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Perimenopause or Something Else? Bringing Nuance Back to Midlife Symptoms · Clearly Hormonal

• 0:01
  Dr. Komal Patil-Sisodia: Welcome to Clearly Hormonal, the podcast where we stop googling our symptoms at midnight and actually start understanding what's going on in our bodies.
• 0:10
  Dr. Komal Patil-Sisodia: I'm Dr.
• 0:10
  Dr. Komal Patil-Sisodia: Komal Patil-Sisodia, an endocrinologist, internist, obesity medicine specialist, and a Menopause Society certified practitioner, which is really just a whole lot of words to say hormones are kind of my jam.
• 0:22
  Dr. Komal Patil-Sisodia: I've spent 17 years watching women try to navigate their hormonal health without ever having been taught the language for what's happening in their own bodies, and then meeting clinicians who want nothing more than to help them figure it out, but are up against 10-minute appointments and a system that just wasn't built for it.
• 0:38
  Dr. Komal Patil-Sisodia: This podcast is my answer to that gap.
• 0:40
  Dr. Komal Patil-Sisodia: We'll cover menopause, metabolism, hormones, and everything in between with real evidence, not trends, and without the overwhelm.
• 0:48
  Dr. Komal Patil-Sisodia: A quick disclaimer.
• 0:49
  Dr. Komal Patil-Sisodia: I'm a physician, but this is education, not personalized medical advice.
• 0:53
  Dr. Komal Patil-Sisodia: Take what resonates and discuss it with your own healthcare team.
• 0:57
  Dr. Komal Patil-Sisodia: Now, let's get into it and talk about what's clearly hormonal and what's not.
• 1:04
  Dr. Komal Patil-Sisodia: If you're a woman somewhere in your 40s and you spend any amount of time online, you've probably seen some version of this.
• 1:10
  Dr. Komal Patil-Sisodia: You're exhausted?
• 1:11
  Dr. Komal Patil-Sisodia: Perimenopause.
• 1:12
  Dr. Komal Patil-Sisodia: You're gaining weight?
• 1:14
  Dr. Komal Patil-Sisodia: Perimenopause.
• 1:15
  Dr. Komal Patil-Sisodia: You can't sleep?
• 1:17
  Dr. Komal Patil-Sisodia: Perimenopause.
• 1:18
  Dr. Komal Patil-Sisodia: You're anxious?
• 1:19
  Dr. Komal Patil-Sisodia: Perimenopause.
• 1:20
  Dr. Komal Patil-Sisodia: Your hair is falling out, your joints hurt, and you can't remember why you walked into a room.
• 1:26
  Dr. Komal Patil-Sisodia: Your libido has disappeared and suddenly you don't recognize your own body.
• 1:30
  Dr. Komal Patil-Sisodia: Perimenopause.
• 1:32
  Dr. Komal Patil-Sisodia: And I want to start today's episode by saying something that might sound a little contradictory.
• 1:36
  Dr. Komal Patil-Sisodia: I am thrilled that we're finally talking about perimenopause.
• 1:40
  Dr. Komal Patil-Sisodia: For a very long time, women weren't given enough information about this phase of life.
• 1:45
  Dr. Komal Patil-Sisodia: Symptoms were dismissed, people were told that they were too young, that they would just have to deal with it, and many women entered their 40s having essentially no idea what to expect from the perimenopausal transition, from the menopausal transition.
• 2:02
  Dr. Komal Patil-Sisodia: So the fact that we're talking about this, that's progress.
• 2:06
  Dr. Komal Patil-Sisodia: But I think we've started to run into a new problem.
• 2:10
  Dr. Komal Patil-Sisodia: We've gone from not talking about perimenopause enough to sometimes talking about it as though it explains virtually anything that happens to a woman between the ages of 40 and 55.
• 2:23
  Dr. Komal Patil-Sisodia: And that's not necessarily better medicine because, yes, perimenopause can affect your body in really-- in very real ways.
• 2:31
  Dr. Komal Patil-Sisodia: But fatigue can also be iron deficiency.
• 2:34
  Dr. Komal Patil-Sisodia: Hair loss can be thyroid disease.
• 2:36
  Dr. Komal Patil-Sisodia: Poor sleep can also be sleep apnea.
• 2:38
  Dr. Komal Patil-Sisodia: Weight gain can have multiple causes.
• 2:41
  Dr. Komal Patil-Sisodia: Palpitations can have multiple causes.
• 2:43
  Dr. Komal Patil-Sisodia: Anxiety can have multiple causes.
• 2:46
  Dr. Komal Patil-Sisodia: And just because something happens during perimenopause does not necessarily mean it's happening because of perimenopause.
• 2:53
  Dr. Komal Patil-Sisodia: So today we're going to try and bring a little nuance back into this conversation.
