E115: The Physical Domain of Perimenopause

Katie: So perimenopause is having a moment. I don't think I've heard the word said out loud as many times in my entire career as I've heard it in the last two years.

Welcome to the "7 Domains of Women's Health." I'm Katie Ward, professor at the University of Utah College of Nursing. I'm a practicing nurse practitioner in women's health. And with me, as always, is Dr. Kirtly Jones, professor of obstetrics and gynecology at the University of Utah. And we've both been thinking about menopause for quite a while.

Kirtly: For quite a while.

Katie: Quite a while. A lifetime. So, as usual, we're going to work through all seven domains, the physical, emotional, social, intellectual, environmental, financial, and spiritual domains of the perimenopause. And I am really excited to have so much time to consider everything that's going on at this complicated time in women's lives.

I feel like, right now, women are coming into my clinic, and they've heard a lot about perimenopause. Maybe it's from friends or social media or books or TV or movies, but they come in with a diagnosis and a treatment plan already in mind. And some of what they've heard is good, and some of it isn't.

So before we get into perimenopause, I want to go back to biology and talk a little bit about eggs and ovaries and hormones and cycles and how all of that works. Kirtly, do you want to give us a biology lesson?

Kirtly: Eggs 101?

Katie: Yeah. Eggs 101, please.

Kirtly: Well, we have evidence from studying fetal ovaries that our eggs start to divide, meaning make more eggs, when the ovaries start to develop at about the late first trimester, about 12 weeks.

Eggs have the power that we don't understand what turns on their dividing process to make more eggs, but they have the power to multiply and make more eggs until about 20 weeks' gestation. Now, we don't know what turns it off at that point, so there's a lot for us to learn. But at 20 weeks' gestation, we have about 6 to 7 million eggs, and then they stop dividing into more eggs.

So we have as many eggs as we're ever going to have at about 20 weeks' gestation, and then they start dying off, even before we're born. We call this normal process atresia.

And there are some conditions where this happens more quickly, such as a condition called Turner syndrome, where a little girl has only one X chromosome. The girls with Turner syndrome have lost almost all their eggs before they were even born. So they get that little 20-week gestation eggs, and then they die off too quickly. And these girls often don't even go through puberty because they have no eggs.

But for most of us, our eggs start to go through the process of atresia when we are born, and we have about 300,000 eggs. So we've gone from 6 to 7 million to 300,000, and this process continues.

At puberty, the brain wakes up and sends a message called FSH, follicle-stimulating hormone, to the ovary to ask some of these little eggs that are in tiny little follicles to grow.

Maybe a hundred start the race to ovulation, but only the fittest and the fastest egg wins, or the fastest two or three, to ovulate and the rest of the runners that month undergo atresia, which would have been their destiny anyway.

And when women use hormonal contraception, like birth control pills, they don't ovulate, but the eggs still undergo atresia. And women who use birth control their entire reproductive life and don't ovulate still go through menopause at the same time.

So we tend to run out of eggs between 45 and 55. We run out. The last ones are in fits and starts. There are still some that like to even make a few hormones after menopause, but that's the story of our ovary stuff.

Now, I want to stop here and talk a little bit about puberty. Puberty is sort of the inverse of perimenopause. The brain starts waking up to do reproduction, a magical process that we might do a "7 Domains" one of these days on puberty.

But the beginning of puberty begins before the first period. Hormones start breast development. There's a growth spurt. Fat deposition begins on the breast and the hips. The brain rewires a little. The first period happens. But the first couple years after the first period, ovulation and periods are often irregular.

Just like the other end at perimenopause, puberty is about a four-year process. But in terms of breast development, and brain development, and growth, it can last 10 years. And as I want to talk about the inverse, it's really the brain waking up, making eggs in fits and starts, finally getting going, ramped up, body changes, and then we're ready to go to make babies.

