Chapter 1 It''s Not All in Your Head "We know our bodies; we know when something physically has changed." "At age forty-seven, I was told by a gynecologist that perimenopause isn''t real and was asked if I had a psychiatrist." "I was told by my former doctor that women use menopause as an excuse to gain weight and that it''s not real." "I was told that it''s all in your head." "Welcome to your new normal." "It''s discouraging to not be taken seriously." "Consulted my ob-gyn about perimenopause and mood swings, sexual interest. She blew me off and said I was too young for menopause.

" "The migraines are a new symptom. I have only had them a few times, but they were debilitating. My doctor suggests I take Tylenol and lie down. I would prefer to address the cause and not just the symptom." "Dr. said it wasn''t perimenopause if I wasn''t having hot flashes." "I had to go to an ob-gyn and three cardiologists before I found one who believed me and had knowledge that it could be linked to hormonal changes." "I was sent for a full blood screening and thyroid testing.

All tests came back with good results, so my complaints were not addressed further." "Still suffering." That''s just a small sampling of comments shared on my social media and in a research study on women''s experiences with menopausal symptoms. The study, published in the Journal of Women''s Health in 2023, sought to understand what kind of support a patient felt she was getting from her healthcare providers (and how that support could be improved). Overwhelmingly, the responses revealed substandard care and weak support. Many patients felt invalidated or reported that they hadn''t been provided with any help or even given access to information that would allow them to understand the cause of their symptoms. My informal "survey" on my social media posts directed to gynecology patients revealed many of the same sentiments. Women said things like "My doctor told me he doesn''t believe in perimenopause" and "I was told it''s just a natural part of aging, get over it," and described encountering a medical attitude of "Welcome to your new normal.

" Sadly, these experiences aren''t the exception, they are the rule. There are so many problems with this that I''m not even sure where to start. But first on the list is the fact that there are major medical consequences of this denial of care and guidance. If a woman in perimenopause or menopause is not getting top-notch care, it''s a matter of life and death. Really. Here''s why: your symptoms, of which dozens (including the well-known hot flashes and the not so well-known frozen shoulder), are the direct result of declining estrogen. My patients, colleagues, and I have been taken aback by the emerging research that''s starting to explore the relationship between the menopausal drop in estrogen and issues like chronic cough, tinnitus, and benign position vertigo--just to name a few. These are issues that many women are attributing to "getting old" while they scramble to be believed, get help, and thrive during what should be a powerful and exciting time in their lives.

Estrogen isn''t just a pretty hormone that''s key to reproductive capabilities; it''s responsible for so much more. There are estrogen receptors throughout almost every organ system in your body, and as your levels drop, these cells begin to lose their ability to assist in maintaining your health in other areas, including your heart, cognitive function, bone integrity, and blood sugar balance. The list goes on, but in these areas alone we can spot a few diseases that regularly land in the top ten causes of death in women: heart disease, stroke, Alzheimer''s disease, and type 2 diabetes. While osteoporosis isn''t on this list, it still presents a serious concern, as one in two women will break a bone in their life because of bone loss from osteoporosis, and hip fractures alone are associated with a 15-20 percent increased mortality rate within one year of the break. All this is to say that estrogen is broadly and profoundly protective of your health, and its diminishing status during perimenopausal and menopausal years is a very big deal and should be treated as such. In the pages to come, I''ll present you with a head-to-toe tour of just what you can do to prioritize taking care of yourself during this big deal phase. Before we get to the strategies, I want to take a step back and establish some foundational understanding of the myriad ways that hormone changes can present themselves and why exactly the symptoms and resulting suffering have for so long been inadequately addressed. Estrogen Replacement and Aging If you are a candidate for hormone therapy, its use may prolong your life: a study published in the journal Menopause reported that a woman starting estrogen at fifty can expect to live up to two years longer than women who do not, and per year it''s associated with a 20 to 50 percent decrease in dying from any cause.

So Many Symptoms, So Little Support Stop me if you''ve heard this one before: A patient walks into a bar . or actually, it goes . a patient walks into their doctor''s office first and then a bar after because they''ve been told, yet again, that the symptoms they''ve been experiencing for months, years even, are just normal or natural and associated with aging, that they''re a manifestation of mood changes that just have to be endured, or, most insulting of all, that "it''s all in your head." (No wonder the rates of alcohol use in women have climbed, although this is not a healthy trend.) The not-so-funny reality is that you''ve likely not only heard it before but experienced it too. The question is: Why? Why can you go to a doctor seeking help, describe your symptom or symptoms, and then walk out feeling dismissed, absent a diagnosis, and without hope of any relief on the horizon? In medicine, we look at this question in terms of access to care. That is, if there''s an ideal patient experience, what are the barriers keeping people from having that kind of experience--the kind where a patient leaves a doctor''s office feeling supported and empowered, and outfitted with treatment options? Let''s take a look at the barriers to this kind of experience. Lack of Awareness One of the most significant issues responsible for inadequate treatment for those in the menopausal transition or in menopause is the insufficient understanding around its pathology, which is how an underlying condition or disease may present itself symptomatically.

Changes in hormone levels can lead to a variety of symptoms that manifest in unique ways in each patient, making it difficult to recognize, diagnose, and treat. It would serve physicians--and patients--well to get to know the list of potential symptoms because it extends far beyond hot flashes, night sweats, loss of bone density, and genitourinary symptoms. Here are many of the symptoms that may be related to perimenopause or menopause (see the Tool Kit for strategies to manage these symptoms). Acid reflux/GERD Acne Alcohol Tolerance Changes Anxiety Arthralgia (joint pain) Arthritis Asthma Autoimmune disease (new or worsening) Bloating Body composition changes/belly fat Body odor Brain fog Breast tenderness/soreness Brittle nails Burning sensation in the mouth/tongue Chronic fatigue syndrome Crawling skin sensations Decreased desire for sex Dental problems Depression Difficulty concentrating Dizzy spells Dry or itchy eyes Dry mouth Dry skin Eczema Electric shock sensations Fatigue Fibromyalgia Frozen shoulder Genitourinary syndrome Headaches Heart palpitations High cholesterol/high triglycerides Hot flashes Incontinence Insulin resistance Irritable bowel syndrome Irritability Itchy ears Itchy skin Kidney stones Memory issues Menstrual cycle changes Mental health disorders Migraines Mood changes Muscle aches Night sweats Nonalcoholic fatty liver disease Osteoporosis Pain with intercourse Sarcopenia (muscle loss) Sleep apnea Sleep disturbances Thinning hair (on head) Thinning skin Tingling extremities Tinnitus TMJ (temporomandibular disorder) Unwanted hair growth (whiskers) Urinary tract infections Vaginal dryness Vertigo Weight gain Wrinkles Simply by looking at this list you can see how profoundly far-reaching hormonal changes can be, and how exactly an individual could visit nearly every medical specialty chasing a diagnosis if the common denominator of diminishing estrogen isn''t identified. This is also why menopause symptoms may be mistaken for symptoms of other conditions, leading to misdiagnosis--or how it is possible to have more than one cause of similar symptoms (hypothyroidism and perimenopause).