I. A Almost Unknown Term
Perimenopause—a stage every woman will experience, yet half of all women are unfamiliar with this term. This isn’t ignorance; it’s systemic silence.
The thirties are a decade filled with hormonal fluctuations. Today, women aged 30 to 39 are the largest reproductive-age group—a group that used to belong to women in their twenties. And within the same decade, many begin to see the first signs of perimenopause.
Postpartum recovery and perimenopausal preparation, two events traditionally considered distinct life stages, are increasingly overlapping in the lives of women. This is not a coincidence; it’s the physical imprint of a changing era.
II. The Adrenal Glands: The Neglected Hormone Factory
Functional medicine gynecologist Wendie Trubow points out that postpartum hormone levels can return to pre-pregnancy levels in up to two years, depending on age, breastfeeding status, and the timing of perimenopause.
She specifically emphasizes the importance of adrenal health. “As the ovaries gradually cease functioning, the adrenal glands take over hormone production. If the adrenal glands are not functioning well, they don’t have enough raw materials to produce female hormones, which exacerbates the perimenopausal experience.”
This means that postpartum supplementation should not be viewed merely as “recovery,” but rather as “prevention.” Protein and collagen are used to build muscle and repair tissue, while calcium and vitamin D are used to strengthen bones—this is especially important considering that women may lose 3% to 5% of their bone mass during pregnancy.
Trubow’s advice is simple and powerful: view postpartum supplementation as ideal preparation for perimenopause. Your future self will thank you.
III. The Perimenopause Dilemma: When Your Body Begins to Betray You
With fluctuations in progesterone and estrogen levels, menstruation becomes irregular. This is usually a slow process, and perimenopausal symptoms may creep in 2 to 10 years before menopause fully takes effect.
Women’s health expert Dr. Sara Szal Gottfried recommends testing hormone levels before symptoms appear to establish a baseline—especially estrogen, progesterone, testosterone, thyroid hormones, insulin, and cortisol, which are most affected by perimenopause.
“I recommend women establish a relationship with a gynecologist who specializes in managing female hormones before they need it, because there aren’t many such doctors in the US, and appointments can sometimes have long wait times,” adds Trubow.
Perimenopause can begin earlier than many people think—sometimes in mid-35, though more common in the 40s—and is accompanied by more than 30 identified symptoms, some of which can be quite severe. Estrogen is intricately linked to every system in the body, so its effects extend far beyond menstrual changes: from decreased energy to depression, slowed metabolism, decreased libido, musculoskeletal pain, and more.
However, there is a huge gap between the level of support women need and the services doctors can provide. Only 20% of OB-GYN residency programs offer menopause training. Therefore, it’s not surprising that one-third of women are misdiagnosed and told their perimenopausal symptoms are caused by other conditions. Complicating matters further is the lack of official diagnostic criteria for perimenopause.
“I like to see the trend of millennials refusing to be ignored by clinicians or subjected to the gaslighting effect,” says Gottfried. “There’s a huge knowledge gap among clinicians, and since women’s health initiatives have been unfortunately misinterpreted, many doctors have overlooked important research findings, resulting in corresponding treatment gaps.”
The conclusion is: We must be our own best advocates.
IV. Proactive Coping: From Passive Waiting to Active Action
Thirty, forty, and beyond, naturally come a decline in muscle and bone mass—not to mention postpartum setbacks for some—as well as metabolic changes. We’re seeing more and more women taking preventative action rather than waiting for problems to arise.
Gottfried warns that with the abnormalities in insulin and blood sugar during perimenopause, women gain an average of five pounds of fat and lose five pounds of muscle every decade—unless we take specific measures.
Stronger, Longer
A large global study in 2023 found that about 40% of women regularly engage in strength training—a 30% increase from 20 years ago.
Gottfried recommends “at least 6 hours of exercise per week, two-thirds of which should be heavy weightlifting and one-third aerobic or cardio. Properly calibrating your exercise routine will keep your mitochondria in good shape, preventing fatigue, especially post-exercise fatigue—a type of fatigue that often worsens during perimenopause and menopause.”