• 2:58
  Dr. Komal Patil-Sisodia: What actually is perimenopause?
• 3:02
  Dr. Komal Patil-Sisodia: Which symptoms do we actually have good enough evidence for that may be associated with it?
• 3:07
  Dr. Komal Patil-Sisodia: Which symptoms might be related but deserve a little more thought?
• 3:11
  Dr. Komal Patil-Sisodia: When should we be looking for something else?
• 3:14
  Dr. Komal Patil-Sisodia: And maybe most importantly, how do we take women's symptoms seriously without automatically blaming everything on their hormones?
• 3:24
  Dr. Komal Patil-Sisodia: So how did we get here?
• 3:26
  Dr. Komal Patil-Sisodia: First, I think it's important to acknowledge why this conversation has exploded.
• 3:30
  Dr. Komal Patil-Sisodia: Because there was a real information gap.
• 3:33
  Dr. Komal Patil-Sisodia: A lot of women grew up knowing about puberty.
• 3:35
  Dr. Komal Patil-Sisodia: They learned about periods, they learned about pregnancy, and then there was this enormous blank space until menopause.
• 3:42
  Dr. Komal Patil-Sisodia: Maybe you were told at some point you'd have hot flashes and your periods would stop.
• 3:47
  Dr. Komal Patil-Sisodia: That was basically it.
• 3:49
  Dr. Komal Patil-Sisodia: Nobody necessarily told you that there could be a transition lasting years.
• 3:54
  Dr. Komal Patil-Sisodia: Nobody explained that your periods might start changing before they stopped.
• 3:58
  Dr. Komal Patil-Sisodia: Nobody explained what was happening hormonally.
• 4:02
  Dr. Komal Patil-Sisodia: And frankly, menopause education within medicine hasn't always been adequate either.
• 4:07
  Dr. Komal Patil-Sisodia: So women started looking for answers elsewhere, and social media filled that vacuum.
• 4:12
  Dr. Komal Patil-Sisodia: In many ways, that's been incredibly valuable.
• 4:16
  Dr. Komal Patil-Sisodia: Women started hearing other women describe experiences that sounded exactly like theirs.
• 4:21
  Dr. Komal Patil-Sisodia: They learned the word perimenopause.
• 4:24
  Dr. Komal Patil-Sisodia: They realized,"Wait, maybe there is a biological explanation for some of what I'm experiencing." And I never want to minimize how powerful that can be.
• 4:33
  Dr. Komal Patil-Sisodia: But there's a predictable thing that happens when a complicated medical topic gets translated into social media.
• 4:40
  Dr. Komal Patil-Sisodia: Nuance disappears.
• 4:43
  Dr. Komal Patil-Sisodia: Algorithms online reward certainty.
• 4:46
  Dr. Komal Patil-Sisodia: Here are several possible explanations for your fatigue is not nearly as compelling as you're tired because your estrogen is crashing.
• 4:56
  Dr. Komal Patil-Sisodia: And once we have a single explanation that seems to connect everything, it becomes very tempting to put every symptom into that bucket.
• 5:05
  Dr. Komal Patil-Sisodia: That's where I think we need to be careful.
• 5:08
  Dr. Komal Patil-Sisodia: The correction for decades of under-recognizing perimenopause should not be diagnosing perimenopause from every symptom a woman experiences in midlife.
• 5:17
  Dr. Komal Patil-Sisodia: We can do better than both extremes So let's define what we're talking about.
• 5:22
  Dr. Komal Patil-Sisodia: What actually is perimenopause?
• 5:24
  Dr. Komal Patil-Sisodia: Perimenopause is the transition leading up to menopause, and menopause itself is actually one point in time, your final period.
• 5:33
  Dr. Komal Patil-Sisodia: Clinically, in the usual situation, we recognize that you've reached menopause after you've gone 12 consecutive months without a menstrual period.
• 5:42
  Dr. Komal Patil-Sisodia: The average age of menopause in the United States is around 51.
• 5:46
  Dr. Komal Patil-Sisodia: Perimenopause usually begins sometime before that, commonly in the 40s, although there is obviously individual variation.
• 5:54
  Dr. Komal Patil-Sisodia: I've seen it as early as the 30s and as late as the early 50s.
• 5:59
  Dr. Komal Patil-Sisodia: One of the most important things to understand is that perimenopause is not simply a state of low estrogen.
• 6:05
  Dr. Komal Patil-Sisodia: I hear this all the time,"My estrogen is dropping.
• 6:09
  Dr. Komal Patil-Sisodia: My hormones are depleted.
• 6:11
  Dr. Komal Patil-Sisodia: My body isn't making estrogen anymore." That's not necessarily what's happening in early perimenopause.
