Early Signs of Perimenopause: Why Your Body May Feel Different Even When Your Labs Are Normal

Many women begin noticing changes in their late 30s and early 40s—trouble sleeping, mood shifts, weight gain, or feeling more anxious than usual. Yet when they seek medical care, their lab tests often come back completely normal.

In this episode, Dr. Brandi Sinkfield speaks with menopause specialist Dr. Leah Millheiser about the early stages of the menopause transition and why perimenopause is often overlooked in clinical care.

Dr. Millheiser explains why hormone levels fluctuate dramatically during this phase of life, why lab testing may not always capture what’s happening in the early stages of perimenopause, and why many women feel their symptoms are treated individually rather than understood as part of a larger hormonal transition. The conversation explores common symptoms and why these changes can begin years before menopause itself.

Dr. Sinkfield also reflects on how learning more about perimenopause has changed the way she views patient care in her own clinical practice, highlighting how hormonal changes can affect metabolism, cardiovascular health, brain function, and overall well-being.

This episode is the first in a multi-episode series exploring perimenopause, menopause care, sexual wellness, and the evolving role of digital health technologies in women’s health.

Topics Discussed

• Early signs of perimenopause

• Why many women experience symptoms years before menopause

• How the Women’s Health Initiative shaped menopause care for decades

• Why hormone testing alone may not diagnose early perimenopause

• Mood changes, anxiety, and sleep disruption during the menopause transition

• Why weight gain is often the symptom that brings women to the doctor

• Emerging technologies like continuous glucose monitors in menopause research

• How to find clinicians who specialize in menopause care

Key Takeaways

Perimenopause can begin years before menopause itself. Many women experience symptoms while their menstrual cycles remain regular and lab tests appear normal.

Hormone levels fluctuate dramatically during the menopause transition. Because of this, lab tests alone may not always detect early perimenopause.

Symptoms often appear across multiple body systems. Perimenopause can affect metabolism, sleep, mood, cardiovascular health, bone health, and sexual health.

Weight gain is one of the most common reasons women seek care. Changes in metabolism during perimenopause can contribute to shifts in body composition.

Finding a menopause specialist can make a significant difference. Resources such as The Menopause Society help women loca

Disclaimer
The information in this podcast is for informational purposes only and is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare providers with any questions you may have regarding a medical condition or treatment.

The personal views expressed by guests on Women's Digital Health are their own. Their inclusion here does not constitute an endorsement from Dr. Brandi, Women's Digital Health, or associated organizations.

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Edited by Steve Woodward at podcastingeditor.com/

Transcript

 Dr. Brandi: You know, many women begin noticing changes like around their late thirties and early forties. It starts with just a little trouble sleeping, a little weight gain, a little irritability, maybe feeling bluer a lot more often, or feeling very anxious a lot more often than they're used to. But then when they go to the doctor, all the labs, all the diagnostic testing come back completely normal.

So what is actually happening? Over the past year, this topic kept showing up again and again in conversations with my friends in my own health journey, and even when reviewing patient charts in my clinical work. In this episode of the Women's Digital Health Podcast, I'm joined by Dr. Leah Miler. A.

Perimenopause menopause specialists to talk about the early signs of perimenopause and why they are so often missed. We'll talk about the symptoms that can appear years before menopause itself. Why hormone testing doesn't always tell the full story. Why many women feel like they're not being heard when they seek care?

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This is the first episode in a series where we explore the perimenopausal transition and how women can better understand what's happening in their bodies during this stage of life. 

Dr. Millheiser: Most of us as physicians or clinicians of any type who have graduated anytime between 2000 and 2025. Mm-hmm. I had a ton of training and never did on menopausal concerns.

 Right. Like you went through med school and residency, you probably didn't get it. Um, I'm an OB, GYN, and I think I had maybe a week or two of working with a clinician. You know, in my residency program who did menopause, but I graduated at the time of the WHI. It came out when I was a second year resident and it changed the way we took care of women going through menopause.

So really the baby boomers have suffered as a result of the study. Yeah, and I'm sure we'll get into that.

