It’s Not You. It’s Perimenopause.  🔗 **Source:** [It’s Not You. It’s Perimenopause.](https://share.snipd.com/episode/ec21d5c5-5e55-4ff7-8d21-77b88e36a446) ## Highlights - **Perimenopause Is A Long Zone Of Hormonal Chaos** - Perimenopause is a prolonged chaotic hormonal transition where brain signals no longer regulate ovaries predictably. - Mary Claire Haver calls it a “zone of chaos” lasting 7–10 years with wildly fluctuating estrogen that can be very high or plummet for months. Transcript: Mary Claire Haver Telling the ovaries to ovulate each month. So all of this starts in the brain, not the ovaries. So we have these hormones coming from the brain, stimulating hormones that say, our estrogen level dropped normally after ovulation, right? We need estrogen again. So it starts pumping out these signals to the ovary. The ovary's like, oh, here we go. Let's make more estrogen. We'll ovulate. Then we'll make progesterone. The whole thing starts every month over and over again, roughly every 28 days, okay? That looks like an EKG. It is this ebb and flow that is very predictable for a healthy woman. So on day 12, she does this. Day 14, she does this. Day 18, she does that. And it just is this gorgeous curve. Perimenopause is when the signals coming from the brain don't work on the ovaries anymore like they used to. So the brain starts freaking out. What's going on? Where's my estrogen? And then it starts pounding the ovary with higher and higher levels of that stimulating hormone. So this perimenopause transition where you went from normal, regular ebb and flow predictable to now if I take spaghetti and throw it at the wall, the curves look... My hands are waving all around for those listening. The curves are everywhere. And so we can see much higher estrogen levels than we ever had, like as high as they were in pregnancy. We can see them plummet and then tank for three or four months, then pop back up. So we call it the zone of chaos. And it can take seven to 10 years to get through it. ([Time 0:04:29](https://share.snipd.com/snip/d9e3aebf-0c14-4443-bc68-8ed7721fce77)) - **Personal Memory Of Scarce Menopause Education** - Mary Claire Haver recounts vague early exposure to menopause via her mother's secrecy and minimal medical training on the topic. - She remembers only a few lectures in med school and no deep endocrinology of the transition. Transcript: Mary Claire Haver Vague notion. And she would go into her dark room and just say, it's menopause and disappear for hours at a time. So I just understood it to be a bad thing. I didn't really understand what was happening to her. And she never sat me down and said, you know, this was my menopause experience, nothing. So now if I go to medical school, you know, go to undergrad and then go to med school. And, you know, it was mentioned, I think we had six one-hour lectures. We didn't have like a menopause clinic or any like specific focused, like taking care of women after reproduction ends. That didn't exist. Becky Kennedy Interesting. And in medical school, was perimenopause even, was it mentioned? I don't think so. Mary Claire Haver I don't remember learning that word. And I can remember it being mentioned. And in my mind, it was like the... I thought it was this gentle decline of ovarian function until the ovaries just kind of stopped putting out. And it was just... I learned how to pronounce it. ([Time 0:07:27](https://share.snipd.com/snip/e26d1214-19d7-4e5d-a884-067cb174ad82)) - **IDFLM Captures Perimenopause Brain Changes** - Women report “I don't feel like myself” as measurable cognitive and resilience loss during perimenopause. - Studies quantify IDFLM as brain fog, loss of resilience, and emotional reactivity tied to neuroendocrine upheaval. Transcript: Mary Claire Haver That? And yeah, what's going on there? We have a paper. So presented at the Menopause Society meeting last year, the woman who wrote the paper and it was published in 2024. They actually, it's called IDFLM. I don't feel like myself. And they quantified it. They gave it a scale, a scoring system, and they interviewed thousands and thousands of women and what that actually meant. And it's usually some form of cognitive issue like brain fog, right? Plus loss of resilience, like things that used to not bother you, things that you could handle. This life you built for yourself, you could manage the ups and flows and the ups and downs. But all of a sudden, all the processes you had put in place that you could manage the life you built start failing. So seeing that paper made me realize I had to write this book. You know, for those of us, you know, I'm well past transition. I'm very much post-menopausal, but for Mary Claire 10 years ago, who had nothing, who was navigating this blind and yelling at my kids and talking, you know, considering divorce and, You know, leaving my job, which actually was a good thing in the long run, you know, like all of these things that