Is It Perimenopause, or Something Else?

Perimenopause is kind of everywhere right now. Instagram, podcasts, magazine articles, ads for hormone replacement and special supplements, all promising to help you feel like yourself again. You just want to feel like, oh wait, there I am.

I think it’s amazing that all this information is out there. But we may be swinging a little too far in the other direction, from not talking about it at all to blaming everything on perimenopause. You’re tired? Gaining weight? Can’t sleep? It’s all perimenopause. Can’t remember why you walked into the kitchen? That may or may not be perimenopause.

It could be your hormones, 100%. But what if it’s something else? What if your fatigue, brain fog, or anxiety has something to do with disrupted sleep or your thyroid? What if you’re iron deficient because you’ve had years of heavy cycles and didn’t even know that was a thing? What if you’re struggling to exercise and not recovering, and that’s iron deficiency too?

Please don’t go to Dr. Google and decide every possible thing I mention is your problem. Let’s hold off and pay attention. I want you to get curious about your body instead of frustrated with it.

One of the foundational principles of Living F.R.E.S.H. is that you can’t make informed choices without accurate personal information. Sometimes getting that information starts with questioning some of the explanations you’ve already been given. Not all doctors, but I could talk all day about the way some women are treated in doctors’ offices.

So why can perimenopause look like everything?

Menopause is officially defined looking back: 12 consecutive months without a cycle, assuming there isn’t some other medical explanation. Perimenopause is all the time leading up to that. Not much of a definition, right? And it isn’t just a decline in estrogen. There’s a ton of hormonal variability. Some days it’s up, some days it’s down. Sometimes you know exactly when your cycle is going to start, and sometimes you don’t. Progesterone, part of what rules our cycles, becomes inconsistent. Estrogen can fluctuate all over the place, spiking and then dropping out. All of those fluctuations affect multiple systems throughout the body.

Start with the brain. Estrogen influences neurotransmitters, the little molecules that let your brain talk to itself. They’re involved in mood, temperature regulation (anyone for a little night sweat action?), and cognition. Hello, word-pulling. Oh my gosh, I can’t think of that word. Hormonal changes can contribute to all of that. But brain fog is a symptom, not a diagnosis. So how’s your blood sugar? If you’re not feeding yourself properly, your brain can’t work properly. It uses a ton of energy, almost as much as your muscles. And are you dehydrated? If you are, you’re not going to think clearly either.

Then there’s sleep, one of my favorite things to talk about. Hot flashes and night sweats can interrupt sleep over and over. Poor sleep comes with its own set of symptoms: fatigue, irritability, difficulty concentrating (back to brain fog), increased appetite because you’re trying to get the energy you didn’t get from sleep, and reduced exercise recovery. I had one of those days recently where leg day was impossible, and it was definitely all about sleep. So is the hormone fluctuation directly responsible for how you feel, or is disrupted sleep contributing? It can be both.

That’s a big thing in functional medicine. Usually what’s going on is multifactorial. It isn’t as easy as pegging it to one thing and taking one supplement for it. It’s about how your body is functioning through these hormonal swings, how to balance things out a little better, and where you have control.

Body composition is the hardest one, and it’s the main thing I hear about in my practice. Menopause is associated with changes in where fat is distributed on your body. These little tummies we never had before. What happened to my back? It used to look amazing! At the same time, aging, physical activity, resistance training, nutrition, and sleep all influence muscle mass. Not every pound you gain after 45 is caused by estrogen. A whole bunch of other things influence it, and in the Living F.R.E.S.H. Collective we start taking those pieces apart so you can assess what’s happening in your individual life, which may be different from what’s happening in mine.

And yes, we’re going to talk about your cycle. As ovulation becomes less predictable, your cycle can become irregular. That can be caused by excess estrogen, excess progesterone, low progesterone, or low estrogen. There’s a big dynamic there to pin down. The hormonal transition itself can also contribute to a second condition, like iron deficiency, because some women have heavy bleeding, clotting, and weeks and weeks of bleeding. Ladies, that is not normal. It isn’t something you just have to handle. There are answers for it, including natural answers. You don’t have to go through that.

Perimenopause can be the beginning of the story without being the entire story.

Sometimes we plunk everything into the bucket called perimenopause, and that’s not great clinical reasoning. It’s settling on a diagnosis before adequately considering the alternatives. Clinicians do it, and I’m guilty sometimes too. Patients do it. It’s human nature. Our brains want an explanation. It’s part of the way God put us together. But an explanation isn’t necessarily complete just because it’s plausible.

I’ll say that again. An explanation isn’t necessarily complete just because it’s plausible.

Here’s one of my favorite analogies, and y’all know I have a giant dog. Say your dog is scratching. What’s wrong with him? Maybe he has fleas. But maybe he has ticks. Same dog, same symptom, two different problems that need very different treatments. And here’s the kicker: that poor dog could have both. Just because we found fleas doesn’t mean we stop looking for ticks. If we treat the fleas and ignore the ticks, we’ve still got an itchy dog.

That’s exactly what can happen with perimenopause. We find a legitimate reason for your symptoms and say, here we go, there’s our diagnosis. But finding one explanation doesn’t mean we’ve found the only explanation.

That doesn’t mean 4,000 lab tests or chasing some obscure diagnosis. It means good clinical investigation, which is what functional medicine doctors are trained to do. We look at patterns. We look at your timeline. When did this start? Was there an event that started it? We look at physiology and context.

