The Ultimate Guide to Perimenopause: Perimenopause Symptoms, Lab Tests, and Natural Support
Perimenopause can feel like a wild ride—bringing new physical and emotional symptoms, often without warning or guidance.
If you’re noticing changes in your body, your mood, or even how you experience your own skin, know that you’re not alone. Many women find this time of life overwhelming, especially with symptoms that seem to come out of nowhere.
Irregular periods and return of heavy bleeding episodes, hot flashes, headaches, intense mood swings, persistent fatigue, and stubborn weight gain—especially belly fat—are all common in perimenopause.
It’s easy to feel isolated or confused, but these changes are part of a natural life transition.
This guide answers common questions like:
What is perimenopause?
How do I know if I’m entering perimenopause?
What can I do now to feel better?
With a clear approach and tools for understanding your unique experience, you can take control and navigate perimenopause with more clarity and confidence.
What is Perimenopause, and When Does Perimenopause Start?
Perimenopause is the transitional period leading up to menopause, the point when your menstrual cycle permanently stops. During perimenopause, hormone levels fluctuate significantly, affecting each woman differently.
While the beginning of perimenopause, as well as how long it lasts, can vary greatly, experts give perimenopause an average timeline of about 4 years.
Most women begin perimenopause anywhere between the ages of 35 and 50, with symptoms appearing gradually.
Factors including genetics, lifestyle, and underlying health conditions can influence when perimenopause starts and how intense the symptoms are.
In fact, even gut health plays a role. New research into the estrobolome (part of the microbiome, that has major implications for your hormone balance) shows that a healthy microbiome can make perimenopause much easier.
Perimenopausal changes can begin as subtle irregularities in your menstrual cycle or slight shifts in mood, gradually building to more recognizable patterns.
Understanding that perimenopause is a normal part of life helps take some of the stress out of managing the symptoms.
But don’t worry: we’ll also cover how to help make this transition easier for you.
Early Perimenopause vs. Late Perimenopause: What’s the Difference?
Perimenopause consists of two primary stages: the early transition and the late transition.
In the early transition of perimenopause menstrual cycles remain mostly regular, but minor irregularities start to appear like cycles that vary by more than seven days.
This stage marks the beginning of the decline in ovarian follicles (follicles are the tiny pockets in ovaries that contain immature eggs; during ovulation, one follicle usually matures and releases its egg).
The beginning of ovarian follicle decline means occasional rises in follicle-stimulating hormone (FSH) and other subtle hormonal shifts. It also means more anovulatory cycles, which means periods where you did not ovulate during the previous cycle.
Anovulatory cycles come with a change in hormone patterns including higher FSH, lower inhibin B, and lower estradiol levels than in ovulatory cycles.
In the late transition, menstrual irregularities become more noticeable, with longer gaps of amenorrhea (periods of time with no periods or bleeding) lasting 60 days or more.
Late perimenopause brings more intense hormonal fluctuations, including higher FSH levels and unpredictable estrogen levels which lead to more severe symptoms like hot flashes, mood swings, and disrupted sleep.
The late transition signals that menopause is approaching and is often when perimenopausal symptoms are most intense.
Key Perimenopause Symptoms to Watch For
Perimenopause symptoms vary widely and can mimic other health issues. If you’re experiencing any combination of the following, it could be a sign that perimenopause has begun:
Menstrual Changes: periods may become irregular, lighter or heavier, shorter or longer. Some women experience intense bleeding or spotting between periods.
While changes in bleeding can be a normal part of perimenopause, continuous bleeding or bleeding that persists despite reasonable attempts to treat it require additional assessment for conditions such as uterine fibroids or cancer.
Mood Shifts: emotional ups and downs are common. You may feel unusually irritable, anxious, or experience mood swings. These mood swings can feel like PMS symptoms that don’t go away or that come and go erratically, or they can remind you of when you went through puberty.
Sleep Disturbances: trouble falling asleep, staying asleep, or waking up feeling unrefreshed are signs your hormones may be shifting. It may be especially common to begin waking in the middle of the night and struggle to get back to sleep.
Hot Flashes and Night Sweats: sudden warmth, often followed by sweating and chills, can disrupt daily life and sleep.