But this process, for all young women, is a confusing time. Her body is changing. Her brain and emotions are changing as her brain is rewiring for bonding, and sex, and reproduction.

And some women seek medical attention for painful or heavy periods, and some young women get pregnant by accident. But as body- and mind-altering as puberty is, the vast majority of young women get through it without seeking medical attention.

Their parents here may watch this happen with some dismay. And Katie, you didn't watch girls . . . Well, you did. You have a daughter, and you watched her go through this.

Katie: Yeah.

Kirtly: But they see it as a normal process to get through and, in some cultures, to celebrate.

So I specialized in adolescent medicine and these hormone changes, and I never saw girls for non-period-related issues. Maybe their primary care providers or pediatrician saw them. "My boobs hurt. My breasts aren't the same size. I'm growing too fast. I'm growing too slow. I'm moody. I want to eat. I don't want to eat." Puberty has never had a moment like the perimenopause.

Katie: No, not quite.

So we call that first period menarche. You're right. It's a thing that we celebrate, and some cultures celebrate it more than we do, but it's usually a little bit of a rite of passage. It's an event. And probably for most of us who menstruate, we remember our menarche.

Menopause is the last period, right? It's also an event, a five-day event, the last one, but it's a little strange because you don't know it was your last period until you've gone 12 months without having another one.

Or maybe you never know because you had a hysterectomy or an ablation, or you have an IUD, or you're using the pill. So you don't know exactly when you have your last period.

And we certainly don't seem to celebrate it. We don't have any rites of passage.

Kirtly:I think we should. We should.

So I'm going to step in. We used to call, or some people used to call, this process at the perimenopause the climacteric. And it included not only what the ovary was doing but what the body was doing between the ages of about 40 to 60.

So it wasn't just the last period, the menopause, and it wasn't all just about period stuff, ovary stuff. It was about all the things that happened then.

It's a term that's kind of gone by. We don't use that term, the climacteric. Maybe it's too vague for women who are experiencing it. "I'm in my climacteric." Perimenopause, maybe, is something . . . I don't know. Maybe I'm too old. Katie, I don't know if you ever heard that term, the climacteric.

Katie: Yeah. Well, there's a journal by that name.

Kirtly: There is or was. Yeah.

Katie:I think the language gets confusing because menopause technically being your final period, but after you've had your final period, then you're in menopause. And I think historically, we talked about perimenopause being the time around the final menstrual period. But now I feel like the way it's used currently, people are talking about perimenopause as this period of time leading up to your final menstrual period and then ending once you've had that last one.

So the language sometimes is confusing for people, I think. But in any event, the average age of the final menstrual period in the United States, and pretty much around the world, is around age 51.

There are a couple things that I really think help people understand how our hormones work that I think are important to talk about. So one is where they come from. Estrogen and progesterone, the main sex steroids, aren't being made by the ovary globally, but they're being produced, or technically converted, each month in the tissue surrounding the developing egg.

And so this is why the number of eggs that you have matters. And it's a link that I often talk to my patients about. It's because the hormones are being made by the egg. Not sort of in some other tissue while eggs are happening, but being constructed by the egg itself.

I think that that helps people understand that each month, since you have a different egg, you get a different amount of hormones. And every month is just a little bit different. So I think that's an important conceptual thing to think about.

The hormones go through kind of a regular fluctuation across the month. And a period follows every ovulation if no pregnancy occurs, because the tissue around the egg that's making that can only sustain it for so long. But estrogen and progesterone levels have been declining that month, and the decline is what triggers the period.

And then another follicle and an egg start developing, and the hormones fluctuate again over the next month. So they're always rising and falling in a very predictable way when you're ovulating and having periods.

As you get down to the last eggs, the highs and the lows get more dramatic. So a lot of what we think of as the unpleasant symptoms of the perimenopause are more related to the fluctuations than just an absolute lower amount.

