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Perimenopause Is Not a Lab Value: How to Recognize It and Get the Right Care · Clearly Hormonal

• 0:06
  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.
• 0:14
  Dr. Komal Patil-Sisodia: I'm Dr.
• 0:15
  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.
• 0:26
  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.
• 0:42
  Dr. Komal Patil-Sisodia: This podcast is my answer to that gap.
• 0:45
  Dr. Komal Patil-Sisodia: We'll cover menopause, metabolism, hormones, and everything in between with real evidence, not trends, and without the overwhelm.
• 0:53
  Dr. Komal Patil-Sisodia: A quick disclaimer.
• 0:54
  Dr. Komal Patil-Sisodia: I'm a physician, but this is education, not personalized medical advice.
• 0:58
  Dr. Komal Patil-Sisodia: Take what resonates and discuss it with your own healthcare team.
• 1:01
  Dr. Komal Patil-Sisodia: Now, let's get into it and talk about what's clearly hormonal and what's not.
• 1:08
  Dr. Komal Patil-Sisodia: I want you to imagine a scenario with me today.
• 1:11
  Dr. Komal Patil-Sisodia: Imagine that you're in your mid-40s.
• 1:13
  Dr. Komal Patil-Sisodia: Your periods used to be predictable, but now some are coming early, others are coming late.
• 1:18
  Dr. Komal Patil-Sisodia: The flow is all over the place.
• 1:21
  Dr. Komal Patil-Sisodia: You're waking up at night.
• 1:22
  Dr. Komal Patil-Sisodia: You feel more irritable.
• 1:24
  Dr. Komal Patil-Sisodia: You're having difficulty finding the right words in the middle of a conversation, and you wonder, could this be perimenopause?
• 1:31
  Dr. Komal Patil-Sisodia: Someone checks your hormones and tells you the results are normal, but you still don't feel like yourself.
• 1:37
  Dr. Komal Patil-Sisodia: So what happens next?
• 1:39
  Dr. Komal Patil-Sisodia: This is such a common presentation that I see in my clinic on a, almost a daily basis.
• 1:47
  Dr. Komal Patil-Sisodia: Last year, I got a chance to attend the Menopause Society Conference virtually.
• 1:51
  Dr. Komal Patil-Sisodia: one of the most interesting talks that I saw was the one about the most common symptom of perimenopause, and that is,"I just don't feel like myself." This can mean so many different things to so many different doctors that you see, and it's not a very specific symptom, and I think this is what makes perimenopause so difficult to diagnose for women.
• 2:13
  Dr. Komal Patil-Sisodia: And it can be a very frustrating point in life where you think,"Gosh, why is there just not a test to make this completely clear to everyone?
• 2:23
  Dr. Komal Patil-Sisodia: And what do you mean measuring my hormones won't help?" Today on Clearly Hormonal, I want to kick off our Menopause Awareness Month episodes.
• 2:33
  Dr. Komal Patil-Sisodia: And last month, I focused on PMOS, or polyendocrine metabolic ovarian syndrome, and it was also Perimenopause Awareness Month.
• 2:41
  Dr. Komal Patil-Sisodia: So before we get into the meat of all of the menopause stuff, I figured that I owed perimenopause at least one episode today on the podcast.
• 2:50
  Dr. Komal Patil-Sisodia: So I wanted to make sure that we talk about how we recognize perimenopause, when testing helps, and why your history matters.
• 2:59
  Dr. Komal Patil-Sisodia: All of these things are really important in order for women to get appropriate diagnosis and appropriate care, and to understand what their options are.
• 3:07
  Dr. Komal Patil-Sisodia: And here's what I want you all to know.
• 3:10
  Dr. Komal Patil-Sisodia: A normal hormone test result does not rule out perimenopause.
• 3:15
  Dr. Komal Patil-Sisodia: Your symptoms and the pattern of your symptoms and how they change over time is really what deserves the most attention.
• 3:24
  Dr. Komal Patil-Sisodia: To get a diagnosis of perimenopause, there are three things that I focus on to make sure that I'm guiding patients in the right way so that they're able to get answers.
• 3:34
  Dr. Komal Patil-Sisodia: The first is going to be age.
