Perimenopause is a normal part of the female aging process leading into the menopausal phase of life. While it is normal, the symptoms experienced can feel anything but - irregular periods, changes in mood, hot flashes, and sleep impairment can contribute to feelings of despair and unknown. Fortunately, a smooth transition is possible. Working with a functional medicine doctor, specialty labs can uncover the reason behind uncomfortable sensations, and an integrative treatment plan can support hormone balancing to help the body adjust to the menopausal stage of life.

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What is Perimenopause?

Perimenopause, meaning "around menopause," encompasses the final years of a woman's fertility. This menopausal transition is characterized by the natural decline in reproductive hormones as ovarian function diminishes.

There are two stages to perimenopause: the early and late transitions. Perimenopause begins with the onset of menstrual irregularity. During the early transition, menstrual cycles are fairly regular, with cycles typically varying from 21-35 days. The late transition is characterized by prolonged amenorrhea, with the absence of a menstrual period for at least 60 days. The end of perimenopause is marked by twelve consecutive months without a menstrual period, at which point menopause has officially been reached. (1)

Perimenopause Symptoms

Up to 70% of women experience symptoms from perimenopause through menopause (1). Levels of estrogen and progesterone shift unevenly and unpredictably through perimenopause, causing hormonal symptoms, which include (2, 3):  

• Irregular periods and reduced fertility
• Hot flashes
• Insomnia
• Night sweats
• Changes in mood: depression, mood swings, irritability, and rage
• Changes in sexual function: vaginal dryness and atrophy, painful intercourse, low libido, reduced sexual arousal, difficulty achieving orgasm
• Weight gain
• Breast tenderness
• Brain fog, forgetfulness, and difficulty concentrating

Reductions in estrogen levels are also associated with increased risk for vaginal and urinary tract infections, osteopenia, osteoporosis, dyslipidemia, and heart disease (4).

Perimenopause Age Range

On average, perimenopause begins 8-10 years before menopause. For most women, this means the menopausal transition starts in their mid-40s. Community-based studies indicate that the distribution of menopausal age displays a bell curve that ranges from age 40, ending around the age of 54, generally clustering around the ages 45-55. (5, 6)

How Long Does Perimenopause Last?

The duration of perimenopause varies between women. Perimenopause can last from months up to 10 years, although the average time until reaching menopause is four years. (2)

Functional Medicine Labs to Diagnose Perimenopause

The diagnosis of perimenopause does not require lab testing and is typically made based on the patient's age and medical history. However, functional labs can help confirm clinical suspicions and to correlate hormonal status with clinical symptomology.

Hormone Panel

A female reproductive hormone panel measures the primary female hormones involved in the hypothalamic-pituitary-ovarian (HPO) axis to detect and treat hormonal imbalances. Classic lab results indicative of menopause include a consistently elevated FSH and reduced estrogen and progesterone. Because of the erratic secretion of estrogen and progesterone during perimenopause, hormonal fluctuations are common, and it can be beneficial to do serial testing to make connections between hormone levels and patient symptoms during this time.

Functional Medicine Labs to Individualize Treatment for Perimenopause

Functional medicine labs help practitioners personalize treatment options for their patients and improve treatment outcomes. Below are some of the most common labs ordered for patients transitioning to menopause.

Thyroid Function

The incidence of thyroid disorders increases during the perimenopausal and menopausal periods, and symptoms of thyroid dysfunction and perimenopause can be challenging to differentiate from one another. Therefore, ordering a thyroid panel to monitor thyroid function can be beneficial to rule out thyroid disorders masquerading as perimenopausal-type symptoms.

Adrenal Function

Adrenal assessment is important during symptomatic perimenopause because the adrenal glands are responsible for producing sex hormones as ovarian function declines. Functional adrenal dysfunction can also cause maladaptive stress responses and impair optimal thyroid function.

The DUTCH test is an extensive sex and adrenal hormone profile that measures free cortisol, organic acids, melatonin, and reproductive hormone metabolites with a simple urine collection. This is a popular test option among functional doctors because it comprehensively analyzes hormone levels and adrenal function in one panel. Biomarkers on this panel can also provide insight into possible causes for sleep and mood disturbances commonly experienced by women during this phase of life.

Micronutrient Testing

Suboptimal and deficient nutrient status can impair the body's ability to synthesize hormones (reproductive, thyroid, and adrenal) and increases the risk of osteoporosis and heart disease. A micronutrient test measures vital vitamins, minerals, amino acids, antioxidants, and fatty acids to identify nutritional imbalances impacting their health.

Comprehensive Gut Assessment

The liver and intestines are the primary eliminatory organs responsible for metabolizing and eliminating excess hormones. Imbalances in the estrobolome, the collection of beneficial bacteria in the gut responsible for metabolizing and modulating the body's circulating estrogen, can lead to hormonal imbalances and symptoms. A comprehensive stool analysis and liver panel provide helpful information about the status of the microbiome, digestive function for nutrient digestion/absorption, and liver function.