• 6:18
  Dr. Komal Patil-Sisodia: Sure, hormone production becomes more variable, ovulation becomes less predictable, estrogen can fluctuate, and your levels can be relatively high at one point and low at another, and that variability is part of the reason symptoms can feel unpredictable.
• 6:35
  Dr. Komal Patil-Sisodia: One month you think,"I'm fine." The next month you're waking up drenched in a sweat at 3:00 in the morning wondering what happened to your body One of the biggest clues that someone is entering the menopausal transition is a change in their menstrual cycle.
• 6:50
  Dr. Komal Patil-Sisodia: Maybe your cycles used to be incredibly predictable, and now they're shorter or longer.
• 6:55
  Dr. Komal Patil-Sisodia: Maybe you're skipping periods.
• 6:56
  Dr. Komal Patil-Sisodia: Maybe the flow changes.
• 6:58
  Dr. Komal Patil-Sisodia: Maybe the timing becomes unpredictable.
• 7:01
  Dr. Komal Patil-Sisodia: Those changes give us useful information about what's happening with ovarian function.
• 7:07
  Dr. Komal Patil-Sisodia: Now, does that mean you can't possibly have symptoms until your periods become wildly irregular?
• 7:12
  Dr. Komal Patil-Sisodia: No.
• 7:13
  Dr. Komal Patil-Sisodia: Biology is not that neat and tidy, but menstrual history is an important part of the clinical picture, and that's something that gets lost when we reduce perimenopause to a giant checklist of symptoms.
• 7:25
  Dr. Komal Patil-Sisodia: Because if you search online, you can find lists with dozens and dozens of symptoms of perimenopause, and eventually those lists become so broad that almost every human being could check several boxes: fatigue, headache, bloating, forgetfulness, mood changes, weight changes, sleep changes, joint pain.
• 7:44
  Dr. Komal Patil-Sisodia: If our diagnostic criteria are basically,"Are you a human being experiencing midlife?" We're going to have a specificity problem.
• 7:52
  Dr. Komal Patil-Sisodia: That brings me to one of my favorite topics as an endocrinologist, hormone testing.
• 7:58
  Dr. Komal Patil-Sisodia: Because understandably, people think if we're trying to figure out whether this is hormonal, why don't we just measure the hormones?
• 8:04
  Dr. Komal Patil-Sisodia: That seems logical, and sometimes testing is absolutely appropriate.
• 8:09
  Dr. Komal Patil-Sisodia: But for the typical woman in her forty with characteristic menstrual changes and symptoms, a single FSH, follicle-stimulating hormone, or estradiol level is often not going to give you the definitive answer you're hoping for.
• 8:24
  Dr. Komal Patil-Sisodia: Why?
• 8:25
  Dr. Komal Patil-Sisodia: Because these hormones fluctuate.
• 8:26
  Dr. Komal Patil-Sisodia: You can measure estradiol on one day and get one result and measure it at another point and get something very different.
• 8:33
  Dr. Komal Patil-Sisodia: So a normal estrogen level doesn't necessarily mean,"Nope, not perimenopause," and one isolated abnormal value doesn't mean,"Great, we've discovered why you're tired, gaining weight, anxious, losing hair, and waking up at night." Current ACOG guidelines specifically note that most women do not need hormone testing to determine whether they're in perimenopause.
• 8:54
  Dr. Komal Patil-Sisodia: Their age, symptoms, and menstrual changes usually tell us more.
• 8:58
  Dr. Komal Patil-Sisodia: Testing can become more relevant when symptoms or menstrual changes occur at younger ages or when the clinical situation is atypical.
• 9:07
  Dr. Komal Patil-Sisodia: So whenever I see somebody selling the idea that one hormone panel is going to reveal the entire story of your health, I want you to be skeptical, because sometimes the more useful question isn't,"What's my estrogen?" It's,"Is there another reason I feel this way?" Let's make this concrete with a patient example, with someone I'll call Jen.
• 9:29
  Dr. Komal Patil-Sisodia: This is not a real patient, but kind of a composite of the people that I see.
• 9:36
  Dr. Komal Patil-Sisodia: This is not a real patient, but a composite of the conversations I have on repeat.
• 9:42
  Dr. Komal Patil-Sisodia: Jen is forty-four.
• 9:43
  Dr. Komal Patil-Sisodia: She comes in and says,"I'm exhausted, I'm gaining weight, my hair is thinning, and I can't sleep.
• 9:48
  Dr. Komal Patil-Sisodia: I think it's perimenopause." And here's what I do.
• 9:52
  Dr. Komal Patil-Sisodia: I don't say yes, and I don't say no.
• 9:54
  Dr. Komal Patil-Sisodia: I start asking where she is in her transition.
• 9:57
  Dr. Komal Patil-Sisodia: Are her cycles still fairly regular?
• 10:00
  Dr. Komal Patil-Sisodia: Is she having any hot flashes or any night sweats?
