Do Perimenopausal Women Really Have Low Estrogen? (Episode 642)

Full Transcript: Episode 642

Lisa Hendrickson-Jack: This is the Fertility Friday Podcast, episode number 642.

In today’s episode, we are going to be going through some really interesting perimenopause data. If you work with clients in perimenopause, or if you work generally with women of reproductive age, you will find this so interesting. And especially if you have been thinking about incorporating advanced cycle charting or using the menstrual cycle to help you interpret complex cases, you will also find this really interesting.

I want to start by setting the stage so that you have a client in mind. I want to set up a case study. You have a client, she’s 46 years old, and she’s noticing that her cycles are different, that her periods are significantly different. She’s starting to have a lot heavier periods. They’re longer, they’re unpredictable. She’s starting to notice more breast tenderness, headaches. She’s having difficulty sleeping.

I want to really set the stage because then you can see this paper in context. In this case study, this particular client of yours has already been to her doctor, and you already know what they’re telling her to do.

Since her periods have been heavy for a while, typically the first port of call is either the birth control pill or the insertion of a hormonal IUD. And if the bleeding is exacerbated, if it starts to get really bad, then inevitably they will encourage her to have an ablation, which cauterizes the uterine lining to stop the bleeding. So we’re going from minimally invasive to maximally invasive. And in this stage of life, in perimenopause, things can move very quickly. What I’ve observed is that symptoms can get significantly worse in a short period of time.

In a situation like this, how confident do you feel supporting her? Do you have enough training and knowledge to be able to teach her how to chart her cycle so that you can gain more information about it? That is our setup today.

There is a research paper that we are going to be going through, which looked at what’s happening hormonally for women in this stage. This particular study had a little over 1,300 women in their cohort. They were following these women for nearly 10 years. They would see them annually, and they did an annual blood draw to track the trajectory of what was happening hormonally throughout their perimenopausal years. We’re going to go through what they found and how it relates to our case study today.

I’m going to pull out some of the key points that really stood out to me. Their estrogen wasn’t just steadily declining as they were nearing menopause. Nearly half of the women actually had significant rises in their estrogen level.

Perimenopause is defined as the 10 years leading up to menopause. Typically we think about it as a time when your hormones are declining, and the symptoms you’re experiencing could be related to that. But the researchers identified four distinct estradiol trajectories across this transition. Some women did experience a slow decline as the years went on. Some women didn’t really see much of a change — year after year when they were testing, their levels stayed the same. Some women experienced a rise and then a slow decline. And a pretty significant percent, about 30% of the women in the study, experienced a rise in estrogen and then a steep decline.

One thing I’ll say about this study is that they weren’t testing these women every day or every cycle — it was an annual spot check. Of course, there are limitations to the conclusions you can draw. But on the other hand, they were testing annually for an extended period of time, so we are getting an interesting insight into what’s happening.

If we add together the two groups of women who saw rising estrogen and then a subsequent fall, that totaled to nearly half — about 45% of these women. That’s an interesting finding, because obviously we’re seeing disruptions in estrogen throughout this period of time. It’s not just a steady decline.

The other piece we can take from it is that if anybody is trying to tell you there’s one protocol or one way to handle this situation, it’s clearly not true, because the researchers identified four distinct trajectories for what was happening with these women during this time. This is what plays out when we actually dig into what’s happening in the menstrual cycle.

We do have foundational protocols that we teach our practitioners in our Fertility Awareness Mastery Mentorship. But we also know that when we’re tracking the cycle, we’re going to see different patterns, and each woman is not going to respond exactly the same way to each protocol. When we’re able to track what’s happening in the cycle and see in real time how our clients are responding to interventions, we’re able to create a more customized approach for each woman. Not only can we create an initial plan, but as we implement it, we can see how their body is responding in real time based on how their cycle is adjusting — and that means we can course correct as we go.

The data in this study aligns with what we experience when we start using cycle data, because you clearly see that every woman is not having the exact same experience of this.

Another piece of this that was really interesting from the hormonal standpoint was that this study also looked at symptomology. The women who experienced higher levels of estrogen during that period coincided with specific symptoms. This isn’t necessarily surprising, but when we talk about perimenopause, it’s often talked about as a monolith — the story is that our hormones are declining. What we actually see are patterns playing out.

The researchers identified that during the periods when estrogen was at its highest — meaning the women who had rising estrogen followed by either a slow or rapid decline — those times were associated with heavy, prolonged bleeding, breast tenderness, and headaches. During the time these women were experiencing these symptoms, it coincided with when those estrogen levels were extremely high.

When you look at the hypothesis for this change, it’s related to the depletion of the ovarian follicle pool — the ovarian reserve. As the ovaries near the end of cycling, as the pool of follicles starts to dwindle, there are a lot of hormonal changes that essentially trigger our bodies to increase production of follicle-stimulating hormone (FSH). This is thought to trigger excessive estrogen production toward the end of the transition.

Before this phase, when you’re cycling normally and not in perimenopause, every cycle after your period you have a small pool of developing follicles, with normal levels of FSH that gently trigger those follicles to grow and produce small amounts of estrogen until the dominant follicle is chosen. Then you move toward ovulation. But during this perimenopause stage, for the women showing really high levels of estrogen, FSH levels are also really high. One reason estrogen levels rapidly rise during this short portion of the transition is that FSH is over-triggering the follicles. So even with fewer overall follicles, estrogen production is significantly higher because of this hormonal imbalance.

