Think It's Perimenopause? Here's Why That Might Not Be the Whole Story
Fatigue, brain fog, anxiety, weight gain and poor sleep. Are your hormones responsible, or could something else be contributing?
I'm delighted that perimenopause and menopause are finally getting the attention they deserve. For years, women were expected to put up with debilitating symptoms and accept them as an inevitable part of getting older.
But I'm beginning to wonder whether the pendulum has swung a little too far.
I do feel like almost any symptom experienced by a woman in her forties or fifties seems to be attributed to perimenopause. Exhausted? Hormones. Anxious? Hormones. Putting on weight? Hormones. Can't concentrate? You guessed it. Perimenopause
And while changing hormones may absolutely be contributing, what if we're missing something else?
I work with women who are struggling with chronic fatigue, weight gain, digestive problems, anxiety and poor sleep. Sometimes hormonal changes are an important part of the picture, but I also see iron deficiency, thyroid dysfunction, SIBO, blood sugar problems and nutritional imbalances that may be contributing to how they feel.
Sometimes these are the main problem. Sometimes they're making genuine perimenopausal symptoms considerably worse. And often it's a mixture of both.
HRT can be life-changing, but it isn't a cure-all
The conversation around hormone replacement therapy (HRT) has changed dramatically.
Following the 2002 Women's Health Initiative study, concerns about hormone therapy dominated public discussion for years. The findings raised questions about risks, but much of the media coverage failed to explain important details, including the ages of participants, their underlying health and the particular hormone preparations used.
Today, we have a more nuanced understanding.
For many women, appropriately prescribed HRT can make an enormous difference to hot flushes, night sweats, sleep disruption and other menopausal symptoms. It can also help protect bone health and observational studies have linked it to lower cognitive decline.
I'm very supportive of women having access to good information and appropriate medical care. But there's now another narrative emerging online: that every woman needs HRT, preferably for life, or she's putting her long-term health at risk.
Neither extreme is particularly helpful.
HRT can be an excellent option, but it doesn't replace good nutrition, adequate protein, resistance exercise, stress management, blood sugar regulation, sleep and attention to cardiovascular health.
And it certainly doesn't correct an iron deficiency, autoimmunity or an underactive thyroid.
If you're taking HRT but still feeling dreadful, I don't think the only question should be whether you need more oestrogen. I'd want to look at what else might be happening.
Five things that can look remarkably like perimenopause
There ae many more, but I am focussing on the ones I have seen in clinic in the last three months:
1. Iron deficiency, even without anaemia
Heavier periods during perimenopause can deplete iron stores, contributing to fatigue, brain fog, headaches, palpitations and hair loss, even when haemoglobin is normal.
Low iron can also affect thyroid hormone production, potentially adding to fatigue. But one marker never tells the whole story. Ferritin, for example, can rise with inflammation and mask low iron stores. Looking at a full iron panel, blood count and inflammatory markers together gives us a clearer picture, even when individual results fall within NHS reference ranges.
2. Thyroid problems
Fatigue, weight gain, constipation, hair thinning, low mood and feeling cold. Sound familiar? These can all be symptoms of an underactive thyroid, not just perimenopause.
Thyroid hormone production also depends on nutrients including iron, iodine and selenium, while autoimmune thyroid conditions are particularly common in women.
TSH alone doesn't always tell us everything. Looking at thyroid hormones and, where appropriate, antibodies alongside iron status and other markers can help us understand what might be contributing to your symptoms.
3. Blood sugar regulation and insulin resistance
Falling and fluctuating oestrogen can affect insulin sensitivity, while poor sleep and stress make blood sugar regulation harder. In turn, blood sugar fluctuations can contribute to fatigue, cravings, irritability, brain fog and disrupted sleep.
Insulin resistance can develop long before type 2 diabetes and often overlaps with changes in cholesterol, triglycerides and abdominal fat.
Looking at HbA1c, glucose, triglycerides and other metabolic markers together can reveal patterns that one result alone might miss. Improving blood sugar regulation can benefit energy, weight management and cardiovascular health.
4. Nutritional deficiencies and digestive health
Low B12, folate or vitamin D may contribute to fatigue, poor concentration or muscle weakness, while inadequate protein can affect strength and recovery.
But why might these nutrients be low? Poor dietary intake, digestive problems, coeliac disease, medications and absorption difficulties can all play a part.
Nutrient levels, blood count and digestive symptoms need to be considered together. Simply taking supplements without understanding the underlying issue may miss something important.
5. Autoimmune conditions, inflammation and poor sleep
Coeliac disease, autoimmune thyroid conditions and other inflammatory disorders can produce symptoms that overlap with perimenopause.
Inflammation can affect how your body handles iron, while poor sleep can worsen insulin resistance, fatigue and mood. Sleep apnoea is another possibility, particularly if you're waking exhausted despite spending enough time in bed.
These systems don't work independently. That's why I look at how inflammation, thyroid function, iron status, blood sugar and nutritional health interact, rather than interpreting each result in isolation.
My Wellness Check brings these markers together in a comprehensive blood assessment. Using a functional approach, I consider not only NHS reference ranges but also how results relate to one another, your symptoms and opportunities to optimise your health.
Perimenopause may be part of the picture, but it doesn't have to explain every part of it.
So should your hormones be tested?
