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The perimenopause upgrade – How to turn perimenopause madness in your 40ies into a win

You are in your 40ies, you wake up at night in a sweat, your periods are erratic and heavier, your libido has dropped, and a muffin top appeared?

Don’t despair! There is much new research into the why’s and how’s to prevent, optimise and smoothen out this transition.

Menopause is the time that marks the end of your menstrual cycles. It is diagnosed after you have gone 12 months without a menstrual period. It can happen in your 40ies and 50ies, but average age is 51 in the UK. The actual menopause is not what causes the mentionned symptoms. The dreaded trouble that is often associated with that time in a woman’s life, is actually part of ‘Peri-menopause.

Peri-menopause is that transitional state ‘around’ menopause, and can start as early as your late thirties and last over a decade with its symptoms averaging 3 to 4 years.

The most common complaints are:

  • Hot flashes and night sweats
  • Trouble sleeping
  • Irritability and anxiety
  • Weight gain around the midline- that muffin top that won’t budge
  • Memory problems and brain fog
  • Erratic cycles & heavier periods
  • A drop in libido along with vaginal dryness

… yikes!

Most doctors are taught that hot flashes and night sweats come purely from falling estrogen levels. That means that when you go to see your doctor with these complaints, you’ll likely get a prescription for hormone replacement (HRT).

Yet while all women’s estrogen will drop eventually, not all are experiencing the sometimes debilitating symptoms. So how can it just be from falling estrogen levels? That simply doesn’t make any sense… Also, many women continue to flash for years after their last period, long after their estrogen level should be more stable.

Another interesting fact is that far fewer Japanese, Korean, and Southeast Asian women report having hot flashes. In Mexico’s Yucatan peninsula, women appear not to have any at all. https://www.health.harvard.edu/womens-health/perimenopause-rocky-road-to-menopause

Luckily science has dedicated a good amount of time and effort into this over the past decades, and has come up with interesting research and explanations. Other than estrogen’s hikes and drops, there appear to be other major players involved in the dreaded symptoms, and which, tahtah, luckily can be influenced by targeted dietary and lifestyle tweaks. These include:

  1. Estrogen dominance
  2. Progesterone
  3. Testosterone
  4. Thyroid
  5. Cortisol
  6. Noradrenaline
  7. Insulin resistance
  8. Gut & vaginal microbiome
  9. Nutrient deficiencies
  10. Inflammation, free radical load & an overburdened detox system
  11. Low estrogen & serotonin

… and more. But before we dive into the intricacies of how they are all related and what you can do about it, a quick word on why it matters.

First of all, and maybe the most obvious reason, is quality of life. Perimenopausal symptoms can turn that time in your life, that could be dominated by finally knowing yourself better, being more centred within yourself, more settled in life and work into a dreaded time of hormonal chaos.

But what many aren’t aware of, is that research indicates that the severity of hot flashes, so called vasomotor symptoms, not only are irritating, but are further also linked to a higher risk of cardiovascular decline, atherosclerosis, coronary heart disease and lower bone mineral density down the line. Recent work even goes that far as to suggest that the presence of flushing may be a marker of underlying cardiovascular disease (1, 2, 3).

In addition, the age of menopause onset matters too. Research has shown that going through menopause earlier not only has a major impact on fertility potential but also increases the risk of cardiovascular disease, osteoporosis, cognitive decline and mortality later in life (4).

This all sounds doomy and gloomey? As promised earlier on, the great news is that with research’s discovery of underlying mechanisms, as always within the Functional Medicine approach to health optimisation, one can then address these to optimise, support and prevent, putting your health back into your own hands.

Without further ado, let’s dive into some of the underlying mechanisms and how they relate to perimenopausal symptoms.

As always, I want you to understand at least somewhat the basics of biology so that you can then become the CEO of your own health journey, and pick and choose tools from the toolbox that best fit your lifestyle and preferences, rather than a diet that you don’t understand the reasoning behind, doomed to be yet another wagon to fall off.

The top 11 underlying triggers for perimenopausal madness

1). Estrogen dominance

Despite the common conception that most of menopause’s symptoms are to blame on low estrogen, the years leading up to menopause are actually often defined by erratic fluctuation, and mostly too high levels of estrogen rather than too little, combined with not enough progesterone to oppose it.

