterone starts declining around 40. But the shifting balance of hormones moves you toward a more testosterone-heavy state, which tends to increase visceral (deep belly) fat and cardiometabolic risk. And the long game matters here: muscle, bone and brain health are all part of this stage.

Treatment: the honest version

Two things are true at once. Menopause hormone therapy (often called MHT or HRT) is a medicine — with real risks and real benefits — not a wellness trend. And menopause does not require treatment. If you don't need it, you don't have to take it, and no one should feel they're missing out by not being on it.

What changed in the conversation. For two decades, much of the fear around hormone therapy traced back to early readings of the Women's Health Initiative (WHI). Since then that data has been re-examined, and a key idea has emerged: the timing hypothesis — that the risk–benefit balance depends heavily on your age and how close you are to menopause when you start, with a more favourable profile for women who begin before 60 or within about 10 years of menopause. In November 2025, the U.S. FDA moved to remove the decades-old "boxed" warning from menopause hormone therapy products, reflecting this shift (FDA announcement; news coverage).

The options, in plain terms:

• Progesterone — helpful for heavy or abnormal bleeding and for sleep, and it protects the uterine lining. Oral progesterone has calming, sleep-promoting effects; if it isn't well tolerated, an IUD may be the better route.
• Estrogen — the mainstay for vasomotor symptoms. Transdermal forms (patch, gel, cream) have the safest profile for clotting and metabolism; the choice among them often comes down to dosing and preference.
• Vaginal estrogen — for genital and urinary symptoms, with very low risk.
• Testosterone — considered in specific situations; the evidence here is still developing.
• The pill or an IUD — especially useful when heavy, unpredictable bleeding is affecting quality of life, and when contraception still matters as cycles become erratic.
• SSRIs and targeted supplements — have a role for some women, depending on symptoms and preferences.
• New non-hormonal medications are coming to market and becoming more popular.

The best combination depends on your risks, your preferences, and what you're actually trying to treat — symptoms, quality of life, or longer-term health. Conditions like endometriosis, depression or fibroids shape the choice, and even past 52 there can be good reasons to discuss hormone therapy for longer-term health.

One last thing: this field is changing fast, and education is thin in a busy clinician's world. If your provider isn't fully up to date, that's not a reason to panic — it's a moment to get educated together, or to ask for a referral.

The foundations really do help

Strength training. From the medical side, muscle and strength matter enormously right now — for stability and avoiding frailty, for bone health and preventing osteoporosis, for glucose metabolism, and for brain health and long-term independence. It ties straight back to body composition and cardiometabolic health. One caution from the exercise side: "lift heavy" is everywhere, but if you haven't been training, you lay the foundations first and build up — not straight to the heaviest weight.

Nutrition. If you change one thing, make it regular meals. Don't fear carbohydrates — your brain needs them, especially premenstrually — and prioritise fibre. Pick one thing to lead with rather than overhauling everything at once.

And the rest of the foundation — sleep, stress resilience, and joy and connection — matters just as much. The trap in this stage is the overwhelming "self-care to-do list." You don't have to do all of it. Choose one place to start.

Advocacy, in our healthcare system we all need to do it at times...

Most of us get about ten minutes with our doctor, and it goes fast. A few ways to make those minutes count:

• Track your cycle changes and top symptoms before the appointment.
• Lead with what affects your life most.
• Ask for a follow-up — if you see your doctor every 2-3 weeks for a few appointments you can get a lot accomplished.
• Labs can help, but they aren't always necessary.
• Know that the information around menopause and especially the guidelines around treatment are changing quickly, your provider may not be as up to date as you'd hope — and it's okay to name that.
• Ask for a referral if you need one.

It also helps to understand how different kinds of care fit together — family medicine, naturopathic and integrative care each bring something — and it's important for you to seek help from whoever you feel is helping.

If you take one thing from all of this, let it be this: understanding your own body, and being aware of what's happening, is the single most important piece — and it's the one most people are missing.

It is the whole reason I have started this blog. I believe a better healthcare experience and system is rooted in more health education to the public.

This is general education, not personal medical advice. For what's right for you, talk with your own healthcare provider.