Not necessarily.
This is where I think there's a lot of confusion, especially with the growing availability of private hormone testing.
During perimenopause, oestrogen and other reproductive hormones can fluctuate considerably. A single blood result may tell us what was happening on one particular day without providing a reliable picture of the whole transition.
NICE recommends identifying perimenopause clinically in otherwise healthy women aged 45 and over who have typical symptoms and menstrual changes, rather than relying on hormone blood tests.
But not getting a hormone test from the GP is very different from not needing any blood tests at all.
If you're exhausted, losing hair, experiencing unusual palpitations or struggling with symptoms that are severe or worsening, I think it's important to consider what else could be contributing.
The blood tests I'd be interested in
I believe a comprehensive blood test is one of the most useful ways to understand your health, particularly during midlife. Rather than testing one or two markers in isolation, I want to see how the different systems in your body are working together.
That's why my Wellness Check looks at a broad range of markers, including:
Iron status: Full blood count, ferritin and a full iron panel.
Thyroid function: TSH, free T4, free T3 and thyroid antibodies.
Blood sugar regulation: HbA1c and glucose, alongside other metabolic markers.
Cardiovascular health: Cholesterol, HDL, LDL, triglycerides and apolipoproteins.
Nutritional status: Vitamin B12, folate and vitamin D.
Hormonal health: Sex hormones including oestradiol, testosterone, FSH and LH, remembering that hormones fluctuate considerably during perimenopause.
Wider health: Kidney and liver function, inflammatory markers and other important indicators.
If cardiovascular health is a particular concern, I may also recommend lipoprotein(a), or Lp(a), as an additional test. It's largely genetically determined and can reveal cardiovascular risk that standard cholesterol testing may miss.
What makes the Wellness Check valuable isn't simply the number of markers tested. It's how I interpret them together.
I use a functional approach, looking beyond whether results fall within NHS reference ranges to consider whether low-normal or changing markers could be relevant to your symptoms and where we might improve your nutritional health.
For example, low iron can affect thyroid hormone production, inflammation can influence iron markers, and blood sugar regulation is closely connected to cardiovascular and hormonal health.
It's about joining the dots, understanding what your results mean for you and identifying practical nutritional changes that could make a difference.
The point is to use testing to answer useful questions, not simply collect numbers.
What if you really are perimenopausal, with nothing else in the mix?
You may well be, and HRT might be exactly what you need.
For women experiencing troublesome menopausal symptoms, HRT is an evidence-based option worth discussing with a suitably qualified prescribing clinician.
But I'd also encourage you to think about the foundations that HRT cannot provide on its own.
Are you getting exactly what your body needs to maintain muscle? Are you supporting your bones through nutrition and resistance exercise? What does your blood sugar regulation look like? Are you eating enough fibre and healthy fats? Is poor sleep affecting everything else?
HRT and nutritional therapy aren't competing approaches. They can work alongside one another.
How I work with women in midlife
When a woman comes to me struggling with fatigue, weight gain, digestive problems or symptoms she's been told are 'just menopause', I want to understand the whole picture. We start with a detailed health history, looking at symptoms, menstrual changes, medications, diet, sleep, stress, digestive health and existing blood results.
Sometimes we discover that nutrition and lifestyle changes are an obvious place to begin.
Sometimes I recommend further testing or ask a client to speak to her GP about something that needs medical investigation.
And more often than not we find several contributing factors that need addressing together.
My Wellness Check & my nutritional therapy programmes
For women who need more than a one-off review such as the Wellness Check described above, my programmes allow us to investigate more deeply and powerful make changes over time. These are the most popular, with a package of six sessions over three months being the one 80% of my clients go for.
We can work on hormonal health, blood sugar regulation, digestive health, nutritional deficiencies, muscle and bone support, energy management and sustainable personalised nutritional changes. I want to know about your life, know what changes can easily be made and what can be made with a little planning. I meet you where you are and we move at a pace that is achievable. I'm not after a quick fix, and I don't want you saying no to social engagements.
I also use functional testing selectively when it can help answer a particular question.
The aim isn't to chase perfect test results. It's to understand what may be contributing to your symptoms and develop a practical nutritional plan that helps you feel better.
Could it be perimenopause AND something else?
Absolutely. And that's really the point I want you to take away.
You might benefit enormously from HRT and still have an iron deficiency. You might be experiencing genuine hormonal changes while an underactive thyroid is contributing to your exhaustion. Or your sleep, blood sugar regulation and nutritional intake may be making an already difficult perimenopause feel considerably worse.
You don't have to choose between acknowledging hormonal changes and investigating the rest of your health.
If you're in your forties or fifties and no longer feel like yourself, don't simply accept that it's inevitable.
Let's find out what might be going on with a free 20-minute Health Conversation
We can discuss your symptoms, what you've already investigated and whether a Wellness Check or nutritional therapy programme might be appropriate.
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"Working with Gemma was life changing. She was able to pin point why I was feeling the way I was feeling and helped me manage all the issues with nutrition. I was able feel so much better and actually get out of bed without feeling fatigued. She planned every session considering everything I said to her and always dealing with the main problem. She listened and gave me a encouragement in every session. Gemma explained everything and I learned so much to build healthier habits. This was the best investment into myself and I could not have done this without Gemma's guidance."
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