I'm like, what's wrong with me? I'm not myself. So it's quantifiable and loss of resilience, brain fog, and the emotional changes that are coming. So our neuroreceptors, so our neuroreceptors change and the neurotransmitters, so serotonin, dopamine, norepinephrine, all of them are affected by these hormone levels. It's a back and forth endocrine system. So our neuroendocrine system goes through a massive upheaval, and then it kind of calms down in postmenopause. ([Time 0:10:40](https://share.snipd.com/snip/72131ffb-4f28-46db-b6de-2f1316ceb966)) - **See A Menopause Expert Before Starting Psychiatric Meds** - If new anxiety, depression, sleep loss, or reactivity appears without new stressors, seek a menopause-educated clinician. - Stabilizing hormones often helps more than immediately starting antidepressants or anxiolytics. Transcript: Mary Claire Haver Where would you go next? So if you find yourself living a life you built and, you know, there's no new external stresses. You are managing day to day and all of a sudden you find yourself with new anxiety, new depression, snapping at your kids, not sleeping, or just feeling this like overall sense of this Isn't me. Okay. You're losing satisfaction. You know, we call it anhedonia, which is loss of joy. You're not depressed maybe, but you just aren't finding joy in the same things. Take a deep breath. Look at your external stressors. Has anything changed? Those are the common things, right? But if it hasn't, you need to find a menopause-educated clinician to begin having this conversation. Because guess what? Stabilizing your hormones through this transition is showing to be more effective than starting you on an antidepressant or anti-anxiety med. ([Time 0:15:10](https://share.snipd.com/snip/9bad54b9-9008-4724-b56c-ff5744b4e778)) - **HRT History Explains Present Hesitancy** - Hormone therapy's reputation swung sharply after the Women's Health Initiative but later data showed more nuance and benefits. - As of 2023 only ~4% of women were on FDA-approved HRT despite growing evidence and demand. Transcript: Mary Claire Haver So great question. So when you have a patient and they did this study in Australia, and this is for mental health, who has a new onset anxiety or depression, starting those patients on menopause hormone Therapy dosing. So estradiol, the exact equivalent of what your ovaries used to make, plus or minus a progestin, they do a lot better. And we are seeing this clinically. Those of us who are doing menopause medicine are seeing this clinically. Is it a fad? The more science we learn, the pendulum really swung. The first pendulum swung because there was this Get Your Wife Back book that was written. And it was really like how to keep your wife sexual, right? And estrogen was touted as this miracle hormone so that your wife would want to have sex with you, okay? And it was written by a male physician basically for husbands. It was crazy viral. It was the ickiest, skankiest book you've ever read in your life. And all these husbands are pushing their wives to get on estrogen. So then lots and lots of people are on estrogen. Well, it turns out they feel better. Their bones are stronger. They have less heart disease. They die less, you know, they live longer, all these benefits. And they don't necessarily want to have more sex with their husbands, but they're seeing benefits. Then the Women's Health Initiative came out basically to study, does a woman on hormone therapy, is she really going to have less heart attacks? Is it really cardiovascularly protective or is just, it's an artifact because healthier, wealthier women who have better socioeconomic stuff go on HRT. And this is just because they're healthier from baseline. Okay. The best gold star, $1 billion study. Again, didn't look at the nuanced data. The results did not reach statistical significance and said, oh my God, they should call up, cause a press conference, which went viral before viral, that estrogen causes heart attacks And estrogen causes breast cancer. And none of that turned out to be true. But that messaging was really hard. Once that genie got out of the bottle, it was really hard to shake it. I remember hearing it. I remember being scared of hormone therapy. I remember like, oh, we only use it if she's severe. And we just for the lowest amount for the shortest time possible, like this is it. We could hurt her with this. And exactly the opposite is true. Every medication Becky has risk benefits, you know, every single medication we prescribe to patients. And you know, this, this is just a tool in the toolkit, but now that we understand the nuances behind that and how safe the medication actually is and how it can be beneficial, the pendulum Is swinging. ([Time 0:16:11](https://share.snipd.com/snip/9230d2d2-be6a-4770-9e06-3f4fb00016eb)) - **Perimenopause Impacts The Whole Body** - Perimenopause affects nearly every organ system: skin, hair, lungs, gut