Perimenopause is a normal stage — a normal transition, literally a transition from regular ovulation to depletion. What the research tells us is that when we reach menopause, we typically have about a thousand follicles left, but this process marks the end of normal cycling.

This research points to some differences from what’s commonly talked about. There are a lot of implications here from a practitioner standpoint. If you have training in this area and understand what’s going on within the context of the menstrual cycle, you can train your clients to track their cycles and understand better what’s happening hormonally. You can help them recognize that the phase where estrogen rises significantly is not something that goes on forever — it happens quite close to the end, close to when the ovary is essentially depleted, when the remaining thousand follicles are reached and ovulation is done.

That was a temporary period associated with heightened symptoms. In the perimenopause industry, perimenopause is often taught as though it’s a condition that’s never going to end. What’s missing is an understanding of what’s happening hormonally. Most women never learn how their cycle works in general, how to identify ovulation, or basic cycle information — and of course, we’re not learning about perimenopause either. A lot of the research is aimed at helping pharmaceutical companies provide drug solutions, like everything else.

So where’s the missing piece of education so women can really understand? During this phase, I’d argue it can be an incredible asset for your clients to track their cycles and start to understand what’s happening. For many women during this phase, it’s common for their cycles to change — whether cycles get shorter for a period and then start to lengthen, or whether cycles become irregular and bleeding starts to change, potentially getting heavier, like in our case study example. Either way, charting is the missing piece that helps women know what’s going on and identify any obvious issues to start working on. Even if your client ends up needing hormone therapy to help mitigate symptoms, if she’s able to get a baseline of what’s happening hormonally and apply foundational strategies that support optimal hormone health in this age range, she would likely need less of it and would have a much greater understanding of what’s happening hormonally.

Going back to the case study for a moment — I have, over the years, worked with many clients who experienced this bleeding issue as they got a little older. It doesn’t automatically mean these women were exactly at the last stages where they saw the increase in estrogen. But what we do know is that when you’re working with clients in their 40s who suddenly experience a lot heavier bleeding, that’s typically associated with some sort of hormonal issue — typically unopposed estrogen, or higher levels of estrogen relative to lower levels of progesterone. Even if estrogen itself isn’t high, having irregular cycles — cycles over 35 days combined with a short luteal phase — meaning far more days of estrogen relative to progesterone in the menstrual cycle, can also lead to heavier bleeding.

This points back to the benefit of knowing what’s happening in the cycle to support your client, instead of being in the dark and assuming everything for a woman over 40 is perimenopause. If we’re able to look at her cycle and start to identify and understand what’s going on, we’re not just blaming the boogeyman — we can actually find out what’s happening in her cycle and get a much greater handle on that information, instead of always pointing to perimenopause as the reason for every issue.

There was also one interesting point that stood out to me in the paper. When comparing symptoms and estrogen trajectory, they found a difference between leaner women and women with a higher BMI. Leaner women tended to have more dramatic hormonal changes — the disrupted pattern of estrogen rising and then rapidly or slowly declining was more likely to be seen in lean women, according to these researchers. Women with higher BMI tended to fall more into the flat trajectory category. The researchers hypothesized different reasons for this — one being that adipose tissue produces its own estrogen, which may counter and change how the ovaries respond, leading these women to have more of a flat estrogen trajectory during perimenopause, versus lean women who experienced far wider fluctuations.

This goes a little deeper into the four different categories the researchers identified for how estrogen was presenting. One of those ways was flat and stable — not a lot of ups or downs, but not random either. There was a distinct correlation where women of higher BMI tended to be more likely to have that presentation. Every woman doesn’t have the same experience — this is just one example of factors that differ among women.

When they looked at women of different ethnicities, there were also differences between Black women, white women, and Asian women in terms of how they experience perimenopause.

The purpose of today’s episode is that there’s not going to be just one experience, not just one set of factors. For us as practitioners to support women regardless of these differences, we really want to think about what tools we have at our disposal to help customize the care we’re providing. As someone who has been in the menstrual cycle weeds for many years, I would certainly say that having your clients track their cycles can really be that great differentiator for you in your practice — a tool that allows you to customize, because you can see what’s happening and how your client is responding in real time.

As I bring today’s episode to a close, my summary highlights some of the key points we talked about. One is that what’s happening for women in perimenopause isn’t just a gradual decline in hormones — we actually see different patterns for how this plays out for different women. Some women experience a significant increase in estrogen that correlates with some of their most significant symptoms. The good news is that, at least according to the study, this is a temporary stage — occurring shortly before these women had their last period and met the definition of menopause, which is going one full year between periods.

The other point is that all the data these researchers presented goes to show there is not just one generalized way that women experience this transition. There are a variety of different hormonal trajectories that researchers have found, and likely these four are not the only ones. This should inform our understanding — instead of trying to understand perimenopause as a monolith or assuming women go through this the same way, we should find ways to provide customized care for clients and women dealing with these challenges.

Fortunately, this is exactly what we do in our Fertility Awareness Mastery Mentorship. Head over to the Fertility Awareness Institute website for more information about what we do — that’s fertilityawarenessinstitute.com.

If you’re listening to this in September of 2026, you can still join us in our September group. Make sure to join the waiting list or head over to fertilityfriday.com/FAMMLIVE for additional details about joining us for our September group.

I hope you have a wonderful week, or weekend, whenever you’re tuning into the show. And, as always, until next time — be well and happy charting.