• 10:02
  Dr. Komal Patil-Sisodia: And that's useful information.
• 10:04
  Dr. Komal Patil-Sisodia: In this particular case, let's say that her cycles are still fairly regular, and she is not having hot flashes or night sweats.
• 10:12
  Dr. Komal Patil-Sisodia: Then I ask about each symptom on its own.
• 10:16
  Dr. Komal Patil-Sisodia: Fatigue and poor sleep in someone who does not have any vasomotor symptoms like hot flashes and night sweats sends me looking elsewhere first.
• 10:24
  Dr. Komal Patil-Sisodia: So we'll check things like iron, thyroid studies, and talk about sleep in detail.
• 10:31
  Dr. Komal Patil-Sisodia: So for Jen, turns out she's waking up at two AM most nights, snoring and waking up tired no matter how many hours of sleep she gets.
• 10:39
  Dr. Komal Patil-Sisodia: That's not a hormone story.
• 10:40
  Dr. Komal Patil-Sisodia: That's likely sleep apnea, and so I send her for a screening.
• 10:45
  Dr. Komal Patil-Sisodia: Her thinning hair turns out to track almost exactly with a significant stretch of weight loss eight months earlier, a nutritional and shedding pattern, not androgenetic alopecia, and her weight changes track with a new desk job and a knee injury that stopped her usual workouts.
• 11:02
  Dr. Komal Patil-Sisodia: Not a mystery, just a life change None of this means Jen isn't perimenopausal.
• 11:08
  Dr. Komal Patil-Sisodia: She might be later, and we'll revisit it.
• 11:12
  Dr. Komal Patil-Sisodia: It means that on the day she walked in, its perimenopause would have closed four different doors that needed to stay open.
• 11:19
  Dr. Komal Patil-Sisodia: That's this whole episode, honestly, in one visit So to help you navigate where you may be, I've put together a four-question framework, symptom by symptom.
• 11:30
  Dr. Komal Patil-Sisodia: And let's do this because I think it's more useful than a yes or no list.
• 11:34
  Dr. Komal Patil-Sisodia: For each symptom, I'm gonna run the same three questions that I just used with Jen.
• 11:39
  Dr. Komal Patil-Sisodia: Could perimenopause contribute?
• 11:41
  Dr. Komal Patil-Sisodia: What else could cause this?
• 11:44
  Dr. Komal Patil-Sisodia: And when should we look further?
• 11:45
  Dr. Komal Patil-Sisodia: Keep that rhythm in your head because we're gonna come back to it as a full framework at the end of the episode.
• 11:51
  Dr. Komal Patil-Sisodia: Let's talk about fatigue.
• 11:52
  Dr. Komal Patil-Sisodia: Could perimenopause contribute to fatigue?
• 11:54
  Dr. Komal Patil-Sisodia: Absolutely.
• 11:56
  Dr. Komal Patil-Sisodia: Think about how that could happen.
• 11:58
  Dr. Komal Patil-Sisodia: If you're having night sweats and waking up four times a night, you're probably going to be tired the next day.
• 12:03
  Dr. Komal Patil-Sisodia: If you're struggling with insomnia during the menopausal transition, you're probably gonna be tired the next day.
• 12:08
  Dr. Komal Patil-Sisodia: But fatigue itself is incredibly nonspecific.
• 12:12
  Dr. Komal Patil-Sisodia: Iron deficiency can cause fatigue, anemia, hypothyroidism, sleep apnea, depression, certain medications, nutritional deficiencies, not eating enough, and other medical conditions.
• 12:23
  Dr. Komal Patil-Sisodia: So if someone comes to me and says,"I'm forty-four and exhausted, therefore I know I'm in perimenopause," I don't wanna dismiss perimenopause, but I also don't wanna stop thinking.
• 12:33
  Dr. Komal Patil-Sisodia: Fatigue is a symptom.
• 12:34
  Dr. Komal Patil-Sisodia: It's not a diagnosis.
• 12:36
  Dr. Komal Patil-Sisodia: Next up, let's talk about weight gain, and I'll say this upfront, this deserves its own full episode, so consider this the preview.
• 12:44
  Dr. Komal Patil-Sisodia: There are real changes in body composition that happen in midlife and the menopausal transition, including a tendency towards gaining more visceral or central fat.
• 12:55
  Dr. Komal Patil-Sisodia: At the same time we're aging, muscle mass is changing, activity is changing, sleep is changing, life is changing, and there can be metabolic factors and medication effects that layer on top of this I want you to hold two different statements apart.
• 13:11
  Dr. Komal Patil-Sisodia: My body composition has changed during the menopausal transition is reasonable.
• 13:16
  Dr. Komal Patil-Sisodia: My estrogen dropped, and that's why I gained twenty pounds is a much more specific claim, and biology is usually more complicated than that.