microbiome, joints, and genitourinary health. - Symptoms include acne, formication, asthma worsening, gut shifts toward male-like microbiome, and genitourinary dryness. Transcript: Mary Claire Haver If you start noticing, so we'll kind of go top to bottom. Great. Mental health changes. So we'll start with the brain, right? So you are having increasing anxiety or depression, right? If you were having sleep disruptions, okay, either difficulty falling asleep or waking up at 3 a.m. You've done all the sleep hygiene stuff. You've, you know, did all the checkboxes. Phones out of the room. Becky Kennedy Yep. Mary Claire Haver You're doing all the things and you are still consistently, I mean, sleep, insomnia is now a risk factor for cardiovascular disease. Like not having good quality sleep is a risk factor for so many diseases, obesity, heart disease, diabetes, everything. So it is so, so, so important, okay, that we get on top of this. Skin, it's legion. So you can have dry skin, oily skin, acne, itchy ears. I mean, it's a combination of the nerves and the skin can become inflamed. So people can feel ants crawling on them. It's called formication. All of a sudden you're having dry skin way out of the ordinary for you. I mean, my acne cleared up. So that was a plus for me. Hair changes. So hair loss in areas you want to keep it or hair gain in areas you don't want to have it, the chin and mustache. You can see asthma affected. So if you're noticing that your asthma is worse or you're struggling, you need to get evaluated for that. Sleep apnea becomes a problem. Gastrointestinal changes, the gut microbiome changes to that of a man's. So that affects everything, how we absorb nutrients, how we absorb drugs. ([Time 0:21:46](https://share.snipd.com/snip/9d283064-03d7-4729-806b-c98d20f65fc7)) - **Brain Glucose Drop Underlies Perimenopause Fog** - Perimenopause reduces glucose uptake in memory-related brain regions, producing brain fog and lowered resilience. - Lisa Moscone's scans show those brain areas struggle to fire during the transition. Transcript: Mary Claire Haver You know, you're really on the struggle bus, like your resilience, your ability, you know, first of all, you're having brain fog. So the parts of the brain responsible for memory aren't getting as much glucose basically in this transition. And it's great scans done by Lisa Moscone who wrote The Menopause Brain. I'm really looking at like glucose utilization and uptake and how those parts of our brain are really struggling to fire. And so here you are, you know, trying to, you've got a kid who's going through their own hormonal upheaval with, you know, and, testing boundaries and all the thing. Plus, a lot of us who are in our career are at really crucial points in our career. It's like a perfect storm. So what we do in our clinic, I'm just trying to give them their resilience back. I can't fix that they have teenagers or, you know, give them a skill set to deal with aging parents, but I have resources, right? We have books, you know, Good Inside. We have podcasts. We have ways to help them cope. What I'm trying to give them back is if this is hormonally related, we can try to give you back some resilience. First of all, you need to sleep. We've got to have restful sleep. Nothing's going to work well, okay? ([Time 0:25:42](https://share.snipd.com/snip/15ce7186-debb-4db8-8cb7-47c92768d2b2)) - **Double Down On Sleep First** - Prioritize sleep restoration as a first-line step for perimenopausal symptoms. - Treat hot flashes or progesterone-related awakenings, use CBT for racing thoughts, and retrain learned 2–3 a.m. awakenings before meds. Transcript: Mary Claire Haver First of all, you need to sleep. We've got to have restful sleep. Nothing's going to work well, okay? And if the hot flashes are waking you up or progesterone loss is waking you up, we can fix that. Becky Kennedy Double down on sleep for a little bit with me because it's, it's also something that's interesting. I say this a lot to parents of teens, and it's one of the reasons why sleep hygiene phones out of the room. I just think, you know, whatever a kid's going through, if they are so sleep deprived, it's hard to even assess exactly what it is until sleep is a little, you know, has a better rhythm. Are you saying the same thing is true for any of us going through perimenopause? Absolutely. Mary Claire Haver Like these have disrupted our sleep, you know, in the last 10 years. Becky Kennedy Yeah, I'm holding up my cell phone. Mary Claire Haver I just got the Brick app because I had to turn it, you know, figure out a way to like take it away from myself. So my menopause friend group, we call ourselves the Menopausee, have all gotten Bricks. So, you know, when you work on social media, as you do too, you find yourself falling into the trap a little more. Becky Kennedy You're saying also there might be real hormonal changes also that no matter what you do with your