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Are your hormones imbalanced?

Updated: Apr 20, 2022

If you're in perimenopause, well, yes.

It's your ovaries' grand finale. And it can be full of surprises and symptoms that no one told you about. Today I want to clarify why you don't need to test your hormones while they play out their final menstrual cycles. I'm a huge fan of patient choice, but I'm not a fan of misogyny and snake oil, which for decades has found a welcome home in the area of perimenopause care. So, this article is here to help you understand hormones in perimenopause, and how the concept of testing and balancing hormones during this transition is generally worthless.

So here's the hormone story: In our reproductive years, our menstrual cycles (if they are regular) follow a pattern. It looks something like this*:

What you can see is that the hormone levels change over the course of the cycle. But the change is part of a pattern that repeats every month. The pattern is predictable, month after month, so that if we know when your last period was, we know the range of where your hormones should be if we tested them.

Fast forward to a year or so after menopause, when our periods have stopped forever, the hormones will be the same one day to the next. No menstrual cycle, minimal fluctuation. Stable and predictable. And we have an idea of where your hormones should be, if we tested them.

The hormone levels of pre-menopause and after the menopause transition are well documented. So, what happens in between, during the perimenopause (menopause transition)? The lazy explanation is to connect the dots, and assume that our hormone levels fall steadily.

You'll see this stated in articles and represented in graphs all over the internet. But it's wrong! This idea that our hormones smoothly transition in perimenopause is not based in reality. In perimenopause, the ovulation cycle stops going smoothly. We enter a period of unpredictable hormonal shifts caused by the hormone changes in aging ovaries. Sometimes we get a nice normal ovulation (and period), sometimes we don't, and sometimes we get TWO, a couple weeks apart (instead of the usual 4 weeks apart). The hormonal shifts are erratic and without a pattern, shown by this record of 6 months of a single perimenopausal woman's hormone levels:

Now, no one would argue that this is orderly. It is chaotic and we know that many of the symptoms of perimenopause are directly related to these fluctuating hormone levels in the graph above. But we should ask ourselves: does that make it a medical problem? Before you answer, compare the situation of a perimenopausal woman to that of a 13 year old girl who just got her first period. The 13 year-old's periods may not be regular for a few years. Her ovulation and bleeding will happen unpredictably and if we measured her hormones every day we may see a similarly chaotic pattern to the one above. But (thank goodness) no one is suggesting she needs to test her estrogen and progesterone. No one is trying to "balance" those hormones for her. Because we know what she is experiencing is normal. It's the way the reproductive system comes online. Over time, her reproductive system will mature and settle into the stable pattern of the reproductive years. And that is what will happen to perimenopausal women too: over time, the reproductive system will mature and settle into the stable pattern of the post-reproductive years.

Portraying the imbalanced hormones of perimenopause as a medical problem to be fixed is as insidious as treating pregnancy or puberty like a disease. Perimenopause, like pregnancy and puberty, is a normal, temporary state of the female body. So as you move through this transition, breathe deep and know that your hormones are in the process of balancing themselves. Ideally, avoid providers that make a point of testing hormones (especially through saliva or urine tests that are not covered by insurance). The test results are useless, because your levels are all over the place, and your results this week will look really different from two weeks from now.** A person basing medical care off hormone tests in perimenopause is lacking a fundamental understanding of the process, so having their "help" may not be that helpful. Menopause-aware healthcare providers generally don't need hormone tests to tell us that our patients are in perimenopause. We figure it out by carefully listening to what they tell us about their bodies.

And just like good health care for our 13 year old in puberty includes helping her with controlling heavy bleeding, helping her with acne or irregular periods if they are distressing to her, and treating any anxiety or depression, good health care in perimenopause means attending to hot flashes, insomnia, anxiety, depression, irregular or heavy bleeding and other symptoms. Using a variety of approaches, including hormonal and non hormonal options, we can ease the transition when needed.

You may choose to use hormone therapy, not because we think your hormone levels are low, high, or unbalanced, but because based on research we know they can treat the symptoms you're experiencing. Western medicine gets a bad rap for treating symptoms instead of curing the disease but please remember that in perimenopause there is no disease to cure, just like in puberty there is no disease to cure. Each stage is a temporary state of imbalance; the body's transition from cycling hormones to non-cycling hormones. The imbalance is part of the process, it's expected, and it doesn't last forever.

The bottom line: Testing hormones in perimenopause is unnecessary, and a waste of money. No one needs to "balance" you, but if you need help, it's here for you.

*if this graph showed the hormones in their true comparative concentrations, progesterone would go about 20 times higher in the second half of the cycle than it does on this graph, but that would make it harder to read and understand.

**this is true in perimenopause, of the hormones shown in the graphs here. Not every hormone fluctuates in perimenopause. In general though, if you had symptoms that required checking your hormones, the test will probably be done with blood, not urine or saliva.


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