• 3:36
  Dr. Komal Patil-Sisodia: If we look at the average age of women when they enter perimenopause, it's usually in their 40s, but the timing can vary.
• 3:45
  Dr. Komal Patil-Sisodia: The next part of the puzzle for me when I'm talking to a patient is What do your periods look like?
• 3:53
  Dr. Komal Patil-Sisodia: People can have changes in the timing of their periods, which can be an important clue.
• 3:58
  Dr. Komal Patil-Sisodia: They can have changes in the flow, in how long the periods are lasting, and all of these things are little clues as to what might be happening.
• 4:07
  Dr. Komal Patil-Sisodia: And then lastly, what symptoms are you having?
• 4:10
  Dr. Komal Patil-Sisodia: Perimenopause can bring out the same symptoms that we attribute to menopause.
• 4:14
  Dr. Komal Patil-Sisodia: But because periods are still happening, women's concerns are brushed off.
• 4:18
  Dr. Komal Patil-Sisodia: I have so many women who come into my office thinking,"Gosh, do I have a thyroid disorder?
• 4:22
  Dr. Komal Patil-Sisodia: Is it my adrenals?" What's going on?
• 4:25
  Dr. Komal Patil-Sisodia: And it can be very confusing.
• 4:28
  Dr. Komal Patil-Sisodia: And it's very important at this time when periods are still happening in women to look at those symptoms and rule out potential other causes.
• 4:35
  Dr. Komal Patil-Sisodia: But common things that can happen in perimenopause are similar to menopause, hot flashes, night sweats, sleep changes, and other symptoms like joint pain and brain fog and difficulty with finding the right words, anxiety, depression, so many different things that can come out, right?
• 4:53
  Dr. Komal Patil-Sisodia: Now let's talk about menstrual cycles a little bit.
• 4:56
  Dr. Komal Patil-Sisodia: Your menstrual cycles will tell a story.
• 4:59
  Dr. Komal Patil-Sisodia: Your cycle length is the number of days from the first day of one period to the first day of your next period.
• 5:06
  Dr. Komal Patil-Sisodia: I want to take a minute and just talk about the menopause transition, as we call it.
• 5:10
  Dr. Komal Patil-Sisodia: The menopause transition consists of perimenopause, which is the two to 10 years prior to the last menstrual period, which is defined as menopause.
• 5:19
  Dr. Komal Patil-Sisodia: The last menstrual period and the 12 months of no periods after it are menopause.
• 5:24
  Dr. Komal Patil-Sisodia: And then beyond that is what we consider postmenopause.
• 5:28
  Dr. Komal Patil-Sisodia: When I talk about perimenopause, I'm talking about those years that are happening before that last menstrual period.
• 5:36
  Dr. Komal Patil-Sisodia: There is a system, there's a framework that we use in medicine called the Straw Plus 10 system that looks at all of these different years and what we call the reproductive lifespan of a woman.
• 5:50
  Dr. Komal Patil-Sisodia: So starting when women are able to start reproducing, so basically when they hit puberty.
• 5:56
  Dr. Komal Patil-Sisodia: But in the menopause transition, what we talk about is early perimenopause and late perimenopause.
• 6:03
  Dr. Komal Patil-Sisodia: And I want to distinguish the two because earlier in that transition, what we call early perimenopause, cycles will vary just a little bit.
• 6:12
  Dr. Komal Patil-Sisodia: They may be differ by at least seven days of what you expected, right?
• 6:17
  Dr. Komal Patil-Sisodia: So one month you may have a cycle that's 21 days if you have a normal 28 day cycle.
• 6:22
  Dr. Komal Patil-Sisodia: The next month you may have something that's 35 days away.
• 6:25
  Dr. Komal Patil-Sisodia: And it varies in that range so that it's not particularly predictable, but it's not like you're skipping months at a time.
• 6:32
  Dr. Komal Patil-Sisodia: That kind of variation happens throughout that early perimenopause transition.
• 6:37
  Dr. Komal Patil-Sisodia: Later in the transition, what we call late perimenopause, you may go 60 days or longer without a period.