Weight Gain: many women struggle with perimenopausal weight gain, particularly in the abdominal area, which can be frustrating despite healthy eating and regular exercise. Estrogen may regulate appetite, and low estrogen can cause overeating as well as increase inflammation, which also boosts cortisol output. Cortisol is the hormone responsible for stubborn belly fat.
Skin and Hair Changes: thinning hair, dry skin, or a sudden appearance of acne or facial hair may also be connected to hormone changes.
A sudden increase in wrinkles or feeling like your skin is rapidly aging is linked to declining estrogen levels, especially if you have a lot of sun exposure.
In many women, increasing acne or facial hair in perimenopause and menopause is linked to declining levels of female hormones to balance out the effects of testosterone. This can also be accompanied by increased hair loss, also due to new estrogen/testosterone imbalances.
Decreased Libido and Vaginal Dryness: shifts in hormone levels can affect sexual drive and comfort during sex and/or intimacy.
While these symptoms are a natural part of perimenopause, they can be overwhelming and difficult to manage alone. This is where functional medicine and targeted lab testing can make a big difference.
The Importance of Functional Medicine Lab Testing in Perimenopause: How It Helps
Functional medicine lab testing can provide a personalized look at what’s happening in your body during perimenopause. It offers specific insights that general healthcare visits might miss, especially in cases where symptoms feel overwhelming or unpredictable.
Lab testing can reveal hormone imbalances, nutritional deficiencies, and metabolic risks that contribute to perimenopause symptoms.
Here are the most beneficial tests to consider for a holistic understanding of your health.
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Top Functional Medicine Lab Tests to Understand Perimenopause Symptoms
The following functional medicine tests can shed a new world of insight into symptoms that can make you feel like things are suddenly spinning out of control.
Comprehensive Hormone Panel
A comprehensive hormone panel helps to understand fluctuations in hormones like estrogen, progesterone, testosterone, cortisol, and DHEA-S. Testing these hormones gives you a clearer picture of your body’s unique needs.
I prefer the DUTCH (Dried Urine Test for Comprehensive Hormones) Plus test, which shows levels of many hormones and their metabolites, including:
Sex Hormones and Metabolites
Estradiol (E2)
Estrone (E1)
Estriol (E3)
2-OH-E1 (2-Hydroxyestrone, estrogen metabolite)
4-OH-E1 (4-Hydroxyestrone, estrogen metabolite)
16-OH-E1 (16-Hydroxyestrone, estrogen metabolite)
Progesterone (through metabolites like a-Pregnanediol and b-Pregnanediol)
Testosterone
5a-DHT (5 alpha-Dihydrotestosterone)
Androstenedione
Adrenal Hormones
DHEA-S (Dehydroepiandrosterone sulfate)
Cortisol and Cortisone Metabolites
Cortisol (free and metabolized forms)
Cortisone
THF (Tetrahydrocortisol, cortisol metabolite)
THE (Tetrahydrocortisone, cortisone metabolite)
11β-HSD1 and 11β-HSD2 enzyme activity markers for cortisone/cortisol conversion
Cortisol Awakening Response (CAR) to assess HPA-axis function (this is essential in people with a history of trauma, PTSD, chronic stress, or chronic inflammatory conditions who are also struggling with hormone symptoms!)
Other Hormones and Biomarkers
Melatonin: via its metabolite 6-OH-Melatonin-Sulfate
Organic Acids
B6 (Pyridoxine) Marker: Xanthurenate
B12 (Cobalamin) Marker: Methylmalonate
Glutathione (Antioxidant marker): Pyroglutamate
Neurotransmitter Metabolites:
VMA (Vanilmandelate) for norepinephrine/epinephrine
HVA (Homovanillate) for dopamine
When to Test
Tests like the DUTCH Plus test are excellent for women who are noticing irregular periods, mood changes, shifts in libido, as well as changing or increasing mood symptoms. Hormone testing can identify imbalances contributing to these symptoms.
Why It’s Important
Discovering that shifting hormone levels are responsible for overwhelming symptoms can be life-changing for women: knowing that it’s NOT all in your head is the first step to making changes that matter.
Testing cortisol and DHEA-S, hormones produced by the adrenal glands, is also important.
