Perimenopause
Everything at once? It is all connected.
You sleep less well, although nothing has changed. Your cholesterol is rising, although you eat as you always have. Suddenly red wine no longer agrees with you, and your digestion reacts to things that were never an issue for twenty years. Does this sound familiar?
All of this is connected, and that is precisely what makes this phase of life so fascinating from a medical perspective. Hormones alone, however, cannot resolve everything. That is why I look at the whole picture.
What happens during this time
Oestrogen does far more than regulate the cycle
Oestrogen is a true all-rounder: it acts on the blood vessels, glucose metabolism, bones, muscles, gut and mast cells. When it fluctuates and eventually declines, all of these change along with it, neither simultaneously nor in the same way for every woman. For many women, incidentally, hot flushes are not the real problem at all.
Lipid metabolism
LDL and ApoB frequently rise during this phase, without any change in diet or weight. Some of this improves with hormone therapy, but not all of it. And what remains should be treated: it is the reason why women's risk of heart attack catches up after the menopause.
Insulin sensitivity
It declines, often years before blood glucose becomes abnormal. This also explains why your weight suddenly behaves differently, although you are doing nothing differently.
Muscle and bone
Both are lost at an accelerated rate during these years. Both are measurable (grip strength, muscle mass, bone density), and both can be influenced. But only if you know where you stand.
Histamine tolerance
The connection that is most often overlooked. Oestrogen and histamine influence each other, while progesterone has a mast cell-stabilising effect. When progesterone falls in the perimenopause, histamine rises further, and for many women the balance tips. Suddenly there are reactions to red wine, mature cheese, tomatoes. Without knowing this, one ends up on an elimination diet and still does not improve.
The gut
Digestive complaints such as bloating, diarrhoea or constipation appear for the first time or change in character. Before anyone is given a diagnosis of irritable bowel syndrome (IBS), other causes must be ruled out. This is my specialty, and remarkably often a different cause emerges.
Iron and thyroid
Heavier bleeding very frequently leads to iron deficiency, which causes exactly what is often attributed to the menopause: exhaustion, difficulty concentrating, hair loss. Thyroid disorders also become more common during this phase of life.
Sleep
Sleep apnoea becomes considerably more common in women after the menopause and is often overlooked because it presents differently than in men: not loud snoring, but exhaustion, morning headaches and rumination at night.
And the hormones
Whether hormone therapy is advisable is determined by your symptoms, medical history and risk profile, not by a laboratory value. If it is an option, I initiate and adjust it and accompany you throughout.
When hormone therapy is already in place
… and something is still not right
I know this situation very well from my consultations: the dosage is right, the values are good, the gynaecologist has done everything correctly, and yet something is not improving.
In that case, it is usually due to one of the areas above: iron, sleep, the gut, the thyroid or histamine tolerance. Hormone therapy can achieve a great deal, but not everything. This is exactly what this consultation is for: the part that remains.
The same applies when several conditions coincide, such as mast cell activation, hypermobility, circulatory regulation disorders or persistent exhaustion after an infection. These conditions regularly worsen in the perimenopause.
How I talk about hormone therapy
You have probably heard a great deal of conflicting information on this subject. That is understandable: the major studies from the early 2000s are interpreted very differently today than they were at the time. Four questions are decisive: at what age is treatment started, how long ago was the last period, which progestogen is used, and is the oestrogen given through the skin or by mouth?
It does not follow that hormone therapy is right for every woman, nor that it is dangerous. It follows that the decision is an individual one, and that you have the right to understand it rather than simply accept it. If you prefer not to take hormones, we treat without them.
What I deliberately do not do
Dose hormones based on saliva tests
Saliva levels fluctuate so widely and correlate so poorly with what actually reaches the tissue that no dose can be derived from them.
Compounded preparations without a reason
Where a licensed preparation exists, I use it: the dose and the evidence are known. I use a pharmacy-compounded preparation when there is no suitable alternative, for example for testosterone replacement, for which there is no product licensed for women, or in mast cell activation with intolerance to excipients.
Start hormones before everything else has been investigated
When a woman presents with exhaustion and a ferritin of 18, hormone therapy is not the first answer. It may be the second.
Procedure and costs
Well prepared for our consultation
Blood is taken about one week before the appointment, so that the results are available when we meet.
Detailed medical history and examination, 50 minutes, including ultrasound or ECG where needed. If hormone therapy is an option, I initiate and adjust it.
With blood tests, ECG and ultrasound of the abdomen, thyroid and carotid arteries, about 60 minutes. Advisable if a check-up is due in any case. Laboratory costs are usually covered by your statutory health insurer.
Where there is a medical indication, laboratory costs are generally covered by your statutory health insurer. Follow-up appointments for adjusting therapy are billed according to duration.
Frequently asked questions
What women ask me beforehand
I still have a regular cycle.
That rules nothing out. The perimenopause often begins years before the last period and with a completely regular cycle. Symptoms from around the age of forty should be investigated, not simply waited out.
Do I need my hormone levels measured?
No. During this phase, levels fluctuate so widely that a single measurement says very little. The diagnosis is based on your symptoms. We need laboratory values for other questions: iron, thyroid, metabolism.
Does this replace my gynaecologist?
No, nor is it intended to. Smear tests, breast examinations and gynaecological screening remain with her. I take care of the internal medicine side and coordinate with her if you wish.
Can I send my results in advance?
By all means. The more information is available, the more time remains for our conversation during the appointment.
I am being treated elsewhere and would like a second opinion.
That is also what this appointment is for. Bring whatever you have, and I will review it.
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