So I think that's one concept that I think is important to understand. And then the second one is just about how hormones work. They function like a key in a lock. Each hormone fits into a specific lock, or a receptor. It's on or inside a cell. And when the key turns the lock, then the cell's behavior changes.

I think the other thing that we don't talk about enough is that no two women have the same number of locks on their cells. So women's tissues are . . . some women's have lots of receptors, and a small amount of hormone produces a big effect. And other women's tissues are sparser and need more hormones to get the same response.

And we don't have a way to measure that receptor density in someone's tissue. So when someone comes into my office with a hormone panel, it doesn't tell me that much about how a person is going to feel or respond to treatment.

I'm going to come back to this point more than once, I think, over the course of this discussion about perimenopause. But the levels of hormone in your bloodstream are not what makes women different. It's how their tissue responds to that. And we only really know that by talking to people.

Kirtly:Well, I want to talk a little bit about that too. When people say, "I want you to measure my hormones," I say, "Well, which ones would you like me to measure? And exactly what minute would you like me to measure them?" Because they go up and down. Cortisol goes up and down during the daytime, and estrogen goes up and down, especially in the perimenopause. And so measuring your hormones is really not helpful.

And in the post-menopause, people say, "I want you to measure my hormones." I'd say, "Why don't you give me the money to see exactly what your estrogen and your progesterone level are?" if they're four or five years after menopause.

So a hormone panel, I just don't think that's terribly helpful, particularly, especially in the perimenopause.

But I want to jump in and introduce the concept that you talked about, Katie, that women in the perimenopause are different. Not only because of the number and actions of their estrogen and their testosterone and progesterone levels, which are all over the map, and every day in the case of cortisol, or every month in the case of estrogen and progesterone and testosterone, but they're also different because of who they are as people, their culture, their home and work environment, their psychological response to stress, their access to good food and health environment at home and at work.

The wholeness that makes us who we are and how we respond to what's a normal process called perimenopause has been framed as the biopsychosocial model. The perimenopause is normal transition superimposed on a person at a very complex time of their life.

You're the only you there is, and there's no one approach or vitamin or concoction that will work for everyone, even though it may be marketed on social media that way.

I mean, whole cultures have a different set of symptoms that women have concerns about. Asian women have more headaches and more abdominal complaints and less hot flushes and joint pains. And so, biologically, they go through the same evolutionary evolution of their ovaries that we do, but they just have different symptoms. Is that culture, or is it receptors?

Look at pioneer women's diaries. They don't talk about perimenopause. They don't talk about brain fog. I'm still wondering what that really is in a neurochemical way. But they were pregnant and breastfeeding for many years of their lives, so irregular periods were common.

They lived under conditions that we would consider enormously stressful, and they wrote about that and acknowledged that they didn't associate with the reproductive changes in life these stresses and aches and pains. They were often exhausted, their children died, their husbands often died, and perimenopause wasn't having a moment back then.

So getting back to what's normal, for most of our evolution as human beings, we didn't have regular periods. We were pregnant or starving. And in the last several hundred years, we were still often pregnant or breastfeeding, but we in European cultures weren't starving so much.

It's only been in the last 75 years that women had lives that were well-fed and contraception practiced. So we could actually gather data about what was the menopausal transition.

The first large database came from the women of Minnesota . . . my heroines, yay Minnesota . . . who kept detailed diaries of their cycles throughout the reproductive life. And a researcher named Dr. Alan Treloar started in 1934, collected 2,700 women, over 250,000 menstrual cycles over 30 years.

He and those who followed analyzed this database. The perimenopause was marked first by periods that were a little closer together, but not in all women, and then a little farther apart, and then a little irregular, and then they stopped.

But we know from ultrasound and endocrine studies that the ovaries continue to make estrogen and testosterone, and we can see follicles on ultrasound that grow and shrink, but they don't ovulate, and they don't make a period in the time after the last menstrual period.