High stress levels can aggravate hormone symptoms: this means that adrenal health is every bit as important in perimenopause as it was in earlier years, including pregnancy and postpartum.
Hormone testing allows for targeted support, so you can address specific imbalances and improve your quality of life.
Comprehensive Thyroid Function Tests (TSH, Free T4, Free T3, Reverse T3, Thyroid Antibodies)
The thyroid plays a vital role in regulating energy, mood, and metabolism, all of which are impacted during perimenopause. This panel provides a full view of thyroid function and can reveal if underlying thyroid issues are contributing to symptoms.
When to Test
I prioritize thyroid testing in women with unexplained fatigue, weight gain, hair loss, or mood swings, especially within the last several months to one year.
The thyroid gland is a bit like a motherboard, and it will try so hard to respond to changes in your body’s hormone levels and energy needs, potentially to the point of burning out.
It’s essential to keep the thyroid in mind during perimenopause, because symptoms of thyroid issues can overlap with perimenopausal symptoms, leading to under-diagnosis and undertreatment in women who need help.
Why It’s Important
Just like other shifting hormone levels, many women experience thyroid fluctuations during perimenopause. Thyroid hormone shifts, thyroid burnout and autoimmune thyroid issues can be especially prevalent in the setting of chronic stress (and in PTSD), which is so common during the perimenopausal time of life.
Catching and addressing these changes early can significantly improve energy levels, mood, and weight management. It can also reduce a woman’s risk of developing cardiovascular disease and osteoporosis, which can be caused by thyroid dysfunction.
Comprehensive Cardiometabolic Testing
This is one of my favorite tests for just about everyone, really.
In perimenopause, an in-depth panel that looks at your overall metabolic and cardiovascular health is especially important because perimenopausal hormone shifts can have a big impact on your cardiometabolic health.
During perimenopause, decreasing estrogen levels and rising cortisol levels lead to weight gain and increased abdominal fat, raising the risk of heart disease, type 2 diabetes, and osteoporosis.
Expect a comprehensive cardiometabolic panel to include:
A comprehensive metabolic profile (CMP): this tests liver and kidney function. Non-alcoholic fatty liver disease is a major cause and consequence of metabolic dysfunction, specifically high blood sugar and triglycerides, and increases risk of developing certain cancers and cardiometabolic disease later.
Fasting glucose: a quick snapshot of blood sugar levels when fasting, this gives a sense of whether you’re living with chronically elevated blood sugar levels due to metabolic dysfunction.
Fasting insulin: fasting insulin is a key marker of insulin resistance and often rises before blood sugar levels do. Detecting this early allows for timely interventions to help manage and prevent further health issues.
Hemoglobin A1c (HbA1c): a marker of average blood sugar levels over time. HbA1c is another method for assessing average blood sugar levels, and monitoring a person’s response to medications and lifestyle interventions to control blood sugar issues.
Uric Acid: uric acid is a key biomarker for cardiometabolic health because high levels are linked to increased risk of hypertension, heart disease, and insulin resistance, making it an early indicator for these conditions.
A Full Cholesterol Panel: beyond a basic lipid panel, a full cholesterol panel may include lipid markers such as ApoB, ApoA1, Lp(a), sdLDL and oxLDL (small dense and oxidized LDL particles, which increase a person’s risk of cardiovascular disease).
sdLDL, one of the most atherogenic particles out there, tends to rise in perimenopausal and menopausal women! This is essential to assess in perimenopausal women.
Additional Options
Continuous glucose monitoring (CGM) and biometric analysis can provide real-time data to better understand your body’s response to diet and lifestyle.
I’ve used CGMs for years in my cardiometabolic, weight loss, and comprehensive women’s health programs, and they are a GAMECHANGER for so many patients. There’s nothing in the world like instant feedback.
When to Test
Persistent belly fat, fatigue, or a family history of cardiovascular issues are reasons to consider this testing. But again, every perimenopausal woman should strongly consider a comprehensive cardiometabolic assessment.
Why It’s Important
Cardiovascular and metabolic risks increase during perimenopause. Identifying these early on can help you make lifestyle changes that reduce risk and improve long-term health.
Comprehensive Stool Testing
A comprehensive stool test evaluates the gut microbiome and estrobolome (gut bacteria that metabolize estrogen), which both play important roles in hormone balance.