Dr. Brandi:  Okay guys, you have to bear with me. I'm gonna get a little passionate here because of the timeline that Dr. Leah is talking about. So when she talks about doctors who were trained during the 2000 and quite frankly, up until 2025, I immediately recognized the timeline because that's the time in which.

I was trained, many of us who were trained during that era of medicine. We entered the practice at a time when perimenopause and menopause care was dramatically shaped by the Women's Health Initiative. There were headlines that followed the study that changed the way an entire generation of doctors thought about hormone therapy, including my own.

The result for many of the women of the baby boomer generation, those women born between 1946 and 1964 when they entered menopause just as a women's health initiative dramatically changed. It changed how clinicians were thinking about hormone therapy in medicine. Menopause became something you were expected to just endure, and the message to many families was just power through suffer through it.

And I saw that in my own family, in my own community. These women were navigating anxiety, depression, sleep loss, mood changes, weight gain, and then later on hot flashes without any language to describe what they were experiencing. So for those of you who are listening right now, who are trying to figure out why your doctor might be struggling to recognize perimenopause or menopause, why your symptoms aren't immediately being connected to hormonal changes.

That is why for many clinicians, perimenopause and menopause was simply not a major part of their formal medical training, and it's exactly why conversations like the one I'm having with Dr. Millheiser matter. So my name is Dr. Leah, Millheiser. I am a board certified OB, GYN. I've been practicing for about 21 years now.

After residency, I spent the majority of my career up until almost a year ago, uh, at Stanford University. I started a female sexual medicine program there within the division of gynecology. I became a Menopause Society certified practitioner a little bit later in my career. So I focused. The last 10 years on really the health and wellness of the aging woman.

So perimenopause and beyond, uh, specifically focusing on menopausal concerns and female sexual function. And my bosses today would kill me if I didn't say I now work at the Palo Alto Medical Petition. Yes. 

Dr. Brandi: Okay. Before we dive in, I wanted to say one quick thing about how this episode is structured. This conversation with Dr.

Millheiser is a blend of conversation and education. So some moments may feel very educational and some are just moments of discussion and I may slow things down a bit so we can really understand what's being said. 'cause these are the kind of conversations I want you to feel prepared to have when you walk into a doctor's office.

So we've talked about why physicians and clinicians may struggle to recognize perimenopause and the menopausal transition, a lack of training, decades of confusion after the Women's health initiative and a healthcare system that historically hasn't even focused on this phase of women's health. But that leads to the question many women are asking, which is what is actually happening during perimenopause?

What are the earliest signs and what symptoms are being overlooked when a woman walks into a clinic looking for answers? How would you describe those earliest signs of perimenopause, uh, that women experience and quite frankly, those signs of symptoms that doctors who may not have this background, that they often overlook when a woman comes into a clinic.

Dr. Millheiser: We sort of traditionally think of women who are menopausal as women in their late forties, early fifties, sometimes later, and we sort of, you know, I would say pigeonhole ourselves into, well, if you're in that age range and you come in with hot flushes and night sweats and insomnia, okay, or vaginal dryness, you are probably perimenopausal or menopausal.

The truth is those symptoms can start years before perimenopause. On average, so can be longer, can be shorter, is about four and a half, 4.7 years. If you look at the data, there are different things that influence how long your perimenopausal journey is. Your race, your ethnicity, all play a role. So you kind of have to think about, you know, you have to look at women as an individual.

Mm-hmm. And ask a couple of questions. One, do you know when your mom went through menopause or a sister went through menopause? Because there is a genetic link. If somebody's a smoker, they're probably gonna go into menopause early. 

Dr. Brandi: So I wanna emphasize this is a really, really important part of what Dr. Millheiser is trying to say. Many women experience the symptoms of perimenopause. Years before. In other words, you may still be having a menstrual cycle. Your menstrual cycle still may be regular, and you are still experiencing some of these symptoms that are a part of early perimenopause, and that's the phase of perimenopause that often gets dismissed in the clinic.