• 6:44
  Dr. Komal Patil-Sisodia: And I always tell my patients that is like the last one to two years before your periods stop altogether.
• 6:50
  Dr. Komal Patil-Sisodia: That's generally what we see in most women.
• 6:53
  Dr. Komal Patil-Sisodia: Menopause is that final period, again, that's confirmed after 12 months without another period and when you haven't been able to prove another cause of making the period stop altogether.
• 7:05
  Dr. Komal Patil-Sisodia: This is really what helps my colleagues and I describe reproductive aging.
• 7:11
  Dr. Komal Patil-Sisodia: One unusual cycle is not going to do that by itself, but really we look at a pattern, and it can be frustrating to wait to dissect that pattern.
• 7:21
  Dr. Komal Patil-Sisodia: But this is why I tell women it's so important to track your cycles.
• 7:25
  Dr. Komal Patil-Sisodia: These patterns are going to be clues, not a test that you have to pass before asking for help.
• 7:30
  Dr. Komal Patil-Sisodia: So if somebody's helping you put this picture together for yourself, you can actually come out with a diagnosis of perimenopause, and you can start getting help for your symptoms before your final menstrual period.
• 7:42
  Dr. Komal Patil-Sisodia: There are a few different things though that can make this a little harder to dissect.
• 7:47
  Dr. Komal Patil-Sisodia: So for example, if you're on birth control, sometimes that can mask symptoms of perimenopause until they start to break through the birth control effects.
• 7:57
  Dr. Komal Patil-Sisodia: Having a hysterectomy when you're no longer having periods can make it harder to predict.
• 8:03
  Dr. Komal Patil-Sisodia: And then having a condition like PMOS, which is polyendocrine metabolic ovarian syndrome, used to be called PCOS.
• 8:10
  Dr. Komal Patil-Sisodia: In that particular population, we see that people have irregular cycles for most of their lives, so it can be very difficult to tell are these actually changing during perimenopause or not?
• 8:21
  Dr. Komal Patil-Sisodia: Some women actually find when they have PMOS that their cycles get a little bit more regular as they hit perimenopause and then go haywire again.
• 8:30
  Dr. Komal Patil-Sisodia: But that's not always the case.
• 8:31
  Dr. Komal Patil-Sisodia: Again, the pattern matters, and the symptoms during that change in pattern also matter.
• 8:37
  Dr. Komal Patil-Sisodia: Hormone tests that a lot of patients come in asking for are things like FSH, which is a signal from the brain that tells your ovaries to work, and estradiol, which is the major form of estrogen that's made from the ovaries.
• 8:50
  Dr. Komal Patil-Sisodia: I want to reiterate, a hormone test is like a snapshot.
• 8:52
  Dr. Komal Patil-Sisodia: It's like a selfie you take one day.
• 8:55
  Dr. Komal Patil-Sisodia: And your menstrual history and your symptoms are if you took a video and were watching the video from beginning to end.
• 9:03
  Dr. Komal Patil-Sisodia: One still frame of the video is not going to give you the same picture as a whole video itself.
• 9:09
  Dr. Komal Patil-Sisodia: I don't often check FSH and estradiol in patients just because I don't think it particularly helps us get to a diagnosis, and it's spending your money when you don't necessarily need to.
• 9:19
  Dr. Komal Patil-Sisodia: There's other tests like AMH or ultrasound measurements of the ovaries.
• 9:23
  Dr. Komal Patil-Sisodia: Those also don't necessarily help in this particular scenario.
• 9:27
  Dr. Komal Patil-Sisodia: One of the biggest myths that I hear is,"If my hormone levels are normal, I can't be in perimenopause." I hear this so many times.
• 9:36
  Dr. Komal Patil-Sisodia: I actually hear clinicians telling patients that, and it's blatantly wrong Here's what the evidence says.
• 9:43
  Dr. Komal Patil-Sisodia: Hormones will fluctuate during the menopause transition, but a result within the lab's normal range can't rule it out I named this episode Perimenopause is Not a Lab Value, but that doesn't mean that blood tests never help.
• 10:01
  Dr. Komal Patil-Sisodia: The question is always going to be, what are we trying to learn from those blood tests?