So the length of the perimenopause is 2 to 10 years, or longer. We use the statistical average for the range of menopause. That is the last period. It's about 45 to 56 years, with the average at about 51.

We consider that women who have had their menopause, no more periods, before the age of 40 as having premature menopause. And there are a bunch of conditions that can make you run out of eggs faster, and maybe that's happening a little bit more these days because of environmental stuff. So stay tuned for our environmental domain because we'll be talking about that.

Katie: Yeah. So the two physical symptoms that are most specific to perimenopause are changes in the menstrual cycle, as you've talked about. They could be closer together or then eventually skipping them. And then the other thing that people start to experience are what we call vasomotor symptoms, or hot flashes and night sweats.

The hypothalamus is the part of the brain that regulates body temperature, and it is very sensitive to swings in reproductive hormones. And so when these fluctuations start to get wild, like they do in the perimenopause, the hypothalamus sort of briefly misreads your body temperature and signals that it needs to warm up. And then your cooling system kicks in, and you do what you do to cool down, flush and sweat, and that brings you back down to normal, but may leave you feeling chilled.

So both directions of those swings are uncomfortable. And when it happens at night, it often interrupts people's sleep, and that sleep disruption becomes its own problem.

Disrupted sleep, I think, starts to lead to a lot of the other symptoms that people are experiencing in terms of fatigue and brain fog and all the other things that we mentioned.

But beyond the two irregular periods and the vasomotor symptoms, everything else that women in their 40s and 50s are reporting has a more complicated story. So fatigue, joint pain, palpitations, weight gain, sleep disruption, vaginal dryness, urinary changes, headaches, hair thinning, skin changes, mood shifts, and brain fog. There are so many, and they all have multiple causes. So the fluctuating hormones are just part of the story, but not always the whole story.

For example, I was a runner, and I sort of wrecked my knees, and I have osteoarthritis in my knees, and my knees hurt. I use hormone therapy, but I'm not expecting it to fix my knee pain because there's another cause for that.

So a skipped period in the 40s certainly can be the first sign of perimenopause, but it could also be other conditions. It could be a pregnancy or polycystic ovarian syndrome, or now polymetabolic endocrine ovary syndrome.

Mood changes, of course, can be hormonal, but they can also be untreated depression or anxiety. And fatigue can be perimenopause, or sleep apnea, or anemia, or thyroid dysfunction. Weight changes might have a small hormonal contribution, but they're usually better explained by changes in diet, and activity, and sleep that comes with this stage in life.

So when I'm seeing a perimenopausal woman, I'm also thinking about lots of other things: autoimmune disease, liver problems, thyroid disease, type 2 diabetes, sleep apnea, anemia. I mean, the list goes on.

That's the art of being in this space, is not to sort of think everything is perimenopause right off the bat, but kind of keep that list of other things in mind and screen carefully for what those other causes can be.

I heard a male comedian recently on the radio saying he put all of his symptoms into Google, and the answer came back and told him he was perimenopausal.

Kirtly: Yeah, right.

Katie: And I think that that is a bit of what's happening culturally, is perimenopause is so much in the air right now that women are . . . They have any one of that long list of things and they come in pretty convinced of the diagnosis, and sometimes already convinced about the treatment, and we haven't even had a chance to take their history and kind of look for those other conditions.

What worries me a little bit, as a provider, is people are going specifically to hormone clinics who are not looking for an alternative diagnosis. And I worry that conditions that we need to be paying attention to are going undetected.

Kirtly:Yeah. My own little story, I was not perimenopausal, I was well before that, but I was having a little PMS. And I say a little. I think when I was younger, I had the capacity to deal with the 10,000 things I was doing that would get a little shaky before my period. But when I got older and I had 10,001 things to do, I just wasn't at my best in the week before my period.

I mean, I didn't yell, I didn't hurt anybody, I was still cognitively intact, but I needed to be the best that I could. So I just went on birth control, and I said, "This is what I'm going to do. I'm going to have the same hormones every day."