Dr. Millheiser: You know, there are different stages of menopause. There's something called primary ovarian insufficiencies. That's when women go through it before 40. In those cases, we really have to look and see is there a cause? What happened to put this woman into such an early menopause? There's early menopause, so women who go through it between 40 and 45, we don't look at that as pathological.

It's natural for many women. Early, and so those women come into a different, they fall into a different category for treatment. We are always concerned about people's brains and bones and hearts, but especially for women who go through menopause before the age of 45, and then 95% of women will fall into the perimenopause menopause transition between the ages of 45 and 55.

So that's why we sort of think, oh, well if you're before that, maybe it's not menopause. 

Dr. Brandi: At this point, it's helpful to clarify just a few terms that are often used interchangeably throughout this podcast. So menopause itself is defined as 12 consecutive months without a menstrual cycle, but the years leading up to that point, when the hormone levels begin fluctuating, and symptoms start occurring.

That's known as perimenopause or the menopause transition. Clinicians who specialize in menopause care are often helping women navigate symptoms that occur during perimenopause or before menopause, during the perimenopausal transition and after menopause. So understanding the different stages of perimenopause and menopause helps explain the overall timeline.

But the reality is like women don't walk into a clinic saying, doctor, I think I'm in perimenopause. They come in describing symptoms, sometimes symptoms that don't immediately sound like hormones.

Dr. Millheiser:  Now, the symptoms that are the hallmark of menopause, hot flashes, night sweats, insomnia, mood changes. They aren't always the presenting symptoms, right?

So you, as you know, you'll have women come in and say, you know, I just, my mood is changing and I think I'm depressed, or I'm anxious, and sometimes it just falls around my period. Right? I see so many women who come in with mood instability being their primary symptom, and it was missed. It was diagnosed as depression, anxiety, and they were put on.

An antidepressant. Women who have vaginal dryness and painful intercourse, you know, no one is really picking up on is this related to hormonal changes because they're so young. 

Dr. Brandi: What Dr. Millhiser is describing is something many women experience. Instead of recognizing the symptoms as part of a hormonal transition, they may be treated individually, prescribe a medication for anxiety, then prescribe a medication for depression.

Prescribe a medication for sleep problems and then prescribe another medication or therapy for painful sex without connecting them all to perimenopause. So once we understand that menopause and perimenopause don't happen overnight, the next step is to understand how clinicians actually define the stages of perimenopause.

Dr. Millheiser: I think nomenclature is important in sort of understanding the different phases. So there's early perimenopause and late perimenopause. Mm-hmm. Early by definition is when your periods start to, or your cycles start to lengthen out. So more than seven days consistently or less than seven days consistently.

You may be having symptoms, may not be, and then late perimenopause is when your periods are starting to skip. So maybe you're skipping several months and usually defined by symptoms. Mm-hmm. Tell you that in practice, that is not what I see. Right. What I see of perimenopause and I. Deemed it early, early or pre perimenopause is women come in with normal periods, they have periods every month consistently.

Mm-hmm. They're having hot flashes, night sweats, all the symptoms or a lot of symptoms. Mm-hmm. But if you check their labs, because everybody wants their FS, H and estradiol because they think, okay, if I check that and it's normal, it's not perimenopause. Mm-hmm. True. Your labs will be oftentimes normal in that early, early stage of perimenopause.

Right. Um, so we don't go by that. We go through. You know, okay. When all other things have been, if it, you know, walks like a duck, it quacks like a duck. It's a duck. If somebody is in their early forties, mid forties, and they're starting to have these symptoms, even with regular periods, you have to think about Ari menopause.

Dr. Brandi: I'm just gonna jump in here just real quick because a lot of us are seeing a lot of discussion on social media about hormone testing and these panel tests that promise to diagnose perimenopause. As Dr. Leah  is explaining here, hormone levels can fluctuate quite a bit during this transition, which means that these lab tests alone may not even capture what's going on, particularly if you are in the early stages of perimenopause.

So that leads us to the next question that most women probably have at this point, which is, okay, so how do you bring up these concerns with your doctor? How do you make sure you're actually being her and understood? 