Estrogen often skyrockets in the years leading up to menopause, before dropping. Research shines some light onto potential contributing factors. An imbalanced gut microbiome, meaning not the right kind of bacteria in the gut and an overgrowth of ‘bad guys’ including also the common fungus candida albicans, can make estrogen not being able to be excreted as well both via the bile and the stool, allowing it to recirculate, and further contribute to gallstones, digestive issues and bloating. Both a diet too high in sugars or too high in fat (as in keto) can contribute to excess estrogen levels, as can overdoing both eating and fasting regimes. To achieve and maintain healthy estrogen levels, balance is key.

Other contributing factors can be an overburdened liver, not enough cruciferous vegetables and protein to support the liver in breaking down estrogens, excess alcohol intake (any more than 7 servings a week have been shown to increase estrogen levels!  ). The overabundance of microplastics and other hormone mimicking substances such as found in take away coffee mugs, ready made meals, conventional skincare and household products, synthetic fragrances and can increase external estrogen burden, and overwhelm the body’s estrogen disposal mechanisms.

2) Progesterone deficiency

And what about progesterone?

Progesterone is needed to oppose estrogen’s effect on the endometrium, making cycles heavier and erratic, an increased propensity towards fibroids, cysts, endometriosis, and even cancer growths. Progesterone is also important for the production of the calming neurotransmitter GABA, with lack thereof contributing to increased anxiety, irritability, interrupted sleep. GABA is also important for opposing noradrenaline and hot flashes, but more on that later.

Without going into the details of how the menstrual cycle works here, we need a healthy ovulation in order to have adequate levels of progesterone in the second half of the cycle. This is often not the case in women with perimenopausal symptoms, with common culprits being too stressed out, a thyroid that functions below optimal and being deficient in important nutrients.

3) Testosterone

Low libido? Fatigued and low in motivation? Lacking muscle definition and tone? Testosterone levels that are below optimal may be the culprit. But what are reasons for testosterone saying good-bye?

Lack of exercise and sex, not enough protein, too many or too little carbs and sugars are the most common underlying contributors.

4) Thyroid – is it perimenopause, or a sluggish thyroid?

Another hormone that gets tangled up in perimenopause’s madness, is the thyroid. A thyroid that functions below optimal can cause weight gain, fatigue, cold intolerance, thinning hair, nails and skin, depression, low libido, and a general listlessness.

A sluggish thyroid often gets missed, as common lab ranges only pick up on it when it is already in the danger zone. Many women also have an autoimmune component to it, called ‘Hashimoto’s’, but again, often this goes overlooked and undiagnosed for a long time, due to the lab reference ranges being extremely high. Even low levels of thyroid antibodies can make the thyroid not function as well, while the common marker tested, TSH, may still be in normal ranges. What we want to look for are the actual thyroid hormone levels, free T3 and free T4, and we want them to be in the higher end of the normal range for optimal thyroid function, and if there are thyroid antibodies, work with an experienced Functional Medicine practitioner to find your autoimmune triggers, with IgG food intolerances, chronic infections such as candida albicans and intestinal barrier permeability (‘aka leaky gut’), heavy metal build up and other factors the most common ones.

An optimally functioning thyroid is not only important for energy, mood, weight and hair quality, but also plays a role in progesterone production.

5) Cortisol

Next up, and maybe one of the most important pieces to the puzzle, but often one of the most difficult ones to master, is cortisol. Most of you have heard of cortisol as a nasty stress hormone, culprit of many problems. Our body pumps out cortisol in response to stress, real and perceived. Our brain doesn’t differentiate between actual danger, ie a tiger that is running after us, or our relentless brain, ruminating, worrying, running 100 miles per hour day in and day out. Check in with yourself right now, what is your breath doing? Are you breathing into your chest, with quick, shallow breaths? Or are you calmly breathing into your belly? Most of us are in constant fight-or-flight, even when sitting down, doing yoga, and even while attempting meditation.

However, cortisol isn’t all bad, and in fact we need a spike of cortisol first thing in the morning to kickstart the day. Recent research into the science of circadian rhythm is showcasing the importance of a daily rhythm of cortisol, with a healthy spike first thing, with then supposedly lowering levels throughout the rest of the day, and lowest at night to allow for a restful sleep. Women with increased later day and night cortisol are more likely to experience more severe vasomotor symptoms (hot flashes). On the contrary, women who reported more frequent and severe hot flashes had a smaller increase in cortisol after waking up. A smaller increase in cortisol first thing in the morning has further been linked to an increased risk for cardiovascular disease. https://pubmed.ncbi.nlm.nih.gov/16645535/