And it was well before my perimenopause, but it was really the concoction of the things that were happening in my life that I loved. I mean, the nature of being in your late thirties in a very busy career, meaning you're at the peak of your career in your late thirties, early forties. You've got an adolescent. Your husband's doing a lot. Everything is happening. I didn't need one more thing in my cocktail to make me sometimes get crabby.

Katie: Yeah, I did the same thing.

Kirtly: So in my years of practice in reproductive endocrinology, I saw many women for the period complications of the other end of reproductive life, the perimenopause. But all those years, it wasn't a thing. It wasn't a disease. It wasn't a total body illness.

And I had a longitudinal practice where I saw the same women for 35 years. Many of them had concerns about mood swings, and sleep disturbances, and bloating, and weight gain, and loss of sexual interest. But those symptoms were a concern well before the perimenopause. So because I followed them longitudinally, I knew there were issues before their period started becoming irregular.

And research from large, and I do mean really large, numbers of women who describe their health, their symptoms, their concerns over the premenopause, perimenopause, and post-menopause find that many of the symptoms, not irregular periods or hot flushes, but brain fog or anxiety or sleep disturbances, were present well before their perimenopause. We just don't have a name for the time of life in the late 30s and early 40s.

We know from the U-shaped curve of happiness, the data collected from all over the world in men and women, that happiness starts to decline in the 20s from a population perspective and bottoms out in the mid-40s. It's already on its way down in the 30s. But the good news is, without intervention, it goes back up. So that's really good for everybody to know that it does actually get better.

So, for women, when you follow them longitudinally, many of the symptoms that are concerning to them happen before they're physiologically in perimenopause.

But I think that for women, women with children, women with big jobs, women without children, the late 30s and early 40s are kind of a little scrambled. It is a time where our bodies are undergoing aging. And we don't like to hear that, but we're at our physiologic peak in our late 20s and early 30s.

And then you can see it in performance athletes. By the time they're in their late 30s, they're not performing at the same level, whether they're ovulating or whether they're guys. We start to age. So it's not something welcome, these changes, but they are real.

Katie: Do we have a name for that time in your 30s? I think we should just . . . it's just busy.

Kirtly: Busy. We call it busy.

Katie: It's just life.

Kirtly: We lump it all into midlife. Early midlife.

Katie: All right. Well, let's talk a little bit about treatment in the perimenopause. We kind of alluded to this already.

So let's say you've done the workup and we've ruled out all those other causes that might be going on. And I think it is really important to be very thorough in this time of life because it's an important time to detect other health concerns. But if what we're seeing really is perimenopause, then there are really three big buckets of tools that we have to treat this, and I want to kind of go through them.

As Kirtly and I both talked about, I think we both managed our perimenopause using hormonal contraception. And that really, in my mind, is still sort of the Swiss Army knife of perimenopause treatment. It's often the most effective thing that I have to offer.

Sometimes my patients come in and they don't want to hear this because they've heard so much about menopausal hormone therapy, and they're convinced that that's so much better.

But frequently, if people are still ovulating, using hormonal contraception works really well because it turns off the ovarian fluctuation and replaces it, like you said, with a steady, predictable hormone state. So you're not having such fluctuations from highs to lows. And the symptoms that come from those swings, many of them, like you were describing, the PMS period, improve.

In addition to that, you can give women real control over their bleeding. So you can have a period once a month, or you can use your hormonal contraception in a way that you have a period every other month, or every three months, or maybe not at all. So having some control over whether and when you bleed can be a nice advantage to using the hormonal contraception.

And then, of course, it may still matter because people need contraception. So if you're in your late 40s and you do not want to get pregnant, then contraception is still a very important thing to be considering.

Of course, not everyone is a candidate for a combination contraceptive product. So if you are a smoker after the age of 35, or if you have migraine with aura, or uncontrolled high blood pressure, or a history of blood clots, these women can't safely use combined hormonal contraceptives.

