“I Was Bad at Treating Perimenopause”—And Why That Truth Matters

I have a confession.

I’ve been a menopause specialist for nearly ten years—and when I first started caring for women in the menopausal transition, I was bad at it.

Not careless.

Not dismissive on purpose.

But incomplete.

And that truth matters, because it explains why so many women walk out of medical appointments feeling unheard, unseen, and untreated for the full picture of what’s happening in their bodies.

What I Was Trained to See—and What I Missed

I finished residency in 2012. Like many OB-GYNs, my training focused heavily on:

• Obstetrics and labor management

• Gynecologic surgery

• Acute, clearly defined diagnoses

Early on, I felt confident treating late perimenopause:

• Skipped periods

• Hot flashes

• Night sweats

Those symptoms fit the textbook.

But then came another group of women—usually in their early to mid-40s—who didn’t.

They were still having regular cycles.They weren’t waking up drenched in sweat.But they kept saying the same thing:

“I just don’t feel like myself.”

And honestly?

I didn’t know what to do with that.

When Perimenopause Doesn’t Look “Obvious”

These women came in with:

• Irritability that felt different from anxiety they’d had before

• Joint and muscle pain that wouldn’t respond to physical therapy

• Brain fog, forgetfulness, difficulty concentrating

• A deep sense of being “off,” without a clear explanation

So I did what many clinicians are trained to do:

• Treated symptoms in isolation

• Prescribed NSAIDs for pain

• Considered antidepressants for mood

• Attributed changes to stress, life, or “the messy middle”

None of those approaches were wrong—but they were incomplete.

Even I was missing the early signs of perimenopause.

Why This Happens in Healthcare

Perimenopause is often overlooked because:

• Medicine prioritizes isolated symptoms, not pattern recognition

• Appointments are short, limiting deep context

• Menopause training is limited for most clinicians

• Hormonal symptoms overlap with real life stressors—caregiving, grief, career pressure, sleep disruption

I did this to myself, too.

The Symptoms We Miss Most Often

1. Joint and Muscle Pain

Estrogen has anti-inflammatory effects and supports joint lubrication, collagen, and muscle recovery. As estrogen fluctuates or declines:

• Inflammation increases

• Joints feel stiff and achy

• Pain is often mislabeled as arthritis or overuse

2. Mood Changes That Feel “Different”

Perimenopause isn’t “just stress.”

Estrogen and progesterone directly influence neurotransmitters like serotonin. When hormone levels fluctuate, serotonin fluctuates too—leading to:

• Worsening PMS or PMDD

• Anxiety that feels unfamiliar

• Emotional reactivity that doesn’t respond to usual coping tools

This doesn’t mean antidepressants are wrong. It means hormones may also be part of the picture.

3. Brain Fog and Cognitive Changes

Estrogen receptors exist throughout the brain, including the hippocampus. During perimenopause:

• Short-term recall can suffer

• Multitasking becomes harder

• Sleep disruption worsens cognition

This is not dementia.

It’s physiology.

Perimenopause Is Not a Failure—It’s a Transition

These symptoms don’t exist in isolation.

And perimenopause doesn’t happen in a vacuum.

This transition deserves context, compassion, and care—not dismissal.

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Top 3 Takeaways

1. Perimenopause doesn’t always start with missed periods or hot flashes.

Early symptoms often show up as mood changes, joint pain, brain fog, and a vague sense of feeling “off.”

2. These changes are physiological—not personal failure.

Hormonal fluctuations affect inflammation, neurotransmitters, sleep, and cognition.

3. Treating symptoms in isolation misses the bigger picture.

Perimenopause requires a holistic lens that connects hormones, mental health, sleep, movement, and life context.

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Frequently Asked Questions

Can I be in perimenopause if my periods are still regular?

Yes. Early perimenopause often begins years before periods become irregular. Hormonal fluctuations can cause symptoms even when cycles look “normal.”

Why do my symptoms feel different from stress or anxiety I’ve had before?

Because estrogen and progesterone influence neurotransmitters like serotonin and GABA. Hormonal changes can amplify emotional responses, making anxiety or irritability feel unfamiliar or harder to manage.

Is joint or muscle pain really related to hormones?

It can be. Estrogen plays a role in inflammation control and joint health. As levels change, aches and stiffness may increase—but other causes should still be ruled out.

Is brain fog a sign of dementia?

In most cases, no. Brain fog during perimenopause is common and often improves after the transition, especially with attention to sleep and overall health.

Should I just “push through” these symptoms?

You don’t have to. Perimenopause can last years, and support—education, lifestyle changes, and sometimes medical treatment—can make a real difference.

Is hormone therapy the answer for everyone?

No. Hormone therapy is one tool, not the only tool. The best approach is individualized and considers the whole person.