Excerpt from THE PERIMENOPAUSE SURVIVAL GUIDE by Heather Hirsch, MD,MS,MSCP
INTRODUCTION
Hope for the Biggest Transition of Your Adult Life
Drew Barrymore sat onstage between Oprah Winfrey and me and was spilling her guts to the crowd of women in the audience. Drew, who was forty-eight at the time, admitted that lately she’d been feeling “dead inside.” She’d recently experienced her first hot flash—on TV while interviewing Jennifer Aniston, no less. She knew she was perimenopausal—that period of time during which a woman transitions toward, but is not yet in, menopause—but still, her experience felt really bewildering. “I’ve heard different answers from different doctors,” she said. Things like: You’re not a candidate for hormone therapy if you’re still getting your period; Oh, just reduce your stress; or, The only thing I can offer you is an antidepressant. “I’m incredibly confused and I don’t know what I’m supposed to do,” she confessed.
Drew was sharing so openly because we, along with Maria Shriver and Dr. Sharon Malone, were taping a segment for Oprah’s “Life You Want” series on the topic of menopause. The majority of women in the audience were nodding their heads in recognition and some of them even silently wept. My heart broke in that moment, as it does whenever I hear similar stories from my patients, friends, and family, as well as the women who comment on my social media posts.
Drew Barrymore is just one of the millions of women between the ages of thirty-five and fifty (the average age range of women whose ovaries have begun the transition to menopause) whose health, life, and work are derailed by the symptoms caused by the decline of their sex hormones—which, despite their name, have a major impact throughout the body, not just the reproductive organs.
The result is that women grapple with all kinds of symptoms. Jane, for example, was a high-powered real estate lawyer in her early forties who’d recently become very anxious and couldn’t seem to sleep through the night. Her job was stressful, yes, but she’d never had trouble with anxiety. At age forty-seven, Lucy was having a hard time remembering things—constantly leaving the house without her purse; she was unable to easily recall words, and she forgot to send important emails. She worried, Could this be early-onset Alzheimer’s?, fearing the same thing that happened to her father might happen to her. Her primary care physician referred her to a neurologist, who told her she was fine, but still—why couldn’t she remember things? At age forty-six, Cherise began having incredibly heavy periods—so much so that she had to wear super-maxi tampons and period underwear and still sometimes bled through her pants. When she called her ob-gyn, he terrified her by suggesting she might have uterine cancer, saying she needed an ultrasound immediately. The test results were normal, and though her heavy bleeding continued, she never got a good answer as to why this was happening.
The reality: Jane, Lucy, and Cherise were all exhibiting symptoms of perimenopause. Yet because so many of these symptoms can seem completely disconnected to reproductive health, few women—or even clinicians for reasons I’ll go through in just a moment—make the link between those symptoms and fluctuating hormones.
And here is the harsh reality: Too many women are left to wonder what in the world is going on with them, completely in the dark about the very normal changes their bodies go through in their late thirties, forties, and early fifties, and feeling dismissed and unheard by their health-care providers.
The Long Tentacles of Perimenopause
There’s something else too many of us don’t know about perimenopause: As we go through the menopausal transition, the very underpinnings of our long-term health can become more vulnerable, too. The decline in reproductive hormones has clear and important ramifications that affect our gastrointestinal (GI) system, musculoskeletal system, pelvic floor, mental health, cardiovascular system, and even our brain.
With heart disease being the leading cause of death in women, women comprising two-thirds of all dementia patients, and more women experi- encing osteoporotic bone fractures than cardiovascular events, strokes, and breast cancer combined, it’s vital for us to understand that the entire body feels the decline in hormones starting in perimenopause, and how we address these hormonal changes today will determine the trajectory of our health in the decades to come.
Perimenopause also impacts our work lives and pocketbooks as well as the economy at large. In 2023, researchers at the Mayo Clinic surveyed more than four thousand women who reported having moderate hormone-related symptoms. They found that 13 percent had experienced an adverse work outcome because of those symptoms, and 11 percent were missing days of work because of them. Collectively, the researchers calculated, this was costing the United States $1.8 billion in missed work and $26.6 billion in medical costs. And that’s just in women with average symptoms. A study by Dutch researchers found that of women whose symptoms were severe enough to get them to seek care at a clinic, 76 percent said their symptoms were impairing their ability to perform at work. And who could blame them? It’s tough to be your best when your sleep is impaired, your mood is all over the place, your joints ache, you have brain fog, and you have to run to the bathroom every hour or two to make sure you aren’t bleeding through your clothes.
It’s Time for Perimenopause to Have Its Moment
In the past few years, menopause has come out of the shadows. Coverage by the mainstream media has exploded and multiple books covering the topic—including my own first book, Unlock Your Menopause Type—have led to thousands of women becoming more vocal about their experiences. This is great news!
The not-so-great news?