And by the time we're in our 40s, you're more likely to have stacked up some of those kinds of risk factors. So we screen carefully about that.

But I get a lot of pushback from patients when I bring up birth control pills because I think social media has really implied that hormone replacement is going to be the cat's meow in this stage of life. And if your provider offers you birth control pills, they're just not current with the new suggestions.

I still think, in fact, the combination products, whether it's a pill or a patch or the ring, may still work the best for a period of time by eliminating those fluctuations. And then, of course, we also have progesterone-only pills that can be used in combination with an estrogen patch. So that's a combination that I think works well for women. But my goal is still to turn off what's going on in the background.

A second tool that I use a lot in the perimenopause is to combine a hormonal IUD, so that controls the bleeding part, and then I can add in some estrogen for the vasomotor symptoms and some of the other symptoms.

The IUD doesn't change what the ovaries are doing. So eggs may keep ovulating, and people may still have hormonal fluctuations underneath. But because they've got the IUD there, they have both excellent contraception and excellent bleeding control.

Then if we give additional estrogen, we're not making bleeding worse, which is one of the things that happens if you start using the menopausal hormone therapy in the perimenopause.

And then, of course, the third bucket of options in this period of time is to skip ahead and start the postmenopausal hormone therapy. I will do this if people have reliable contraception of some sort, and many women do, and I know that that's there. If you give somebody in perimenopause who's still ovulating small amounts of hormones, you can actually enhance their fertility.

The postmenopausal hormone therapy is not strong enough to prevent ovulation, so I want to make sure contraception is in place and that bleeding is under control.

But some women, because they've heard so much about hormone therapy, that's the thing that they want to try. And so the thing that guides that choice, of course, is the patient: her risk factors, her bleeding pattern, her contraceptive needs, what's bothering her the most, and what she's willing to try.

But again, it's not a lab value. So I'm really looking much more at what symptoms is she trying to control? Are those cyclic and coming before her periods? Or are they sort of constant? And what are her preferences? We talk about those three buckets and which one sounds like it's going to work the best for her. So it is really back to listening.

Kirtly: I've been thinking about this, and adding your rhythm of hormone replacement on top of your ovaries' rhythm can be pretty confusing to the uterus. And so you can have some unpredictable bleeding.

But if people want to try it . . . I want to keep the relationship going, because if this isn't working, I definitely want them to come back.

And we also have to ask, "What am I expecting this to help with?" Is it going to help with brain fog? I don't know about that. It might help with hot flushes and sleep disturbances a little bit. But the sleep disturbances of midlife in women are partly related to hormones, but partly not. There's a lot going on, and it may not fix that.

And lately, I've been reading about the recent social media claims that the combination of Allegra and Pepcid, two antihistamines, one for your nose and one for your stomach, can help with perimenopausal symptoms.

Now, perimenopause is not an allergic reaction, and there's not much scientific evidence to suggest that perimenopausal symptoms are caused by histamine surges. So taking an antihistamine is presuming that your brain fog or whatever is because of a histamine surge, and there's really no data to support that these work at all. And some people get pretty sleepy on antihistamines.

I'm reminded how women asked for and were prescribed Valium and amphetamines for the midlife symptoms in the '50s. Mother's little helpers, as The Rolling Stones called them. They were Valium-like drugs and amphetamine-like drugs.

But thank goodness, we don't do that anymore. Or do we, Katie? We don't do this anymore.

Katie: No, we don't. Well, I do see that combination, but it gets a different diagnosis than mother's little helper. I think it's ADHD and then sleep disturbances. So I think people do still get that combination, but less for perimenopause.

But I think what we're seeing with the combination of antihistamines, it is a little bit of a social media trend. And so I wonder if it works because it's a placebo effect, that people have heard about it and they expect it to work. And that's a real response. If someone believes something is going to work, then often it does. So I think that's a little bit about what's going on there. But yeah, we don't have any research about that.