Cardiovascular Assessment

Because of the increased risk of high cholesterol and heart disease, a cardiometabolic assessment at least annually is a good idea as part of a preventive health screening during the perimenopausal and menopausal phases of a woman's life. Consider ordering a comprehensive metabolic panel (CMP), lipid panel, fasting glucose and insulin, and hs-CRP to assess lipid and glucose metabolism and cardiovascular inflammation.

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Conventional Treatment for Perimenopause

Hormone replacement therapy (HRT), in the form of birth control pills, skin patches, sprays, gels, and creams, is the most commonly prescribed conventional treatment for managing perimenopausal symptoms and preventing bone loss. (2, 7)

Your doctor may also recommend antidepressants, gabapentin (Neurontin), pregabalin (Lyrica), and vaginal moisturizers as nonhormonal treatment alternatives for managing hot flashes, mood disorders, and vaginal dryness. (7)

Functional Medicine Treatment Protocol for Perimenopause

Lifestyle behaviors and natural supplementation can be highly beneficial in easing the perimenopausal transition. A functional medicine approach to treating perimenopause embraces a highly individualized process, considering the patient's symptoms and lab results to relieve symptoms and prevent aging-related chronic diseases.

Therapeutic Diet and Nutrition Considerations for Perimenopause Patients

An alternative approach to perimenopause isn't complete without addressing proper nutrition. A nutritious, whole-food diet can reduce inflammation, prevent disease, foster a healthy gut microbiome, and prevent nutritional deficiencies. The following are foods to emphasize as part of a perimenopausal dietary plan:

Phytoestrogens

Phytoestrogens are plant compounds with estrogen-like properties. Phytoestrogen-rich food sources include soy, beans, flax seeds, and cruciferous vegetables (9). By weakly binding to estrogen receptors, phytoestrogens effectively reduce menopausal symptoms, like hot flashes, without causing severe side effects. (8)

Protein

Dietary protein requirements increase during the perimenopausal phase because of hormonally-induced tissue protein breakdown. Increasing protein can lessen and prevent weight gain and muscle loss during perimenopause. (10)

Omega-3 Fatty Acids

Omega-3 fatty acids, rich in flaxseeds and fish oil, possess potent anti-inflammatory properties that improve hot flashes, uplift mood, and prevent cardiovascular complications (11, 12).

Foods for Bone Health

Dietary patterns involved in the development of osteoporosis include insufficient calcium, vitamin D, fatty acid, and vegetable intake and excessive salt and alcohol intake.

Calcium-rich foods include dairy, bone-in canned sardines and salmon, tofu, and leafy greens. Optimizing vitamin D intake can be done by increasing sun exposure, taking vitamin D dietary supplements, and increasing consumption of mushrooms, fortified milk, and fatty fish.

Supplements Protocol for Perimenopause Symptoms

The following are natural supplements used to support ovarian and liver health and treat some of the most common symptoms of perimenopause.

FemRebalance®

This herbal blend by Vitanica features borage oil, chaste tree berry, licorice, black cohosh, maca root, and Rhodiola. The synergism of the herbs and ingredients supports hormonal balance, regulates ovulation, and treats perimenopausal symptoms. (13-16)

Dose: two capsules twice daily

Duration: at least three months

Adrenal Assist™

Adrenal Assist™ is another Vitanica formula that combines nutritional and herbal support for healthy adrenal gland function to promote a healthy stress response. This formula contains B vitamins, Vitamin C, zinc, and magnesium, which are essential in regulating the body's stress response and can be quickly depleted during chronic stress. Its combination of adaptogenic herbs helps regulate stress and cortisol levels, reduce anxiety, and support sleep. Some of its ingredients have been shown to target specific menopausal symptoms; for example, Asian ginseng and maca have been shown to improve sexual function, and Rhodiola can enhance cognitive function and memory (15).

Dose: three capsules once daily in the morning or early afternoon

Duration: at least three months

HepaFem™

HepaFem™ by Vitanica combines burdock, dandelion, milk thistle, celandine, fringe tree, and beetroot, traditional herbs for treating liver disease and supporting healthy liver detoxification pathways. Supporting the liver, especially for women on HRT, is important to ensure hormones are properly metabolized to keep a healthy hormonal balance.

Dose: two capsules daily

Duration: at least three months

When to Retest Labs

If your patient is starting HRT, most functional doctors recommend retesting a hormone panel one month after initiation to ensure estrogen and progesterone are within the optimal reference range and in good balance with one another. Because botanical medicine is a slower medicine, expect to wait three months before remeasuring labs. However, it is common for patients to experience improved symptoms before this.

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Summary

Perimenopause is the regular part of the aging process characterized by the natural decline in ovarian function and reproductive hormones. A functional medicine protocol emphasizes dietary and lifestyle behaviors that support hormonal balance and prevent age-related diseases. Your integrative healthcare provider can help you determine the best approach to supporting hormones and treating menopausal symptoms.