When I set out to write this article, I intended to pick one symptom of perimenopause and give tips on managing it. But then I thought, “You can’t just pick one symptom and  get rid of it alone. What women need is help with minimizing hormonal fluctuations so that ALL of the symptoms improve”.

So that’s what I’m doing in this article. It’s not a totally exhaustive guide to all herbal remedies or possible treatments, but I’ll give you ideas that are easy to implement, that are backed by studies and that will help you now as well as 5 years down the road. Hormone Replacement Therapy (HRT) is always an option from your doctor, but for some women it doesn’t make sense and others would prefer to avoid medications.  These ideas are a holistic approach to hormone-balancing and can help you feel like yourself again.

How Do I Know If I’m Perimenopausal?

Perimenopause can go on for many years (see here), and the signs that you’re entering into it can be confusing and a bit inconsistent. One month things seem totally normal, the next month your period comes early, you can’t sleep and you’ve been having PMS for 2 weeks.

The definitive way to know if you are perimenopausal is a hormone panel in combination with looking at your presentation of symptoms. If you are 45 or under, on the second or third day of your period, your doctor will take blood work that looks at estrogen, FSH and a few other things. This is assuming you are NOT taking HRT or on birth control pills, since both these medications will change the results. If you are over 45, this blood work is not always seen as a good marker (source).

As far as your cycles, a change in the bleeding pattern is the main thing to look out for. There can be either shorter or longer cycles than normal (meaning, if your usual cycle is 28 days but you’re now starting to have occasional 21 or 35 day cycles). There can be extremely heavy bleeding or you may only have spotting for a few days.  This happens in large part due to an increase in the number of anovulatory cycles- your ovary didn’t release an egg (ovulate), which results is completely different hormone levels across the board. Researchers estimate that in early perimenopause, about 20% of all cycles will be anovulatory (source).

In my practice the other symptoms women mention are trouble sleeping, hot flashes or night sweats, bloating and weight gain, vaginal dryness, brain fog and anxiety or depression. Many others mention they’re starting to get migraines or increasing PMS.

Why You Should Ask Your Mother When Her Symptoms Began

The biggest predictor of an early onset of perimenopause is being a smoker. Secondly, if your mother had early menopause, there’s an increased chance you will also (source). Interestingly, a difference in hot flashes has been reported based on ethnicity, education, socioeconomic status and BMI (source) So, like many health conditions, the onset of perimenopause and the symptoms you’ll experience is determined by a combination of genetics, lifestyle and environment.

The Good Stuff: My Recommendations

• Eat Your Phytoestrogens! Specifically, isoflavones.  Isoflavones are found in soy (tempeh, tofu, edamame, and miso) and chickpeas. Other sources of dietary phytoestrogens include flaxseed, sesame and sunflower seeds, lentils and quinoa. Researchers believe that two servings per day is optimal. Eating soy won’t increase your cancer risk- this is outdated information that researchers are pretty much in agreement on at this point. Researchers are still investigating their potential health benefits, including cancer prevention, reduction in hot flashes, and reduced bone loss. The studies are quite mixed, and researchers think this may be because only a certain percentage of women (between 20-50%) have the gut bacteria necessary to convert phytoestrogens to a form called S-equol, which is when it seems to be most helpful. For women who aren’t able to convert to S-equol, there is a new supplement version out, but at the time of writing this article it’s pricey and studies on its effectiveness are mixed. For a few more research links and a few yummy tofu recipes see this article.
•  2 TBSP Ground Flax Seed per day: Another win in the phytoestrogen category, studies have shown that adding ground Flax Seed to your diet can result in fewer anovulatory cycles and a slightly longer luteal phase. Overall, this means a more normalized cycle (source). Beyond its hormone balancing effects, Flax Seed has tons of other benefits including cardiovascular health, cancer prevention and reducing inflammation. You can add this to pretty much any food, since it doesn’t have much flavor. I like to add it to my oatmeal in the mornings.
• Make a Stress Management Strategy-  The North American Menopause Society recommends a method called paced respiration for reducing hot flashes. It is essentially focused, slow breathing a few times daily plus during hot flashes. It’s similar to a lot of mindfulness techniques and even to meditation. Preliminary research is encouraging, and if it relaxes you, there’s no downside to trying. Click here for their informational article, and here for a short how-to guide. Please note, if you have any respiratory conditions, please consult with your doctor about the safety of beginning this technique. Cognitive Behavioral Therapy (CBT) has also been shown to help.
• Acupuncture– As an acupuncturist I’m probably a bit biased! Getting regular acupuncture is especially helpful for reducing hot flashes, migraines, anxiety and brain fog. I’ve seen treatments really help women, and a new study confirms this. A study came out in February 2019 showing that a weekly acupuncture session for 5 weeks significantly reduced hot flushes,  sweating, sleeping problems and emotional symptoms. This was a Randomized Controlled Blinded Trial, which means the design of it is of high quality. Read it for yourself here.
• Move Your Body- The results are still inconclusive, but many studies (including this one) show that women who are physically active report fewer uncomfortable symptoms overall. Keep in mind, you can be physically active regardless of your BMI. Some studies show BMI is correlated with worse symptoms but others show no correlation. Physical activity is the important thing here!
• Consider Herbs and Supplements: In my practice I’ve found that for some women, taking a customized herbal prescription can help a lot.  There are a lot of herbs and supplements out there for perimenopause, most commonly black cohosh and red clover. The tricky thing is knowing what dosage to take and finding a formulation that actually contains what it states on the label. Poorer quality brands sometimes don’t even contain the correct herb, let alone the correct concentration! I recommend working with a trained herbalist in order to avoid missteps in this department.

Ladies, I am sorry to say that for most, some perimenopausal symptoms are inevitable. And that is fine, because this is a totally normal, physiological process that all women will experience. When you were going through puberty, big, noticeable changes were happening in your body and this is no different. The really good news is that there is actually a lot you can do to balance out those hormonal fluctuations. My goal is to help you to get through these years without much disruption to your daily life from symptoms, and experience this period of your life as a wonderful culmination of hard-earned experience, wisdom and intuitive powers.