I think the other thing that's going on is that aging is occurring and the loss of reproductive hormones, while it causes specific physical changes that we've talked about, the menstrual changes, the vasomotor symptoms, and real genitourinary changes, we have treatments that work great for those and I'm all in favor of treating that.

But aging is still going on. Joints still hurt, skin gets crepey, maintaining your weight gets harder and takes more deliberate effort than when you were in your 20s or 30s. And none of those are fully caused by your hormones in a way that hormones can fully reverse.

I think the promise that people are hearing on social media is the right combination of hormone therapy and supplements is going to give you your 20-year-old body back. And that's just not a promise that medicine can keep.

I have to say this carefully because I think the whole wellness conversation is so loud right now, but so much of what people are being sold is fear. And it's kind of the fear of aging and the idea that your reproductive hormones can fix all of these things.

And the honest version is that hormones can treat what hormones cause. Yes, you have estrogen receptors everywhere, but estrogen is not the only thing that makes your skin and your joints and your hair or your brain work.

Aging needs different work, different applications of strength and sleep and food and sun and social connection, and you can't really sell those quite so much as you can a supplement or a hormone.

Kirtly: But they are the most powerful medicines. They're the most powerful things that we have in terms of making people feel more resilient, all those things.

Katie: Right. They're there, and they're free, and you know what you're supposed to do.

Someone told me when I turned 40 that the years between 40 and 60 were going to be the best years of my life because that was the age where I'd still have my physical health, and I was at my peak earning years, and I would have the wisdom to know what I really wanted to do.

And I have to say that that has really turned out to be my experience. I definitely had a pang of sadness knowing my reproductive years were over and I wasn't going to have more of my own children, but grandchildren have turned out to be the real joy in life.

I think I've felt most all of the perimenopause symptoms at some point, but none of them have stopped me from grabbing life by the tail and enjoying the ride. And I think if I keep playing my cards right with the exercise and the sun and the friends and all of that, I'm going to extend that 40 to 60 window well into my 70s.

Kirtly: You go, girl.

Well, I agree with Katie. I know there are times from the very busy 30s through the mid-50s when people don't feel the way they want to. Lives are complicated. Work or looking for meaningful, satisfying work, and relationships succeeding or failing, and children succeeding or failing, and parents thriving or not thriving. And the world around us seems risky and angry. It's really hard to feel resilient.

And I'd say myself, I've treated this sense of unreliable and not-as-young body and mind with drugs, and caffeine is my favorite. The bathtub being my second favorite. I've tried calcium and magnesium. That was maybe aspirational, but maybe it worked a tiny little bit. But I knew the time was coming when I would be able to listen to my own heartbeat.

My goal as a clinician was to help every woman who came to see me feel a little bit better about themselves when they left than when they arrived. And for those of us who practice midlife women's health, we want to listen. We want to make sure we don't miss an illness that needs treatment and help with therapies and lifestyle changes that actually have been proven to work.

At the same time, women who come in with something that they've discovered through a magazine or social media and they believe it makes them feel better, then I believe that it does make them feel better. My job is just to make sure that the supplement, or medicine, or physical routine doesn't hurt them.

The perimenopause is a time of change, and what worked today may not work tomorrow because you're changing, honey. We are here to help you if you need it.

The other good news is that the majority of women make it through this transition with grace and style.

Katie: Kirtly, thanks for that. Grace and style. I'm going to take that with me.

So thank you for joining us on the "7 Domains of Women's Health." We'll be moving through all the domains, talking about perimenopause.

And as I said at the start, I'm glad we get the time to really spend on this because it seems like such an important topic right now, and I think it's a really wonderful platform to be able to break it up into all these different aspects.

So you're going to be able to follow the "7 Domains of Women's Health" wherever you get your podcasts, or at womens7.com. Thank you for being here.