• 13:24
  Dr. Komal Patil-Sisodia: So menopause may be part of the picture, but it's not the whole picture.
• 13:27
  Dr. Komal Patil-Sisodia: This matters because if we tell women that estrogen deficiency is the reason for their weight gain, the obvious implication is going to be that replacing estrogen should make the weight come off.
• 13:37
  Dr. Komal Patil-Sisodia: Menopause hormone therapy is not a weight loss medication.
• 13:42
  Dr. Komal Patil-Sisodia: That doesn't mean that it can't be helpful when it's appropriately prescribed for menopausal symptoms.
• 13:47
  Dr. Komal Patil-Sisodia: It means we should use treatments for what they've actually been shown to treat.
• 13:52
  Dr. Komal Patil-Sisodia: We're going to unpack all of this properly in an upcoming episode.
• 13:55
  Dr. Komal Patil-Sisodia: For today, that's just the headline version.
• 13:59
  Dr. Komal Patil-Sisodia: What about brain fog?
• 14:00
  Dr. Komal Patil-Sisodia: Difficulty concentrating, word finding issues, walking into a room and forgetting why you're there, The experience can be very real.
• 14:09
  Dr. Komal Patil-Sisodia: But again, we need to ask what's contributing.
• 14:12
  Dr. Komal Patil-Sisodia: Are you sleeping enough?
• 14:13
  Dr. Komal Patil-Sisodia: Are you having night sweats?
• 14:15
  Dr. Komal Patil-Sisodia: Are you under tremendous stress?
• 14:17
  Dr. Komal Patil-Sisodia: Are you depressed?
• 14:18
  Dr. Komal Patil-Sisodia: Are you anxious?
• 14:19
  Dr. Komal Patil-Sisodia: Could a medication be contributing?
• 14:21
  Dr. Komal Patil-Sisodia: Is there ADHD that previously existed but has become harder to compensate for?
• 14:27
  Dr. Komal Patil-Sisodia: And if cognitive symptoms are significant, progressive, unusual, or interfering substantially with your ability to function, that's an important conversation to have with your clinician, not just assume that it's your hormones changing Next, we have anxiety and mood.
• 14:43
  Dr. Komal Patil-Sisodia: This is where nuance becomes especially important.
• 14:47
  Dr. Komal Patil-Sisodia: Mood symptoms can occur during menopausal transition.
• 14:50
  Dr. Komal Patil-Sisodia: Some women clearly describe feeling emotionally different during this time period.
• 14:55
  Dr. Komal Patil-Sisodia: But there is a difference between recognizing that reproductive transitions can affect mood and deciding that every new mental health symptom in a woman in her forties is an estrogen problem.
• 15:08
  Dr. Komal Patil-Sisodia: Think about the life stage we're talking about.
• 15:10
  Dr. Komal Patil-Sisodia: People may be raising children, caring for aging parents, managing careers, dealing with relationship changes, sleeping terribly, managing financial stress, experiencing health changes, sometimes all at the same time.
• 15:24
  Dr. Komal Patil-Sisodia: Hormones don't exist in a vacuum, and neither do we.
• 15:27
  Dr. Komal Patil-Sisodia: So yes, reproductive hormones may be part of the picture, but we shouldn't use hormones to erase everything else that's happening in someone's life or biology.
• 15:36
  Dr. Komal Patil-Sisodia: Hair loss is one of my favorite examples of this because this is exactly where saying perimenopause can prematurely end an evaluation.
• 15:46
  Dr. Komal Patil-Sisodia: Can hair change around menopause?
• 15:48
  Dr. Komal Patil-Sisodia: Sure.
• 15:49
  Dr. Komal Patil-Sisodia: But if you're experiencing significant hair loss, I want to know what kind.
• 15:53
  Dr. Komal Patil-Sisodia: Is it diffuse shedding?
• 15:54
  Dr. Komal Patil-Sisodia: Is there a pattern distribution?
• 15:57
  Dr. Komal Patil-Sisodia: Did it start after an illness?
• 15:58
  Dr. Komal Patil-Sisodia: After significant weight loss?
• 16:00
  Dr. Komal Patil-Sisodia: Are you iron deficient?
• 16:02
  Dr. Komal Patil-Sisodia: Could this be thyroid disease?
• 16:03
  Dr. Komal Patil-Sisodia: Are there nutritional factors?
• 16:05
  Dr. Komal Patil-Sisodia: Are medications contributing?
• 16:07
  Dr. Komal Patil-Sisodia: Is this androgenetic hair loss, meaning due to high testosterone levels?
• 16:12
  Dr. Komal Patil-Sisodia: Hair loss isn't one condition, and calling it hormonal doesn't tell us which hormone, what mechanism, or what treatment makes sense.
• 16:20
  Dr. Komal Patil-Sisodia: Giving a symptom a hormonal label isn't the same thing as explaining it.