phone, you're still having disrupted sleep, right? Yeah. So the two biggest complaints that we see in clinic in this population is difficulty falling asleep. Mary Claire Haver So that's usually racing thoughts. They can't turn their brain off. And so that responds really well to CBT, cognitive behavioral therapy, retraining your brain. And then, you know, I had a sleep medicine specialist on the middle of the night awakenings. If something's waking you up, a kid, a hot flash, whatever, you know, we can work on that. But if you are spontaneously waking up at two to three in the morning, we have to retrain you. It becomes a learned behavior. And so no sleeping pill is going to fix that, right? There's no medication, no supplement that really fixes that. That is really, you have trained your brain to wake up at three. Try to do box breathing, meditation first. If that's not working, get up. Your bed is for intimacy and for sleep. ([Time 0:26:52](https://share.snipd.com/snip/71301a76-3134-441c-a0d1-65d8c01bd00e)) - **Call Ahead To Confirm Menopause Certification** - Ask before booking: call clinics to confirm Menopause Society certification and telemedicine options. - Use lists of certified clinicians or vetted telemedicine companies to find care; some clinics offer hour-long visits fee-for-service. Transcript: Mary Claire Haver So, you know, if your doctor's not trained and they really have to step outside of their training, most of them now to be qualified to be able to talk to menopause with you. So you really need to find someone who's Menopause Society certified. That's a separate certification that we do outside. And any clinician, we have nurse practitioners, internal medicine, cardiologists, like this is a certification you seek outside of your residency. So that's like one tip. We have a resource on our website where people do testimonials. We have thousands in there from my followers who like just talk about their doctors and we organize them by city and state. That's another resource. So, but you know, ask your friends, did you have anybody that was helpful to you that talked to you? You don't have to pay zillions of dollars. I think the medical system is broken in a lot of ways. These 10, 15 minute visits, you know, really being constrained and only being able to address one problem at a time. And it just, you know, the medical system is not set up to serve women in menopause. But there's some great telemedicine options now. These companies, there's several that have been built seeing a need to serve. So this is another option. Some take insurance, some don't. So the resources are getting better. Right now is not reasonable for you to be able to walk into your great OBGYN, your wonderful internist, you know, and expect that they will have enough knowledge. ([Time 0:29:11](https://share.snipd.com/snip/4cb7355c-df0b-4f1d-9b91-2a784fe907e5)) - **Coordinate Care Rather Than Dump Your Doctor** - You don't always need to “break up” with your doctor; supplement care by sending tasks back and forth. - Menopause clinics can handle hormone care while primary clinicians do biopsies, paps, and procedural follow-up via insurance. Transcript: Mary Claire Haver To break up, but quite often, no. So like our patients, we just do menopause care. We do a lot of preventative medicine. We do a lot of building a runway for the next 30 years around risk of heart disease and obesity and diabetes and stuff. So, but if she needs a biopsy, if she needs a pap smear, we're sending her back to her regular doctor and letting, you know, my clinic doesn't accept insurance because I spend an hour with My patients and insurance won't pay for that. So, so our patient is, it's fee for service. Like I'm a doctor in the 1940s. And so, but you know, if she needs a biopsy or gynecologic care, I'd love for her to go back to her gynecologist. Now I've done that job. ([Time 0:31:36](https://share.snipd.com/snip/d8b47f25-cd52-42d8-9776-c3a7b545c42c)) - **Pause, Rule Out Other Causes, Then Seek Help** - If you're foggy or more reactive, breathe, check external stressors, and pursue evaluation rather than self-blame. - Run labs and rule out iron deficiency, autoimmune or inflammatory disorders while seeking a menopause-aware clinician. Transcript: Becky Kennedy Yes. And I'll kind of end on this one for the mother listening now who feels foggy and unlike herself and more reactive than usual. What do you want to tell her? It's okay. Mary Claire Haver It's okay. You know, take a deep breath, love yourself. Let's go find you a partner in healthcare who's going to listen to you and help you figure this out. It might not be perimenopause. It might be that you have low iron stores. You could have an autoimmune disease. You could have an inflammatory disorder, but you deserve to feel amazing. You deserve to wake up and ready to take on the world. ([Time 0:34:20](https://share.snipd.com/snip/6706e99c-5091-4164-915a-d07686889ca1))