Dr. Millheiser: Yeah. So that is the issue, right? So I usually am the referral, right? I'm the person that a woman is seeing when she hasn't gotten the answers that she's needed or the solution from medication through other providers.

So I'll see them after 1, 2, 3 clinicians. Mm-hmm. And. Women don't feel like they're being heard. They feel like they are being sort of put into a category of, okay, your heart is racing. Okay, right, well, and you're having anxiety. We'll do an antidepressant. Oh, we're gonna do a cardiac workup. Or we're, you know, nobody is sort of looking at the woman holistically.

And I mean, by the time they get to me. There are tears, there are frustration, there's distrust, right? So they start to not trust what they're being told by their clinicians. And so they're seeking solutions outside of sort of the traditional Western medical system. Uh, you know, I see this a lot. 

Dr. Brandi: What Dr. Millheiser is describing is something that so many women experience during the perimenopausal transition. You know, instead of recognizing the symptoms as a part of a larger hormonal shift, they're evaluated separately. You know, anxiety is one thing. Sleep disturbs is another thing. Heart palpitations is something different without connecting the bigger picture.

By the time many women finally reach a clinician who specializes in perimenopause or menopausal care, they have already seen so many other providers and they still do not feel like they have a clear answer. And you know, hearing Dr. Leah describe this pattern also made me reflect on my own clinical practice.

You know, as an anesthesiologist, I run the preoperative testing clinic at my hospital and I review a ton of patient charts. Every day. So for years I might've read something like this, 39-year-old woman, BMI of 31, hypertensive pre-diabetic history of anxiety. But learning more about perimenopause has changed the way I look at those charts.

So now when I see that same patient profile, I sometimes pause and ask a different question. Could this also be a woman experiencing early perimenopause that simply hasn't been recognized yet? You know, it's just a reminder that this hormonal transition is not just about the reproductive system. You know, you have hormonal receptors on your heart and your brain that affect your metabolism, your sleep, your mood.

You even even have receptors that impact your bone health, and there's just so many other systems that are impacted by hormones. 

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Okay, so guys, I know we've talked about a bunch of symptoms, but interestingly enough, Dr. Leah says that while many women experience all these different symptoms during this transition, there's often one issue that finally pushes them to seek answers. Very often that issue is weight gain. 

Dr. Millheiser: You brought up the weight gain issue. Mm-hmm. If I had a dollar for every time weight gain was the number one issue that a woman was facing. Like, yes, she has all the other symptoms, but the weight gain is that one thing that is ruin her life because it's body image, it's self-esteem. It's a lot of things and that is the one that really gets people into my office.

Dr. Brandi: Okay. So guys, what Dr. Millheiser is saying right now really resonates with me personally. You know, when I moved into my late thirties, I started noticing something that a lot of women were talking about, and that's that the diet and the exercise routines that had worked for me in my twenties were not working in the same way anymore.

And then I go to my doctor and the response was basically, well, your labs look normal and your weight is technically normal. Nothing seems medically wrong. But my body, and honestly, my feet begged to differ because I'm on my feet a lot as an anesthesiologist. And so it pushed me, it motivated me to make some changes on my own.

So I hired a nutritionist. I started focusing more on weight training, and those things helped a lot. You know, even earlier this season I joked about what I call my back fat moment. You know, my back fat was a challenge, and it's just one of those moments where. You look in the mirror and you realize your body is changing in ways you just didn't expect, but it also encourages you to be more compassionate and kind to yourself.

And yeah, I'm learning how to approach those changes with more compassion. Conversations like this reminds me that shifts that women notice in their forties. It may not just be about, you know, aging or lifestyle. Some of these are early signals that the hormonal transition of perimenopause may already be underway.

So if weight gain is often the most common symptom that brings a woman into the doctor's office, the next question become what's actually happening with the metabolism during this transition? And is there any way to measure or understand those changes better? 

Dr. Millheiser: I will tell you as somebody who is currently wearing a CGM to get more information about, mm-hmm.

