Filling The Gap Between Pregnancy & Perimenopause 

Perimenopause—the mysterious phase that every woman will go through, yet a term that nearly half of women are unfamiliar with. There is a changing tide in women’s health, though, and these years are demanding increased attention.

Our 30s are a verified buffet of hormonal fluctuations. Women ages 30 to 39 now make up the largest age group giving birth (which was previously women in their 20s), and within this same decade of life, many women see the starting signs of perimenopause.

It can take up to two years for a woman's hormones to get back to pre-pregnancy levels, which will also depend on age, breastfeeding, and perimenopause timing. 

Wendie Trubow, M.D., a functional medicine gynecologist, suggests paying special attention to our adrenal health during this time, “The adrenals pick up the work of making hormones when the ovaries wind down, so if the adrenal glands aren't in good shape, they don't have enough raw materials left over to create female hormones, which can worsen a woman's perimenopausal experience.”

Menopause timing and severity may also depend on whether a woman has had children. Compared to women who had never been1 pregnant, women with one full-term pregnancy had an 8% lower risk of early menopause and an even lower risk of additional pregnancies. In another study, women who have never given birth were half as likely to report hot flashes as women with one or more live births. Women who have never been pregnant also report less vaginal dryness during menopause.

While this won’t change how a woman plans her future family, it’s information worth keeping in mind when visiting the doctor in your 30s and beyond (and something your doctor is unlikely to bring up). 

Perimenopause comes with significant physical and mental stress on the body, and we want to prepare for it as best we can. Protein and collagen are needed to build muscle and heal tissue, and calcium and vitamin D are required to strengthen bones—which is especially important considering women can lose 3-5% of their bone mass during pregnancy.

Perimenopause is an unavoidable and significant shift to a woman’s health, with about 1.3 million U.S. women starting menopause each year. Yet, most of us don’t feel ready for it—with more than 30% apparently dreading it.

As progesterone and estrogen fluctuate, periods become irregular. This is often a slow build, though, and perimenopause symptoms may creep in over the course of 2 to 10 years before menopause is in full effect. 

Sara Szal Gottfried, MD, women’s health expert and medical advisor to Oura, advises women to test their hormones before any changes arise and to know their baseline, especially estrogen, progesterone, testosterone, thyroid, insulin, and cortisol, which are impacted by perimenopause the most. 

Trubow agrees, “I recommend women get into a relationship with a gynecologist who has expertise in managing women's hormones before they need it since there are not a lot of these providers in the US, and it can sometimes take a while to get in to see them.”

It’s also worth noting that perimenopause can start younger than many believe (sometimes in the mid-30s, though the 40s is most common) and comes with more than 30 recognized symptoms that can be quite severe. Estrogen is intricately tied to every system of the body, so it makes sense that it manifests in myriad ways beyond changing periods, from reduced energy to depression, a sluggish metabolism, low sex drive, musculoskeletal pain, and so much more.

There’s a major disconnect between the degree of support women need and the degree our physicians are able to provide, with only 20% of OB/GYN residencies providing training on menopause. So it’s unsurprising that one in 3 women are misdiagnosed and told their perimenopause symptoms are due to a different condition. To further complicate things, there are no official diagnosis criteria for perimenopause in the first place.

Our 30s, 40s, and beyond align with a natural decline in muscle mass and bone mass (not to mention postpartum setbacks for some of us), in addition to metabolic changes, and we’re seeing an increasing number of women take preventative action, rather than waiting for problems to set in. 

Around age 30, we begin losing 3-5% of our muscle mass per decade—a major issue whether you’re focused on picking up toddlers or trying to stay independent in your later years.

As of 2023, a large global study found that roughly 40% of women were engaging in regular strength training (up 30% from 20 years prior).

Gottfried recommends “a minimum of 6 hours per week of exercise, and it should be two-thirds heavy weightlifting and a third cardio or aerobic activity. Getting exercise dialed in will keep your mitochondria in proper form so you don’t experience fatigue, especially post-exercise fatigue, that tends to worsen during perimenopause and menopause.” 

She added, “Having a great exercise regimen in place is likely to reduce your experience of symptoms in perimenopause and is one of the best ways to preserve cognitive function as you age.”

Balancing blood sugar supports mood, weight, and sleep and reduces symptoms like hot flashes. As we enter perimenopause, we also tend to notice we simply can’t eat the way we did in our 20s. Blood sugar and insulin play a big part in that, leading many women to reduce refined carbs and high-sugar foods and focus on fiber, high-quality protein, and healthy fats. 

Hormone replacement therapy (HRT) is finally gaining more positive recognition after years of fear due to misrepresented data from the Women’s Health Initiative study, framing HRT as a risk for cardiovascular disease and breast cancer.

Recent research has found HRT can aid night sweats, hot flashes, lipid levels, metabolic health, and bone health and significantly improve a woman’s quality of life when used correctly (at the right age, dose, etc.).

Gottfried elaborates, ”The biggest trend I see is that the suffering women who have struggled without hormone therapy now can consider whether to start. Many women now know better and are no longer willing to grin and bear it through perimenopause, and are demanding to be counseled and considered for treatment.”

We’re lucky to live in an age where personalized data is readily available, and increasing at breakneck speed. 

Gottfried is all about utilizing certain metrics from wearables and testing to help her patients fully understand and pivot their health accordingly. She utilizes genetic testing, body composition, hormonal testing (through blood, saliva, and urine), DEXA scans, nutrient testing, and data from wearables like the Oura ring and Whoop, as well as other health-tech like the Eight Sleep.

There are multiple reasons women are so under-prepared for these inevitable life changes, with a large finger pointing at the history of clinical studies. In 1977, women of childbearing age were largely excluded from studies due to fear of harming an unborn baby. It wasn’t until 1994 that the FDA created the Office of Women’s Health to actually promote the inclusion of women in clinical trials. As of a 2022 study, only 40% of participants on key women’s health issues are women.

Women’s health is also severely underfunded—attributed to stigmas and the “inconvenience” of hormonal fluctuations―with only 5% of global research and development funding2 in 2020 going towards women’s health research.

When it comes to looking forward, Gottfried offers some uplifting advice, “We need women to do what they do best: tend and befriend. When you learn something important and helpful about perimenopause, like how to measure and address hormone levels, pay it forward by sharing it with three friends.” 

The U.S. menopause market size was estimated at USD 5.3 billion in 2023 and is projected to grow 4.8% from 2024 to 2030, while we’ll also see an increasing preference for holistic natural menopause products and innovative services that make help more easily accessible.

As patients become more informed about their natural hormonal shifts, physicians will be forced to seek greater education in an effort to keep up, and hopefully, misdiagnosis will become less common.

We see a future where women are proactive about their health and experiencing fewer symptoms because of it; where women use integrative methods to maintain the quality of life they deserve; where a generation of women enter perimenopause without fear and menopause becomes an honored right of passage as opposed to an era of invisibility.

Trubow is excited to see HRT back in play, making massive strides for women’s health, as well as the newly FDA-approved QT imaging for breast health without radiation or breast compression and with 40 times more resolution than an MRI.