Dysbiosis, or an imbalance in the gut microbiome, can disrupt the estrobolome's function, potentially leading to changes in estrogen levels and increased risks of estrogen-related health issues.
When to Test
In women who experience bloating, constipation, frequent infections, or mood swings, stool testing can uncover hidden imbalances.
Stool testing can also help women struggling with rollercoaster mystery hormone symptoms find answers, and relief.
Why It’s Important
The gut microbiome is essential for hormone balance and overall health. Stool testing allows you to address gut health, which in turn supports better hormone regulation and reduces symptoms.
Wearable Technology for Tracking Perimenopause Symptoms
Wearable tech is a game-changer for tracking changes that can impact your overall well-being like sleep quality, heart rate variability (HRV), ovulation, and stress response. Devices like fitness trackers and smartwatches offer insights into daily patterns, allowing you to spot trends and adjust your routine.
Many of these trackers can also help track ovulation and may provide insight into mystery symptoms that can finally be attributed to hormonal shifts in ovulatory vs. anovulatory symptoms.
Benefits
Real-time data can help you optimize your sleep, manage stress, and understand how hormonal changes affect your energy.
Popular Devices
Consider a wearable that offers comprehensive data on sleep stages, HRV, and stress levels. Some devices also track menstrual cycles, making them useful tools for observing cycle changes.
I prefer the Oura ring as a wearable biometric device, but there are lots of options available!
Natural and Functional Medicine-Based Support for Perimenopause Symptoms
First, test to discover what’s happening below the surface. This helps your practitioner create a bespoke plan for your hormone woes.
Beyond testing, these lifestyle adjustments, dietary changes, and supplements can ease symptoms:
Lifestyle Adjustments
Prioritize sleep, add regular exercise, and adopt stress management practices like meditation.
Dietary Recommendations
Incorporate anti-inflammatory foods, high-quality protein, and healthy fats. This helps stabilize blood sugar and supports hormone balance, including metabolic hormones like insulin.
Drink plenty of clean, filtered water to support detoxification and bowel regularity, which ultimately promotes hormone health.
Appropriate Supplementation
Magnesium: magnesium can benefit perimenopausal women, mainly through its anti-inflammatory and mood-stabilizing effects.
Magnesium levels tend to decrease in women experiencing perimenopause, which can exacerbate common symptoms like mood fluctuations, sleep disturbances, and vasomotor symptoms (e.g., hot flashes).
Magnesium has also been associated with a reduced risk of depressive symptoms and cardiovascular risk factors, both relevant concerns in perimenopause due to hormonal changes.
Ashwagandha: ashwaganda is a powerful adaptogen that has been shown to significantly reduce stress in women by lowering cortisol levels and improving scores on the Perceived Stress Scale after about 8 weeks of use. This adaptogenic herb supports the body’s stress response, helping to restore balance in the hypothalamic-pituitary-adrenal (HPA) axis and reduce feelings of mental and physical strain.
Evening Primrose Oil: evening primrose oil, rich in gamma-linolenic acid (GLA), may help alleviate night sweats in perimenopausal women by promoting anti-inflammatory effects and supporting hormone balance through prostaglandin production. Additionally, its benefits include improved cardiovascular markers such as reduced hs-CRP, enhancing its potential as a supportive supplement during this transition.
Vitamin D3: vitamin D plays a vital role for perimenopausal women, benefiting more than just bone health.
It supports muscle strength, heart health, and immune function, which can lower risks of osteoporosis, diabetes, and inflammation-linked heart disease.
Vitamin D may also ease genitourinary symptoms, reduce cancer risks, and improve mood, helping to counter depression often seen during menopause.
Mind-Body Approaches
Yoga, mindfulness, and acupuncture have been shown to reduce stress and ease symptoms.
Other supplements may be recommended based on specific lab findings and symptoms.
The Importance of Working with a Functional Medicine Expert
Perimenopause is a unique journey, and working with a functional medicine practitioner can make it easier to navigate.
An expert can guide you through personalized lab testing, recommend specific lifestyle and dietary changes and provide tailored support as your body transitions.
Finding a practitioner who understands perimenopause can help you regain control, feel empowered, and minimize symptoms with a customized approach.
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