Um, insulin and how, you know, the insulin resistance is working in, in perimenopause and menopause. Here's what I tell women when I speak to them. You know, even outside of my office, I say the number one thing you can do is to empower yourself with knowledge. 

Dr. Brandi: Dr. Millheiser mentioned something interesting here. She's personally experimenting with continuous glucose monitor to better understand metabolic changes during perimenopause. In a later episode of this series, we'll explore how emerging technologies like continuous glucose monitors and wearable devices are helping women gain new insights into their health during this transition.

But even with new tools and new information becoming available. The question many women still face is, where do you find trusted evidence-based guidance about perimenopause and menopausal care?

Dr. Millheiser:  So Dr. Google is alive and well with menopause. You have social media docs who I love, I know most of them personally. Incredibly brilliant clinicians. You know, there are a few out there who they, they have a different angle, they have a different approach than sort of the evidence-based, but there are evidence-based physicians out there. There is the Menopause Society, which has information for women who are not clinicians. So lay people who wanna learn more about menopause. 

Dr. Brandi: Today, women have more access to information about perimenopause and menopause than ever before. But as Dr. Millheiser points out, the challenge isn't just access to information. It's figuring out which sources are truly evidence-based.

Dr. Millheiser:  But I think one of the things that you can do, if you're having a hard time finding that person who can really answer your questions from sort of an evidence-based way, right?

Like you want somebody who really understands. 'cause it's not just gynecology and it's not just primary care, right? This cardiology. And it's not just endocrinology. This is a really broad. Phase of life, right? This isn't a disease, right? This isn't disorder. It is a phase that we will all go through that is characterized by metabolic changes, cardiac, you know, bone, like all of these different organ systems.

Every organ in your body needs estrogen to function at its peak form. So I would say. If there's nobody who is really specializing, see if you can find a Menopause Society certified practitioner. You can find that on the Menopause Society website. Mm-hmm. You know, many of these social media influencers will have a list of providers around the country who specialize in menopause care.

Mm-hmm. Um, if you don't have access, then I would go to your, whoever your provider is and say, listen, you know, I think these are menopausal symptoms. Right. Let's talk about all my different options and, you know, hormones aren't always the solution, right? There are non-hormonal options available. Um, not everybody, not, I mean, not that many women are not candidates, right?

 Most women are. There's a select few who aren't. So I think it just takes a very open and honest and, and challenging your clinician a little and say, Hey, what's your background in menopause? And do you know anyone who's specializing in it? 

Dr. Brandi: What Dr. Millheiser is highlighting here is that the perimenopausal care and menopausal care often requires like.

Physicians to and clinicians to zoom out. We need like a broad perspective. The perimenopause menopausal transition is not just about the reproductive system, which is why finding a expert who is familiar with the perimenopausal menopausal care can make a huge difference for women who are navigating this transition.

So guys, don't be afraid to ask for that referral or look for someone on the Menopause Society website.

 Alright, listeners, if there's one takeaway you can get from this conversation, it is that perimenopause is not obvious, not even to doctors. The symptoms can start years before. You recognize them because hormone levels are changing so much and sometimes the lab tests can appear normal.

In our next episode, Dr. Millheiser and I will delve into the most misunderstood topic in perimenopause menopausal care, and that's hormone replacement therapy, including the common misconceptions and what the science actually says. Later in this series, we'll also explore sexual wellness and some of the emerging technologies that are helping women better understand their bodies during this transition.

If today's conversation resonated with you, I'd really, really appreciate if you left a five star review on Apple Podcast, Spotify, audible, or wherever you listen to your favorite podcast. It helps more women find conversations like these that are so sorely needed. And remember, you are enough, even more than that.

Bye for now.

Although I'm a board certified physician, I am not your physician. All content and information on this podcast is for informational and educational purposes only. It does not constitute medical advice and it does not establish a doctor patient relationship by listening to this podcast. Never disregard professional medical advice or delay in seeking it because of something you heard on this podcast.

The personal views of our podcast guests on women's digital health are their own and do not replace  and do not replace medical professional advice.