Imagine a woman in her late 40s. Her cycles have become super heavy and mostly unpredictable. She’s exhausted and having trouble concentrating. Her workouts are almost impossible, like the blood isn’t getting to her muscles, so she wonders if she has a circulation issue. She gets short of breath climbing stairs and figures it’s some kind of perimenopausal thing. But what’s happening as a consequence of those changes? She’s losing more blood, and with that blood, she’s losing iron.

Iron is essential for making healthy red blood cells that carry oxygen to your brain and muscles, and it’s required for cellular energy, your ATP. Low iron can also cause difficulty concentrating and restless legs. There’s our second condition, our ticks and fleas. And iron deficiency can show up before outright anemia. If we only ask whether she’s perimenopausal, we might miss it. Make sure your doctor runs a CBC, which evaluates your hemoglobin and other cell indices, plus ferritin to assess iron storage, and iron studies, including transferrin.

Now the icky part. If you have irregular, heavy bleeding, we need to make sure nothing is going on in your uterus. Find a good gynecologist. Don’t just assume it’s normal because you’re in perimenopause. Most of the time it is, so don’t go down too many rabbit holes. But what if your hormones are changing and your fatigue is being amplified by iron depletion?

Now imagine a woman in her 50s who comes into my office tired, gaining weight, constipated, and mentally sluggish. She’s dealing with mood changes, she’s sensitive to cold, and she has dry skin she’s never had before. She thinks it’s perimenopause. But a lot of those symptoms overlap with hypothyroidism, or low thyroid. Thyroid hormones are part of your metabolism. We’re not going to decide it’s always the thyroid, because it isn’t. But thyroid may play a role. If thyroid hormone production is insufficient, your energy expenditure, the motility of your gastrointestinal system, your cardiovascular function, everything in your metabolism can be affected. That takes clinical discernment: TSH, free T4, free T3, thyroid antibodies. The whole thing has to be looked at.

Those are just two examples. Insulin resistance and metabolic dysfunction can coexist with the menopause transition, and you can go back and listen to my other episodes on those. You may have a chronic vitamin B12 deficiency. So many things can go on besides perimenopause or secondary to it.

I don’t want you walking away thinking you have 25 different diseases to worry about. I want you to understand something way simpler: similar symptoms don’t necessarily mean identical causes. Ticks and fleas.

I want to train you up to be a really good clinical detective, so you know what’s happening in your body. That means asking better questions. Not just “What’s wrong with me?” but “What information would help us understand what’s happening?”

You don’t need a medical degree to become a better observer of your body. You just need to pay attention. That’s what we do in Living F.R.E.S.H.: awareness, then choice, adjust, and continue. Awareness isn’t judgment or panic. It’s looking at what’s happening and saying, okay, I have a choice. What can I adjust? How do I continue? Health isn’t a destination. It’s a direction, and I want to get you headed in that direction.

Ask yourself what else has changed. Did you change your food? The time you get up? If nothing has changed, that’s information too.

Then look for the pattern. Instead of “I’m tired all the time,” maybe you realize, “I don’t sleep well the week before my cycle starts.” That’s a progesterone issue, and knowing when it happens is super important. There are tons of phone apps that can help you track it.

What helps you tell one explanation from another? That’s where you may need a little help. “Can you check my hormones?” may be part of the answer. Or maybe what you need is a really good set of blood work. Hormone testing has its own issues, depending on what day you take it, and just one test isn’t enough. You really need to understand your patterns. That’s a whole episode of its own.

So don’t stop at the label. Is it perimenopause? Maybe. Maybe it’s secondary to perimenopause. Maybe it’s your thyroid. Maybe it’s sleep apnea. Maybe it’s iron deficiency. Maybe it’s a combination of things. And maybe the hormonal transition is making an existing issue more noticeable.

The point isn’t to question everything endlessly. It’s to have enough information to understand what could be happening, so you’re not dumping everything into one bucket when there are things you can actually do about some of them. If you’re iron deficient, that’s a simple thing to fix. Your energy could come back. Your workouts could come back. Your sleep could be better. B12, all of these things can be better when you have the right information.

Notice changes in your energy, sleep, mood, weight, and overall well-being. Don’t automatically assume it’s something you have to tolerate. I hear it so often: “I thought I just had to live with it. I thought that was part of the deal.” It is not part of the deal.

I went through perimenopause with very few symptoms. Now I’m almost ten years into menopause, and I’ve had to change things all the time to stay in the direction of health I want, so I can be on the floor with my grandkids when I’m 85.

Work with your healthcare provider. Reach out to me. Find yourself a really good functional medicine practitioner. Make choices based on understanding rather than assumptions.

That’s what Foundations, the F in F.R.E.S.H., is all about. It isn’t just another collection of rules about how to eat, how much to exercise, or which supplements to take. Yes, there’s some of that too. But it’s really about understanding our changing bodies and making thoughtful choices to care for them.

Renewed health, because when we understand what’s actually happening in our bodies, we can make much better choices about how we care for them. Rooted in truth, because assumptions are not answers, and wisdom means being willing to ask more questions and step up for yourself. Restored by grace, because discovering that something needs attention is not an indictment of how you’ve cared for yourself. It’s an opportunity to move forward with greater understanding, without guilt and without shame.

Comment FRESH below or send FRESH in a DM on Instagram @drkrissargent to learn more about the Living F.R.E.S.H. Collective membership, OPEN NOW for Founding Members.