These findings support the idea that it is not so much just about too much cortisol, but rather a dysregulation of its daily cycle (‘circadian rhythm’), also called HPA axis dysregulation (its regulation from the brain), that contributes to hot flashes and subsequent increased risk for cardiovascular disease. https://www.contemporaryobgyn.net/view/vasomotor-symptoms-cortisol-awakening-response-in-perimenopause

Underlying reasons for this imbalance are often being stressed out over long periods of time, constantly racing from one task to the next, too much coffee late in the day, but also lack of sleep hygiene, going to bed too late, eating and drinking alcohol late at night, night time snacking, overdoing keto and intermittent fasting. More on how to incorporate keto and intermittent fasting for a healthy, anti-ageing lifestyle later.

Having low cortisol first thing, and too much later in the day, not only contributes to hot flashes and irritability, it is also tightly linked to that dreaded belly fat accumulation, called ‘visceral fat’, which is linked to inflammation, more hormonal havoc, and all cause morbidity.

Another reason we want to check in with our cortisol and stress levels are that cortisol, if constantly high, can contribute to ‘pregnenolone steal’. Pregnenolone is the precursor to both our happy, fertile, calm hormone, progesterone and cortisol. If we are constantly stressed out, our brain thinks it isn’t safe enough to ‘make babies’ and directs it down the cortisol pathway, rather than progesterone production.

6) Nordadrenaline & GABA

You have heard of adrenaline, but what please is noradrenaline? It’s like the big brother of adrenaline and cortisol, and gets pumped out by our body when we our body thinks it is in danger. It influences our temperature gauge, and is linked to hot flashes.

GABA is a calming messenger chemical, important for sleep and opposes noradrenaline’s effect. Progesterone is needed in order to produce GABA. In perimenopause, when progesterone drops, and if we haven’t learned to manage our fight or flight response appropriately, our GABA drops as a result, allowing noradrenaline to run amuk, disrupting sleep, contributing to irritability and sleep problems.

7) Insulin resistance and ‘hangriness’

Another one of the big players in the perimenopausal madness is insulin. Insulin is that hormone that helps shuttle sugar (glucose) into our cells to be used for energy (or to be stored for later energy in the form of fat, if too much is present).

Most of us know the word ‘hangriness’ oh too well. That state of being so hungry that you get angry, irritable and MUST EAT NOW. It is such a common phenomenon that most think it is ‘normal’. However, it isn’t! It is a sign of a blood sugar rollercoaster. After a meal high in sugar and carbs (which turn into sugar once inside the body), we get a blood sugar spike, followed by our body pumping out insulin to shuttle it into our cells. Often followed by a drop in blood sugar, making us cranky and hangry, rummaging for the next sugar and carb hit. The rollercoaster continues. Now if this happens over many years, our cells start to stop responding to insulin’s signals as well, something called ‘insulin resistance’.

Our cells can also use ketones for fuel. Ketones are made from fats, and can burn quite efficiently inside our cell’s engines, called mitochondria. They burn slower and give us more constant energy, without the ups and downs. However, the body only makes ketones if blood sugar and insulin drops, such as if fasted or on a low carb (ketogenic) state.

Our brain needs either glucose or ketones to do its thing, and if not enough energy is coming in, it pumps out more noradrenaline and cortisol, and can trigger hot flashes. https://pubmed.ncbi.nlm.nih.gov/14501548/ https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0176430

As most of us have grown up on diets based on sugars and carbs, even if it is the ‘healthy kind’, ie granola, porridge, quinoa, beans, fruit, our body isn’t very metabolically flexible, meaning if sugar supply drops, it isn’t very efficient in creating ketones quick enough, and our brain thinks we are starving. Result? Hot flashes, insomnia, and irritability.

Another downside of our cells becoming insulin resistant over time, and metabolically less flexible, is its contribution to that dreaded muffin top, also called ‘visceral fat’. Visceral fat may not only annoy us for its looks, but in itself causes inflammation, hormone imbalances, and makes us crave highly palatable foods more. A vicious cycle. Unless addressed, so don’t despair. We are getting to how to fix this in the next posts of this series.

Comment below if you found this to  be helpful, or if you have questions. See you in the next post xx

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It is my goal to empower you to become the CEO of your health trajectory, preventing and optimising with precision and science backed strategies to live your best life & thrive.

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It is my goal to empower you to become the CEO of your health trajectory, preventing and optimising with precision and science backed strategies to live your best life & thrive.

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