• 16:25
  Dr. Komal Patil-Sisodia: Sleep is interesting because the relationship can sometimes be much more direct.
• 16:28
  Dr. Komal Patil-Sisodia: If you wake up because you're having a hot flash or you're drenched in sweat, it's pretty reasonable to connect that sleep disruption to vasomotor symptoms.
• 16:37
  Dr. Komal Patil-Sisodia: But if you're waking up constantly and you're not having hot flashes, now we need to broaden the differential.
• 16:44
  Dr. Komal Patil-Sisodia: Insomnia, sleep apnea, restless leg syndrome, alcohol use, anxiety, medications, environmental factors, all of these things can contribute.
• 16:55
  Dr. Komal Patil-Sisodia: And sleep apnea is an especially important one because women do not always present with the stereotypical picture people might imagine.
• 17:03
  Dr. Komal Patil-Sisodia: The mechanism might be obvious, or it might not be, and that's exactly the distinction worth making before you reach for just a hormonal explanation and don't bother to work up the rest.
• 17:15
  Dr. Komal Patil-Sisodia: Low libido is another place where the internet loves a hormone level, particularly testosterone, but libido is complicated.
• 17:22
  Dr. Komal Patil-Sisodia: Pain with sex can affect libido.
• 17:24
  Dr. Komal Patil-Sisodia: Vaginal dryness can affect libido.
• 17:27
  Dr. Komal Patil-Sisodia: Sleep affects libido.
• 17:28
  Dr. Komal Patil-Sisodia: Mood affects libido.
• 17:29
  Dr. Komal Patil-Sisodia: Medications affect libido.
• 17:31
  Dr. Komal Patil-Sisodia: Relationship dynamics affect libido.
• 17:33
  Dr. Komal Patil-Sisodia: Stress, health, all of these things affect libido.
• 17:37
  Dr. Komal Patil-Sisodia: So when someone promises that optimizing one hormone level is going to restore your sex drive, that should immediately be a red flag and make you ask more questions.
• 17:48
  Dr. Komal Patil-Sisodia: Sexual health matters, but it deserves more than an overly simplistic hormone explanation.
• 17:54
  Dr. Komal Patil-Sisodia: There are so many resources out there to help deal with the other things that can contribute to low libido outside of a low testosterone.
• 18:02
  Dr. Komal Patil-Sisodia: And finally, joint pain.
• 18:04
  Dr. Komal Patil-Sisodia: This has become a huge menopause conversation.
• 18:07
  Dr. Komal Patil-Sisodia: Many women report musculoskeletal symptoms during this stage of life, and there is ongoing research into the relationship between menopause and musculoskeletal health.
• 18:16
  Dr. Komal Patil-Sisodia: But here's where I want you to remember the difference between this symptom is reported during the menopausal transition, and we have established that estrogen deficiency is causing your joint pain and therefore estrogen is the appropriate treatment for it.
• 18:30
  Dr. Komal Patil-Sisodia: Those are not interchangeable.
• 18:31
  Dr. Komal Patil-Sisodia: If your joints hurt, there are many potential explanations.
• 18:35
  Dr. Komal Patil-Sisodia: The pattern of the joint pain matters.
• 18:37
  Dr. Komal Patil-Sisodia: The severity matters.
• 18:38
  Dr. Komal Patil-Sisodia: Whether there's swelling or redness matters.
• 18:41
  Dr. Komal Patil-Sisodia: Your personal and family history matter.
• 18:44
  Dr. Komal Patil-Sisodia: Could perimenopause contribute?
• 18:45
  Dr. Komal Patil-Sisodia: Yes.
• 18:46
  Dr. Komal Patil-Sisodia: Should that automatically be the end of the conversation?
• 18:49
  Dr. Komal Patil-Sisodia: No.
• 18:50
  Dr. Komal Patil-Sisodia: And sometimes that means an evaluation that has nothing to do with your ovaries.
• 18:55
  Dr. Komal Patil-Sisodia: Now let's talk about when the statement, quote,"It's just perimenopause," becomes a problem.
• 19:00
  Dr. Komal Patil-Sisodia: Here's the part I care about most.
• 19:03
  Dr. Komal Patil-Sisodia: This phrase can become just as dismissive as the phrase,"It's just stress," which is what women were told for years and years and years before we started having these conversations around midlife.
• 19:15
  Dr. Komal Patil-Sisodia: Because once we decide we know the explanation, we stop asking questions, and sometimes we shouldn't.
• 19:21
  Dr. Komal Patil-Sisodia: Take abnormal bleeding, for example.
• 19:23
  Dr. Komal Patil-Sisodia: Periods often change during perimenopause.
• 19:26
  Dr. Komal Patil-Sisodia: That's absolutely true.