• 10:05
  Dr. Komal Patil-Sisodia: So if you're a person under 40 and you are having missed or irregular periods and you're having symptoms of menopause, you need to be evaluated for premature ovarian insufficiency, and that's when the ovaries stop working normally much earlier than expected.
• 10:21
  Dr. Komal Patil-Sisodia: Between the ages of 40 and 45, FSH testing, there's some data that it might be helpful, but not consistently in everybody.
• 10:29
  Dr. Komal Patil-Sisodia: And if there's an unclear picture, sometimes doing targeted testing for other things that could be affecting periods like thyroid dysfunction, iron deficiency, vitamin deficiency prolactin levels, things like that can be really helpful The other thing that we never talk enough about, which is one of the most common causes of a missed period, is pregnancy.
• 10:52
  Dr. Komal Patil-Sisodia: You are still ovulating in perimenopause, and pregnancy is possible.
• 10:57
  Dr. Komal Patil-Sisodia: So if you miss a period or you miss a few periods, Doing a pregnancy test should be one of the first tests you do.
• 11:02
  Dr. Komal Patil-Sisodia: I have had to tell women in their mid to late 40s that they're pregnant, and it blows people's minds sometimes, but it can and does happen Now let's talk a little bit about symptoms.
• 11:13
  Dr. Komal Patil-Sisodia: Symptoms fall into a few different categories.
• 11:17
  Dr. Komal Patil-Sisodia: When we think about perimenopause and menopause, everybody thinks about hot flashes, night sweats, and then vaginal dryness.
• 11:25
  Dr. Komal Patil-Sisodia: Those are the major things that pop into every person's mind when they are approaching that perimenopause transition.
• 11:31
  Dr. Komal Patil-Sisodia: Because we have estrogen and progesterone receptors everywhere in our bodies, it can actually manifest in different ways for different people.
• 11:39
  Dr. Komal Patil-Sisodia: So when I am thinking about symptoms, I'm grouping them into different categories.
• 11:43
  Dr. Komal Patil-Sisodia: So the first is going to be sleep.
• 11:46
  Dr. Komal Patil-Sisodia: Are you having trouble falling asleep?
• 11:48
  Dr. Komal Patil-Sisodia: Are you waking up during the night?
• 11:50
  Dr. Komal Patil-Sisodia: Is it because you have to urinate, or because you are having night sweats that are waking you up?
• 11:56
  Dr. Komal Patil-Sisodia: There's a few different reasons why you can have sleep symptoms.
• 11:59
  Dr. Komal Patil-Sisodia: I think about mood and thinking.
• 12:01
  Dr. Komal Patil-Sisodia: So if you have irritability, mood changes, difficulty concentrating what people describe as a brain fog, or having difficulty finding the right words, those are symptoms that affect your mood and thinking.
• 12:13
  Dr. Komal Patil-Sisodia: Next, I think about physical comfort, right?
• 12:16
  Dr. Komal Patil-Sisodia: So if you're having joint pain or headaches or any sort of breast tenderness Those are physical symptoms of menopause.
• 12:23
  Dr. Komal Patil-Sisodia: And then you want to talk about sexual and urinary health.
• 12:26
  Dr. Komal Patil-Sisodia: So vaginal dryness, discomfort with sex, an increased frequency of UTI, urinary incontinence, like leaking urine Those can all be symptoms of the menopause transition.
• 12:38
  Dr. Komal Patil-Sisodia: And these symptoms can fit in perimenopause, but they can also overlap with the other conditions we talked about, and that's why I'm always looking at the whole pattern.
• 12:46
  Dr. Komal Patil-Sisodia: I'm considering whether we need to rule out other things as we're working somebody up.
• 12:51
  Dr. Komal Patil-Sisodia: So to review a few things that we discussed.
• 12:53
  Dr. Komal Patil-Sisodia: Thyroid disease, when symptoms are suggestive of thyroid disease.
• 12:57
  Dr. Komal Patil-Sisodia: Anemia, low iron with heavy bleeding, and fatigue can contribute to these symptoms.
• 13:03
  Dr. Komal Patil-Sisodia: Sleep apnea or insomnia, and then there can be medication effects, right?
