Don't Guess: Investigate! Why Perimenopause Symptoms Alone Don't Tell the Whole Story
How testing helps provide the bigger picture to allow an individualized approach to midlife symptoms.
One of the things I hear often from women in midlife is: “I just don't recognize my body anymore.”
The symptoms may be familiar: bloating, water retention, constipation, acne or other skin issues, fatigue, poor sleep, changes in mood, weight changes, headaches, brain fog.
And because we've become so used to associating certain symptoms with certain hormones, it's tempting to jump straight to an explanation.
But symptoms are clues - They aren't the whole story.
A recent client case reminded me exactly why I prefer to test rather than guess.
The obvious assumption
When this woman first came to see me, she was in her mid-40s and experiencing bloating, constipation, bad sleep, some acne and a general feeling of being blown up and inflamed.
At her age, one of the things I would naturally consider was a shift in her sex hormones - including changes in androgen activity.
It would have been very easy to look at the symptoms and make an assumption about what was happening.
But I always like to at least run a detailed blood panel to see what we are actually dealing with.
We tested her hormones.
And the result surprised me:
Her testosterone wasn't elevated.
Her estrogen was.
Really high.
It was one of the highest estrogen results I had seen in a client.
Suddenly, the story looked very different.
And this is exactly why I believe testing still has a place in perimenopause, even though hormone levels can fluctuate considerably.
“But aren't hormones too unpredictable to test?”
This is something I hear all the time. And there is some truth to it.
During perimenopause, estrogen can fluctuate significantly from cycle to cycle - and even every day or hour. A single measurement therefore cannot tell you everything about a woman's hormonal experience.
But that doesn't mean the result is useless.
I don't look at a hormone test as a standalone diagnosis. I look at it as one piece of information in a bigger picture:
What are her symptoms?
How old is she?
Where is she in the menopausal transition?
How is she sleeping?
What does she eat?
How much stress is she under?
Is she getting enough protein and essential nutrients?
How is she digesting?
Is she constipated?
What is her menstrual history?
When did her mother start experiencing menopause?
What medications or hormones is she taking?
And, where relevant, what do her laboratory results actually show?
The value is in bringing the information together.
In this case, the bloodwork changed the direction
I would have suspected her testosterone to be elevated as it happens so often in perimenopause when progesterone drops and impacts the androgen balance. Without the bloodwork, I would have recommended a supplement to support her testosterone metabolism and progesterone levels with HRT.
And because her estrogen was unusually high, I wanted to look more closely at what was happening to estrogen in her body.
That meant thinking beyond production.
Because a hormone isn't simply made and then magically disappears.
It is metabolized.
It is transformed.
It is transported.
And eventually, the body needs to eliminate it.
So rather than asking only, “How much estrogen does she have?”, I also wanted to ask:
“How is she processing and clearing it?”
And that brought us to the gut.
Your gut can be part of your hormone story
We often think of the gut microbiome in terms of digestion.
Bloating.
Constipation.
Food tolerance.
But your gut bacteria are metabolically active. They produce enzymes and transform compounds that pass through the digestive tract, and some of those processes can influence what happens to compounds elsewhere in the body.
One of those enzymes is beta-glucuronidase.
Your liver uses glucuronidation as one of the ways it processes various compounds, including certain estrogen metabolites, helping prepare them for elimination.
Once these compounds reach the gut, bacteria that produce beta-glucuronidase can remove the glucuronic acid group. This can make some compounds available for reabsorption rather than continuing toward elimination.
In other words, this enzyme is "unpacking" used estrogens from your feces and recirculating them into your blood stream. And elevated levels of estrogen can also be a reason for bloating, not only inflammation in your gut.
The gut test added another piece
We didn't discover her high estrogen through her microbiome test.
We already knew that from her bloodwork.
The gut test came later.
And it showed elevated beta-glucuronidase activity. This was another one of those moments where a seemingly separate piece of information became relevant to the bigger picture.
Her microbiome test was a new generation of tests I have just started using in my practice and they actually provide us an overview of the whole gut genome sequence of a person. So this actually showed that this is her genetic gut imprint - she will always have to pay atttention to her estrogen metabolism, because she has a specific combination of microbes that are not unfriendly but they all produce beta glucuronidase as a byproduct. So it has a direct impact on her hormone balance.
And this is what I mean when I talk about connecting the dots.
The hormone test gave us one piece.
Her symptoms and intake form gave us another.
Her age and stage of life gave us context.
And later, her microbiome testing added another layer.
None of these pieces told the whole story by themselves.
Together, they gave us a much more individualized picture.
This is what targeted nutrition actually looks like
There is a tendency in the wellness world to talk about personalized nutrition as though it means having a longer list of supplements.
More tests.
More protocols.
More things to take.
That's not how I see it.
To me, personalization is about using the information you have to decide what actually deserves attention.
Instead of throwing a generic “hormone balance” protocol at her, we had a reason to focus on estrogen metabolism.
Instead of assuming her acne meant high testosterone, we tested.
Instead of looking at her gut microbiome as an isolated issue, we considered it in the context of her hormones and symptoms.
And rather than trying to change everything at once, we could make the intervention more targeted.
This is one of the principles at the heart of the SENSE Framework that I describe in Stranger in Your Body: stabilize first, investigate what may be driving the picture, and then use what you learn to make your interventions more precise.
Because sometimes the difference between throwing everything at a problem and actually making progress is simply knowing what you're aiming at.
Symptoms still matter - enormously
Don't get me wrong, I'm definitely not saying that we should stop listening to symptoms: quite the opposite!
Symptoms are often what tell us that something needs investigating in the first place.
If this client hadn't told me about her bloating and other symptoms, we wouldn't have had the starting point.
Her symptoms gave me the clues.
The testing challenged my initial assumption and completed the picture.
And the broader context helped me interpret the results.
That's the part that can get lost when we talk about either symptoms or testing as though we have to choose one.
We don't.
We need both.
A laboratory result without context can be misleading.
But relying entirely on symptoms can also lead us to assume that the most familiar explanation must be the correct one. And sometimes it isn't.
Your body is not a checklist
This is ultimately why I don't believe in one-size-fits-all protocols:
Two women can both be 45.
Both can have acne.
Both can feel bloated.
Both can tell you they feel “hormonal.”
And they can still have very different biology behind those symptoms.
One may have a different hormonal pattern.
Another may have digestive dysfunction.
Another may be dealing with blood sugar instability, nutrient deficiencies, poor sleep or chronic stress.
And often, there isn't one single explanation anyway.
There are several pieces interacting. That is why I keep coming back to the same principle: don't guess when you can investigate.
Use symptoms as clues.
Use testing where it adds useful information.
Look at the whole person.
Then make the intervention as targeted as you can - with the goal to give your body the support it actually needs.
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