• 19:28
  Dr. Komal Patil-Sisodia: But significant or unusual bleeding should not automatically be written off as perimenopause.
• 19:34
  Dr. Komal Patil-Sisodia: Depending on the situation, there may be other causes that need evaluation.
• 19:38
  Dr. Komal Patil-Sisodia: The same principle applies to symptoms like persistent palpitations, severe unexplained fatigue, significant unexplained weight changes, new neurologic symptoms, hair loss, new or severe headaches, symptoms suggesting thyroid dysfunction, or symptoms that seem unusually early for the menopausal transition.
• 19:57
  Dr. Komal Patil-Sisodia: And I don't want you listening to this and becoming anxious about every symptom.
• 20:01
  Dr. Komal Patil-Sisodia: That's really not the goal of this episode.
• 20:04
  Dr. Komal Patil-Sisodia: But what I want to drive home is that perimenopause does not give you immunity from every other medical condition.
• 20:11
  Dr. Komal Patil-Sisodia: You can be in perimenopause and have iron deficiency.
• 20:15
  Dr. Komal Patil-Sisodia: You can be in perimenopause and develop hypothyroidism.
• 20:18
  Dr. Komal Patil-Sisodia: You can be in perimenopause and have sleep apnea.
• 20:21
  Dr. Komal Patil-Sisodia: You can be in perimenopause and have depression or have diabetes, and so on and so on.
• 20:26
  Dr. Komal Patil-Sisodia: Two things can be true at the same time, and good medicine will keep that possibility open Now, I want to make the opposite point very clearly because I can already imagine somebody taking this episode and saying,"See?
• 20:41
  Dr. Komal Patil-Sisodia: Doctors think perimenopause isn't real." That is absolutely not what I'm saying.
• 20:46
  Dr. Komal Patil-Sisodia: I don't want us to swing the pendulum back.
• 20:49
  Dr. Komal Patil-Sisodia: Women should not have to convince their healthcare providers that perimenopause exists.
• 20:53
  Dr. Komal Patil-Sisodia: You shouldn't have to wait until you're having twenty hot flashes a day before somebody takes you seriously.
• 20:59
  Dr. Komal Patil-Sisodia: You shouldn't automatically be told you're too young simply because you're still menstruating, and you don't need some dramatically abnormal hormone test to validate what you're experiencing.
• 21:10
  Dr. Komal Patil-Sisodia: Perimenopausal symptoms are real, and when symptoms are affecting your quality of life, you deserve a conversation about appropriate treatment.
• 21:19
  Dr. Komal Patil-Sisodia: The goal here is not skepticism towards women, it's skepticism towards overly simple explanations, and those are very different things.
• 21:27
  Dr. Komal Patil-Sisodia: There is a middle ground between everything is perimenopause and none of this could possibly be perimenopause.
• 21:34
  Dr. Komal Patil-Sisodia: The middle ground, in my opinion, is where thoughtful medicine lives.
• 21:38
  Dr. Komal Patil-Sisodia: So if you're listening to this thinking,"Okay, but how am I actually supposed to know?" Here's the same framework we've been running all episode laid out in full.
• 21:48
  Dr. Komal Patil-Sisodia: Question one: Where am I in the reproductive transition?
• 21:52
  Dr. Komal Patil-Sisodia: And here are the questions that come up for me when I'm discussing this with my patients.
• 21:57
  Dr. Komal Patil-Sisodia: How old are you?
• 21:58
  Dr. Komal Patil-Sisodia: What's happening with your menstrual cycle?
• 22:00
  Dr. Komal Patil-Sisodia: Have your periods changed?
• 22:02
  Dr. Komal Patil-Sisodia: Are you having hot flashes or night sweats?
• 22:05
  Dr. Komal Patil-Sisodia: Are you using contraception that changes your bleeding pattern?
• 22:08
  Dr. Komal Patil-Sisodia: Have you had a hysterectomy?
• 22:10
  Dr. Komal Patil-Sisodia: What is the overall clinical picture?
• 22:12
  Dr. Komal Patil-Sisodia: Not one symptom, the picture.
• 22:15
  Dr. Komal Patil-Sisodia: Question two: Is this particular symptom possibly related to perimenopause?
• 22:22
  Dr. Komal Patil-Sisodia: And I deliberately said possibly, not can I find this symptom on somebody's list of seventy-two signs your estrogen is disappearing.
• 22:29
  Dr. Komal Patil-Sisodia: These are symptoms with a stronger relationship to the menopause transition than others.
• 22:35
  Dr. Komal Patil-Sisodia: ACOG, for example, describes vasomotor and vaginal symptoms as those that are most closely associated with the hormonal changes we see in midlife, and that distinction matters.
• 22:46
  Dr. Komal Patil-Sisodia: Question three: Is there another common or important explanation to consider?