Perimenopause has not been part of this conversation—and it’s an entirely different animal:
- In menopause, a woman’s hormone levels are low, but they are steady. In perimenopause, they fluctuate wildly, spiking one week and bottoming out the next, making women confused about their cycles or, worse yet, not realizing that their symptoms are related to their hormones. This means that how I counsel women and treat symptoms of perimenopause is different from how I treat a woman in menopause (and this is the reason I wanted to write a book devoted solely to perimenopause!).
- Menopause has a clear diagnostic criterion—one year without a period. Perimenopause is much trickier to pin down because a blood test captures hormone levels on only one day, when they are changing from week to week and month to month. The result? Women are told, “Your blood levels are normal, so it can’t be your hormones,” which only gaslights them and reinforces the idea that their experiences aren’t valid. It also delays treatment, which then deprives women from feeling and functioning at their best through the transition, which can last as long as ten years. (Ten! Years!)
- Women are starting to acknowledge and talk openly about menopause. But perimenopause is barely part of the conversation— among women themselves or with doctors who are caring for female patients in this age group. As a result, too often women. are blindsided when their hormones start to shift. According to research published in the journal Menopause, 59 percent of women didn’t think it was possible to experience any hormone-related symptoms until age fifty. Yet I see women in their late thirties in my practice regularly. The same study also found that when women experience symptoms earlier than they expected, they have a higher likelihood of holding a negative view of their overall health than women whose perimenopausal symptoms showed up “on time.”
The takeaway? The more women understand what can happen to them in their late thirties and forties, the better they’re likely to feel.
Why I Wrote This Book
My goal for this book is not only to demystify your symptoms, but also to explain how to treat them and why doing so is important to your health today and over the long term. Just as importantly—if not even more so—I want you to finally feel seen and get answers from a woman who is not just an experienced and credentialed clinician, but who is also in the middle of her own hormonal transition. Believe me, I know what you’re going through.
When I started wanting to throw out all my kids’ toys because I couldn’t stand the mess one second longer and began getting really irritable for about a week out of every month, I didn’t think all that much of it—just a bad case of PMS, right? Then I started experiencing the occasional hot flash, but I thought I must have forgotten to turn the heat down before bed, or I was just doing too much that day and was having a hard time settling down. And because I had an IUD and I had only very light bleeding, it took me awhile to put together that my irritability and the hot flashes I was denying were related to perimenopause.
You’d think that as a woman who has spent the past decade treating women going through hormonal transition, I’d have a clue. Well, I didn’t. So, when I finally pieced it together, it only drove home the fact that most women don’t see perimenopause coming.
As bewildering as perimenopause can be, there is hope.
When you get the information you need to help you understand how this major hormonal shift is impacting you, you’ll be empowered to make choices that both relieve your symptoms and shore up your health. You’ll also be better able to advocate for yourself with your doctors to get one of the many evidence-based treatments that suits your unique symptom set, health history, and priorities. You’ll be fully equipped to navigate this yearslong transition so you no longer feel dead inside or wonder if you are losing your mind, but instead can feel like yourself again.
And you’ll be helping to fill the gaping hole in our collective knowledge about perimenopause, which will benefit not only you, but also your friends, sisters, doctor, and everyone who will make their way through this transition with you and after you.
And frankly, it’s far too unlikely that you’ll be able to easily find a doctor who can help guide you through this transition (although I cover how to find one who is knowledgeable in “Appendix B: Resources” at the back of the book).
Why? The vast majority of doctors—even ob-gyns—receive very little training in menopause and perimenopause. A survey of medical residents in the fields of internal medicine, family medicine, and obstetrics and gynecology conducted by the Mayo Clinic found that 20 percent of residents had received no lectures during their training on menopause, and only 6.8 percent felt confident that they had received enough training to help women through the menopausal transition.
Do these stats make you angry? They make me crazy. This lack of education for medical professionals about a perfectly natural yet disruptive transition that happens to half the population is absurd.
I decided to specialize in women’s hormonal transitions when I was a fellow at the Cleveland Clinic and realized that the education about women’s health basically ended with pregnancy and childbirth. It’s not even that perimenopause and menopause were overlooked—they were completely missing from medical school training. They simply weren’t considered important enough to be covered in medical textbooks.
A direct result of this massive gap in our doctors’ education is that the average appointment wait list for menopausal medicine doctors is out seven months. On top of that, according to the experiences of the thousands of women I’ve treated in the past decade, many perimenopausal women see five to six different doctors before getting to the hormonal root of their issues. No wonder my posts on social media get blown up with comments and DMs every day with questions and pleas for help. They are seeking help wherever they can get it and they are hungry for information. Gen X and the older millennials are on the front lines of perimenopause, and they are not taking it lying down!
I am on a mission to do everything I can to get the information, validation, and guidance on perimenopause that women so desperately need into their hands. In fact, I have devoted my entire medical career to studying and treating women’s midlife hormonal transitions. As a certified and experienced menopausal medicine doctor, I want to bridge the information gap with clear evidence-and experience-based guidance that both women and doctors can utilize.
That’s why I wrote The Perimenopause Survival Guide—to help you develop a plan to address your symptoms and protect your long-term health that combines medical treatments—prescriptions, labs, and perhaps even procedures where appropriate—with at-home strategies—dietary changes, supplements, stress reduction tools, exercises, and lifestyle adjustments. Perimenopause is not “menopause light,” and it deserves its own road map.