• 13:07
  Dr. Komal Patil-Sisodia: Or if anxiety and depression are getting worse.
• 13:10
  Dr. Komal Patil-Sisodia: All of those things can contribute to these symptoms.
• 13:13
  Dr. Komal Patil-Sisodia: So testing for some of these things is often appropriate and should be done just so we can be certain somebody is going through perimenopause One of the things that I always try and drive home with my patients who I suspect are in perimenopause is that we need to make sure you don't have another condition that also needs treatment.
• 13:32
  Dr. Komal Patil-Sisodia: It's not very common that treating the perimenopause hormonal fluctuations with hormone replacement or with birth control is going to be the silver bullet, especially if you have something else going on.
• 13:44
  Dr. Komal Patil-Sisodia: Usually when I start women on hormones, if they're not feeling better a few months into therapy, we are looking for other causes and doing tests for all the things that I talked about if it's relevant And I'm going to keep saying this because I think it's important for everyone to know.
• 14:01
  Dr. Komal Patil-Sisodia: Menopause does not look the same for everyone.
• 14:04
  Dr. Komal Patil-Sisodia: My menopause is different than my mom's menopause, is different than my sister's, is different than my best friend's, is different than the next person's walking down the street.
• 14:12
  Dr. Komal Patil-Sisodia: And the way we diagnose perimenopause is usually the same across all racial and ethnic groups.
• 14:18
  Dr. Komal Patil-Sisodia: But the research is showing us that there are differences when menopause happens, which symptoms people report, and how long those symptoms last.
• 14:28
  Dr. Komal Patil-Sisodia: So for example, in the SWAN study, Black women with frequent hot flashes and night sweats reported the longest duration of symptoms with an average of about 10 years.
• 14:43
  Dr. Komal Patil-Sisodia: That's a long time to be dealing with perimenopause symptoms and not getting help.
• 14:48
  Dr. Komal Patil-Sisodia: For Chinese and Japanese women, they actually had shorter duration of symptoms, but it doesn't necessarily mean that every Asian woman who goes into perimenopause is going to have milder symptoms.
• 15:00
  Dr. Komal Patil-Sisodia: They're just happening over a shorter period of time.
• 15:03
  Dr. Komal Patil-Sisodia: And then there was a larger, what we call multi-ethnic, so looking at different ethnic groups, study that found earlier natural menopause among Latina women and later menopause in Japanese American women when they compared them with white women.
• 15:18
  Dr. Komal Patil-Sisodia: These are all patterns across groups of people, but they can't predict exactly what's going to happen to you.
• 15:23
  Dr. Komal Patil-Sisodia: And while we're doing this, there's another thing that I really want to acknowledge because I don't think we talk about this as much as we should.
• 15:31
  Dr. Komal Patil-Sisodia: Stress, your living conditions, your access to care, your experiences of discrimination all shape health and your symptoms can all shape your overall health and your symptoms.
• 15:48
  Dr. Komal Patil-Sisodia: Race alone doesn't always explain someone's experience.
• 15:51
  Dr. Komal Patil-Sisodia: There are other, social determinants of health that can also play into this and make the picture a lot muddier.
• 15:57
  Dr. Komal Patil-Sisodia: So I guess what I'm trying to say is that every woman deserves a very individualized conversation about what her life looks like, what her experience has been so far, what her symptoms are, what her periods look like, and just how she's feeling overall.
• 16:15
  Dr. Komal Patil-Sisodia: We don't have to have women suffer to the nth degree or wait until their periods are gone before we're able to help them And when I talk to my patients, just because their symptoms don't match somebody else's doesn't mean that both parties are not in perimenopause.
• 16:30
  Dr. Komal Patil-Sisodia: So here's what I think needs to go down in a useful appointment for perimenopause.
• 16:36
  Dr. Komal Patil-Sisodia: You should be reviewing your periods, your symptoms, your medications, and your health history with your doctor.
• 16:42
  Dr. Komal Patil-Sisodia: You should be identifying what is affecting your daily life the most, what is affecting your ability to function.
• 16:49
  Dr. Komal Patil-Sisodia: Then you need to decide with your clinician what type of testing would be best for you.