• 22:52
  Dr. Komal Patil-Sisodia: This doesn't mean everybody needs forty-seven blood tests.
• 22:55
  Dr. Komal Patil-Sisodia: Sometimes the history gives us the answer.
• 22:57
  Dr. Komal Patil-Sisodia: Sometimes a physical exam helps.
• 23:00
  Dr. Komal Patil-Sisodia: Sometimes targeted testing makes sense.
• 23:03
  Dr. Komal Patil-Sisodia: The point is to keep thinking the way we did with my example patient, Jen.
• 23:08
  Dr. Komal Patil-Sisodia: Question four, if this is happening during perimenopause, does treating perimenopause actually improve it?
• 23:14
  Dr. Komal Patil-Sisodia: A symptom can be associated with this life stage without automatically becoming an indication for hormone therapy.
• 23:21
  Dr. Komal Patil-Sisodia: And I think that's where a lot of social media conversations will jump a step.
• 23:25
  Dr. Komal Patil-Sisodia: We go from women report the symptom during perimenopause, to estrogen deficiency causes the symptom, to you need estrogen.
• 23:33
  Dr. Komal Patil-Sisodia: These are three separate claims, and each one requires evidence Here's what I hope you take away from this episode.
• 23:41
  Dr. Komal Patil-Sisodia: I'm glad perimenopause is having a moment.
• 23:43
  Dr. Komal Patil-Sisodia: I'm glad women know this word.
• 23:45
  Dr. Komal Patil-Sisodia: I'm glad people are talking about hot flashes and vaginal symptoms and sleep and changing periods and sexual health openly.
• 23:52
  Dr. Komal Patil-Sisodia: I'm glad women are walking into their doctor's office asking questions that previous generations often weren't empowered to ask.
• 23:59
  Dr. Komal Patil-Sisodia: We should not go backwards.
• 24:01
  Dr. Komal Patil-Sisodia: But taking women's symptoms seriously does not mean we have to attribute every symptom to their hormones.
• 24:07
  Dr. Komal Patil-Sisodia: Sometimes taking a symptom seriously means being curious enough to ask,"What else could this be?
• 24:13
  Dr. Komal Patil-Sisodia: Could there be more than one thing happening?
• 24:15
  Dr. Komal Patil-Sisodia: Does the explanation actually fit the physiology, and does the treatment we're recommending have evidence that it will help this particular problem?" Because that's real life.
• 24:26
  Dr. Komal Patil-Sisodia: Oftentimes things are multifactorial.
• 24:28
  Dr. Komal Patil-Sisodia: They have multiple reasons why something is occurring.
• 24:32
  Dr. Komal Patil-Sisodia: Perimenopause is real, its symptoms are real, and women deserve something better than either dismissal or an overly simplistic explanation for everything that's happening in their bodies.
• 24:43
  Dr. Komal Patil-Sisodia: They deserve nuance, they deserve evidence, and they deserve clinicians who keep asking the questions, and that's really what this podcast is about, taking hormones seriously without making hormones the answer to everything.
• 24:56
  Dr. Komal Patil-Sisodia: Before we go, if you've got your own is this actually hormonal question, something you've been told is just perimenopause and you're not sure that that's the whole story, send it in.
• 25:07
  Dr. Komal Patil-Sisodia: You can DM me on Instagram or TikTok,@drpatilsisodia, or you can send a message through Buzzsprout's fan mail.
• 25:16
  Dr. Komal Patil-Sisodia: I'm picking a few for the post-credit segments every episode going forward, and yours might be next.
• 25:22
  Dr. Komal Patil-Sisodia: Thanks for tuning in today, and I'll see you all on the next episode.
• 25:26
  Dr. Komal Patil-Sisodia: Before we go, here's today's quick question, on the segment Is This Actually Hormonal?
• 25:32
  Dr. Komal Patil-Sisodia: The question is,"I'm 46 and suddenly waking up at 3:00 in the morning every night.
• 25:37
  Dr. Komal Patil-Sisodia: Is that perimenopause?" My answer?
• 25:40
  Dr. Komal Patil-Sisodia: Maybe.
• 25:41
  Dr. Komal Patil-Sisodia: If you're waking up hot, sweaty, or because you're having a hot flash, that gives me a pretty convincing mechanism connecting your sleep disruption to the menopause transition.
• 25:50
  Dr. Komal Patil-Sisodia: But if you're waking up at 3:00 every morning without vasomotor symptoms, I'm not automatically going to blame estrogen.
• 25:57
  Dr. Komal Patil-Sisodia: I want to know about insomnia, about stress, about alcohol use, about your medications, about whether you've been evaluated for sleep apnea, and what else is happening in your life and health.
• 26:08
  Dr. Komal Patil-Sisodia: Hormonal is always a possibility, but it's not a permission slip to stop asking questions.