How to Use This Book
The Perimenopause Survival Guide has three distinct parts that correlate to three vital steps for caring for yourself along your perimenopause journey.
Part I, “Understand the Hormonal Hijacking,” provides the background information that will help you understand what you’re experiencing. Starting with a chapter that explains how the hormones that are waning influence much more than your reproductive organs, you’ll learn what each hormone does, how they work throughout the body, and why they have such a huge influence on physical and mental health. I also outline the thirty-four—and counting!—symptoms of perimenopause, so you can start to piece together how your particular hormonal shift may be affecting you in ways you didn’t even realize, as many symptoms are surprising. For example, many women don’t know that perimenopause can connect the dots between their back pain, their low mood, and their newly sprouted chin hairs.
In chapter 2, I explore and bust the many widespread, hard-to-kill myths and misconceptions about perimenopause: Aren’t I too young to be experiencing symptoms? Does a skipped period mean I’m pregnant? Is hormone therapy really safe? And many more. Then in the final chapter of part I, I walk you through the exact same process I take each of my patients through. When I meet my patients, I want to develop a complete picture of how perimenopause is affecting them, and to prioritize which set of symptoms they want to treat first—and the questions in this chapter will help you do the same thing for yourself.
Part II, “Pinpoint Your Perimenopausal Symptom Set,” guides you on how to treat the group of symptoms you have identified as your top priority, outlining all treatments and tactics that have a track record of being effective at reducing symptoms and bolstering overall health. Some of these will require a prescription. After all, I’m an MD. I want to introduce you to and demystify the many FDA-approved medications that can help treat your symptoms—including hormone therapy, although there are more and more nonhormonal treatment options every year that too many women are still unaware of. I’ll also cover the many lifestyle strategies that research and my clinical experience have shown to work. You have many options available to you. Learning what they are will help you engage in shared decision-making with your clinician to personalize your treatment plan.
Then, part III, “Set Yourself Up for Smooth Menopause Sailing,” helps you set the stage for an easier menopause journey and also for your best health in the second half of your life. First, I’ll help you target some of the stranger symptoms of perimenopause that can start now and linger well into menopause, such as ringing ears and itchy skin. Then I’ll offer advice and strategies for how you can confidently take the journey from perimenopause through menopause and recalibrate your lifestyle and habits to accommodate your new self as a woman in her post-reproductive years.
Finally, I’ll answer the questions I’m asked most frequently, such as “How does perimenopause affect fertility?” and “When should I talk to my doctor about perimenopause?” and provide a detailed list of further resources, such as vetted apps, books, and websites that can help you understand—and manage—your symptoms.
You’ll likely notice that many symptom sets have the same or similar treatments, so as you read through you’ll notice some familiar advice. While I definitely don’t want to sound like a broken record, I do want you to have easy access to everything that might help you manage your symptoms without having to flip back and forth through the book. I’ve attempted to include cross-references to other locations in the book where you can find more information about whatever you’re facing.
The Perimenopause Survival Guide is designed to help you understand what’s happening with your body, find and make shared decisions with a knowledgeable clinician about possible treatments, and know what you can do on your own—like taking supplements, implementing dietary strat- egies, and making lifestyle changes—that have a proven, scientifically tested track record of being helpful, as well as what you should avoid.
Please let these words sink in: You don’t have to suffer through your bothersome symptoms and just resign yourself to a life of not feeling all that great. My ultimate aim is for you to be able to walk away from reading this book with a plan that is going to address your symptoms, improve your quality of life, and help you feel educated, confident, and unstoppable in your journey to a healthy second half of life.
Dr. Heather Hirsch, renowned founder of the Menopause Clinic at Brigham and Women’s Hospital and featured expert on Oprah Winfrey’s The Life You Want series, offers a groundbreaking, expert-led guide to not only navigate—but truly thrive—through perimenopause.
Perimenopause, the transitional phase before menopause, can feel like one of the most disorienting and unspoken chapters in a woman’s life. From hot flashes and brain fog to anxiety, back pain, and sleep disruption, the symptoms are real, but the guidance often isn’t. Too many women between the ages of 35 and 50 find themselves confused, dismissed, or unsupported by their providers.
The Perimenopause Survival Guide is a clear, compassionate, and evidence-based resource from one of the most trusted voices in women’s hormonal health. Dr. Heather Hirsch draws on her years of clinical experience to help women understand what’s happening in their bodies, and how to take charge of their care.
In this essential guide, you’ll learn:
- What’s really driving your symptoms and how to decode them
- Proven, FDA-approved treatment options—plus how to evaluate what’s right for you
- The importance of managing perimenopause now for long-term health
- How to advocate for yourself and build a care plan around your individual needs and goals
Whether you’re just starting to notice subtle changes or already deep in the hormonal rollercoaster, The Perimenopause Survival Guide empowers you with clarity, confidence, and the tools to feel like yourself again.