• 16:56
  Dr. Komal Patil-Sisodia: Oftentimes, it's not going to be like the reproductive hormone testing, but it may be testing for other things to make sure they're ruled out.
• 17:03
  Dr. Komal Patil-Sisodia: And then lastly, you should be talking about what treatment options are there, what is the follow-up plan, and if that particular clinician doesn't feel comfortable addressing or treating this for you, where do you go next?
• 17:16
  Dr. Komal Patil-Sisodia: If you're noticing changes to your body, like you weigh the same on the scale, but you don't have as much muscle mass, or you're gaining more weight around your midsection and losing muscle in your arms and legs, I want you to talk to your doctor or your clinician about sleep, about strength, about nutrition, about your metabolic health.
• 17:35
  Dr. Komal Patil-Sisodia: And I'm going to do a separate episode on that altogether because I think that is a whole other conversation that needs to happen.
• 17:42
  Dr. Komal Patil-Sisodia: But there are three takeaways that I really want you to walk away with from this episode.
• 17:48
  Dr. Komal Patil-Sisodia: Number one, perimenopause is usually recognized from your history and your symptoms.
• 17:53
  Dr. Komal Patil-Sisodia: Number two, a normal hormone test result does not rule it out.
• 17:58
  Dr. Komal Patil-Sisodia: And then the third thing I want you to walk away is that your care should include a plan and a follow-up.
• 18:05
  Dr. Komal Patil-Sisodia: And if the clinician that you're seeing can't help you with these symptoms, part of your plan should be,"Who do I go see for this?" So now that we've covered all of that, here's one thing I want you to do.
• 18:15
  Dr. Komal Patil-Sisodia: Before your appointment, write down when your periods are occurring, what symptoms you've noticed, and how they've changed, and the three concerns affecting your life the most.
• 18:26
  Dr. Komal Patil-Sisodia: Bring that to your visit just so you can have a point of reference for when you're talking to your clinician.
• 18:32
  Dr. Komal Patil-Sisodia: You don't need a perfect collated Excel spreadsheet with color-coded tabs and stuff like that.
• 18:38
  Dr. Komal Patil-Sisodia: You just need to have this type of information to be ready to discuss with your doctor.
• 18:44
  Dr. Komal Patil-Sisodia: And the one question you can ask is, could this pattern that I'm experiencing fit perimenopause?
• 18:51
  Dr. Komal Patil-Sisodia: What else should we evaluate, and what can help me right now?
• 18:55
  Dr. Komal Patil-Sisodia: Your story gives us information that a single blood test can't.
• 19:01
  Dr. Komal Patil-Sisodia: And next week we're going to talk about why body composition changes in midlife and what can help.
• 19:06
  Dr. Komal Patil-Sisodia: Thank you all for tuning into this first episode for the menopause series for Clearly Hormonal.
• 19:12
  Dr. Komal Patil-Sisodia: I am so excited for the remaining episodes this month.
• 19:17
  Dr. Komal Patil-Sisodia: I also wanted to let you know that today is the day that my PMOS course, my polyendocrine metabolic ovarian syndrome patient course, is going live today.
• 19:28
  Dr. Komal Patil-Sisodia: And this is a course that I've been working on over the last month and a half, about how to help women advocate for themselves in the doctor's office, how to get a better understanding of PMOS and those types of symptoms, and how to have that conversation.
• 19:46
  Dr. Komal Patil-Sisodia: The course is accompanied with three months of access to the material, plus a monthly webinar Q&A call with me.
• 19:53
  Dr. Komal Patil-Sisodia: The site should be live on my website, and for this first week, There will be an introductory special for the course, and then the pricing will go up to the normal price starting Wednesday of next week.
• 20:07
  Dr. Komal Patil-Sisodia: So if that's something you're interested in, you can always send me an email through my website.
• 20:12
  Dr. Komal Patil-Sisodia: You can DM me on social.
• 20:14
  Dr. Komal Patil-Sisodia: If you have more questions about the course, I'm happy to go into more detail about that.
• 20:18
  Dr. Komal Patil-Sisodia: But thank you all for joining me today on Clearly Hormonal, and I will see you all on the next episode