She adds, “Having a good exercise routine can reduce your experience of perimenopausal symptoms and is one of the best ways to maintain cognitive function as you age.”
Blood Sugar Balance Benefits Hormones
Balancing blood sugar helps improve mood, weight, and sleep, and reduces symptoms such as hot flashes. Entering perimenopause, we often notice we can’t eat as much as we did in our twenties. Blood sugar and insulin play a crucial role in this, prompting many women to reduce refined carbohydrates and high-sugar foods, focusing instead on fiber, good protein, and healthy fats.
Women should be aware that insulin resistance increases as estrogen levels decline during perimenopause. Gottfried is a proponent of continuous glucose monitoring for personalized diets and blood sugar regulation. She also recommends a simple trick: take a 20-30 minute walk after meals to lower post-meal blood sugar and insulin spikes.
HRT—No Longer the Villain
After years of being feared due to misinterpretations of research data from women’s health initiatives, hormone replacement therapy (HRT) is finally gaining more positive recognition.
Recent research has found that HRT can help alleviate night sweats, hot flashes, blood lipid levels, metabolic health, and bone health, and when used correctly (at the appropriate age, dosage, etc.), significantly improve women’s quality of life.
Gottfried explains, “The biggest trend I’m seeing is that women who were struggling without hormone therapy are now considering starting treatment. Many women are now more aware and less willing to grit their teeth and endure perimenopause, instead asking to be consulted and considered for treatment.”
“The biggest challenge is that we haven’t educated women’s health providers about hormone prescription and management, resulting in a huge gap in awareness and coverage. I expect the use of biohomogeneous HRT to increase as women demand help, management, and support,” says Trubow.
V. Data and Tracking: Personalized Insights
We are fortunate to live in an era where personalized data is readily available and growing at an astonishing pace.
Gottfried is passionate about using wearable devices and specific metrics to help patients fully understand and adjust their health accordingly. She uses genetic testing, body composition analysis, hormone testing (through blood, saliva, and urine), DEXA scans, nutritional testing, and data from wearable devices like the Ora Ring and Whoop, as well as health technology products like Eight Sleep.
Trubow advises: “I recommend that women focus on ensuring their emotional and spiritual needs are acknowledged—and truly met.” This may vary from person to person, so listen to your own needs and think about what best serves those parts of yourself.
VI. How Did We Get Here?
Women are so unprepared for these inevitable life changes for a variety of reasons, but to a large extent, it points to the history of clinical research. In 1977, women of childbearing age were largely excluded from research due to concerns about harming unborn babies. It wasn’t until 1994 that the FDA created the Office of Women’s Health to actually promote women’s participation in clinical trials. As of a 2022 study, only 40% of participants in key women’s health issues were women.
Gottfried offers some encouraging advice: “We need women to do what they do best: care and unite. When you learn important and useful knowledge about perimenopause, such as how to measure and manage hormone levels, pass that knowledge on by sharing it with three friends.”
“We have to solve this problem ourselves. It requires a grassroots approach, where we women support each other and share what works, what’s proven safe—strategies studied on women, not men.”
VII. What Does the Future Hold?
As patients learn more about their natural hormonal changes, doctors will be forced to seek more education to keep up, hopefully leading to fewer misdiagnoses.
We envision a future where women proactively take care of their health and therefore experience fewer symptoms; where women use an integrative approach to maintain the quality of life they deserve; and where a generation of women fearlessly enters perimenopause, and menopause becomes a respected rite of passage, not an invisible era.
Trubow is excited to see HRT reinvigorating and bringing tremendous progress to women’s health, and the newly FDA-approved QT imaging technology for breast health—radiation-free, breast-compression-free, and with 40 times higher resolution than MRI.
“The second half of a woman’s life can only get better. I hope that more research, attention, and insights will help close many of the gaps women face in the healthcare system, leading to better care and longer healthy lifespans,” said Gottfried.
