The New Menopause
By Dr Mary Claire Haver – 50 Q&As – Plus a detailed review by Carol Petersen
“The New Menopause” essentially embodies the positions of the Menopause Society, the Endocrine Society and the American College of Obstetrics and Gynecology. These organizations are highly dependent upon PhRMA companies. Their expert committees are always influenced. They have brought us such wisdom as “if you don’t have a uterus, you don’t need progesterone” and “all estrogens are the same” and “bioidentical hormones are a marketing term.”
The medical and scientific literature abounds with deliberate or bought obfuscation making it difficult to sort the truth from the fiction.
Carol Petersen, RPh, CNP
I came across The New Menopause recently. It’s a popular book at the moment.
Carol Peterson and I have done two wonderfully informative interviews:
We agreed to collaborate on a review of this book. I’ve created the Q&As summarizing the book, and Carol has added her thoughts and comments (in italics) at the end of each Q&A.
I’m incredibly appreciative of Carol for helping create this unique book review.
The problem with mainstream medical books is that they include just enough truths and sufficient omissions to shepherd the reader towards an “approved” industrial narrative. That’s how official stories work. The purpose of this collaboration is to help those interested in menopause understand what’s being left out and learn how to navigate the subject matter towards truth.
Gents, this is for you too. Understanding what’s happening with your partner’s body is the first step to being able to support and help.
With much appreciation and gratitude to Carol Peterson.
The Wellness by Design Project - The Wellness By Design Project
50 Questions & Answers plus comments from Carol Petersen (italics)
1. What defines the three stages of menopause and how do they differ from each other?
The menopausal journey consists of perimenopause, menopause, and postmenopause. Perimenopause typically begins in the forties or mid-thirties and lasts an average of four years, marked by irregular periods and hormone fluctuations. Menopause itself is actually just one moment in time - the point when a woman has gone 12 months without a menstrual period, with the average age being 51.
Postmenopause encompasses all the years after that final period, lasting the rest of a woman's life. While symptoms can occur in any stage, they often peak during perimenopause when hormones are most erratic. By 2030, the global population of menopausal and postmenopausal women is projected to reach 1.2 billion, with 47 million new entrants annually.
There is an alarming trend for perimenopausal symptoms to occur much earlier. Younger women who already experience some hormone imbalances are often put off rather than helped. These early symptoms of anxiety and sleep issues can be easily addressed.
2. How do hormone levels change throughout the menopausal transition and what drives these changes?
The primary driver of menopausal changes is declining ovarian function, which leads to decreased production of estrogen, progesterone, and some testosterone. The ovaries begin this decline as they age and deplete their finite supply of follicles. During perimenopause, hormone levels fluctuate dramatically before gradually decreasing, with estrogen levels eventually falling by 85-90% compared to pre-menopausal levels.
This decline isn't linear - levels can spike and plummet unpredictably during perimenopause, which explains why symptoms can be so erratic during this phase. The body attempts to compensate for falling estrogen levels by increasing production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), creating a cascade of hormonal changes that affect multiple body systems.
This book is very estrogen-centric. Dr. Jerilynn Prior The Estrogen Storm Season
Estrogen’s Storm Season: Stories of Perimenopause - The Wellness By Design Project
found that during the perimenopausal years women have the highest estrogen production of their lifespan. Combined with missed ovulations and shortened luteal phases, this makes the imbalance between estrogens and progesterone even more critical. Dr. Prior experienced trouble getting her data published. The prevailing attitude is that estrogen is the most important hormone and causes all the symptoms of peri and menopause. In addition to the perimenopausal increased load of estrogens, we experience additional estrogenic effects from xenoestrogens from plastics, insecticides, herbicides and heavy metals. A disordered microbiome can lead to recycling our own estrogens.
3. What role does estrogen play in the body, and why does its decline impact so many body systems?
Estrogen has receptors throughout almost every organ system in the body, making it far more than just a reproductive hormone. It acts as an anti-inflammatory agent, helps maintain bone density, supports cardiovascular health, aids in cognitive function, maintains skin elasticity, and helps regulate body temperature. When estrogen declines, these protective effects diminish across multiple systems simultaneously.
The loss of estrogen's protective benefits explains why menopause increases risk for conditions like osteoporosis, cardiovascular disease, cognitive decline, and metabolic disorders. This hormone helps maintain everything from collagen production to neurotransmitter function, which is why its decline can trigger such wide-ranging symptoms from hot flashes to mood changes to joint pain.
Certainly estrogen has many beneficial functions and you can identify a lack of estrogen early when the vaginal tissue becomes atrophied and dry. However, progesterone is really the first hormone to drop and when it is replenished estrogen activity is actually improved. A woman may complain of hot flashes early in perimenopause and estrogen has not dropped. Progesterone can quickly resolve hot flashes. This emphasis on estrogen and hot flashes may come from the FDA approval of Premarin for hot flashes. However, Premarin has 60 identified steroidal hormones, some are estrogenic, some androgenic and some progesterone like. Remember that these are pregnant mares and the equine equivalent of progesterone is especially high.
Jerilynn C Prior, Christine L Hitchcock (2012) Progesterone for hot flush and night sweat treatment - effectiveness for severe vasomotor symptoms and lack of withdrawal rebound. Gynecological Endocrinology 28 Suppl 2: 7-11 Oct.
4. Why isn't there a single test that can diagnose perimenopause, and what methods are used instead?
Perimenopause can't be diagnosed with a single test because hormone levels fluctuate so dramatically during this transition that any one-time measurement would be meaningless. Even FSH levels, which generally rise during perimenopause, can vary significantly from day to day or week to week. Instead, diagnosis relies primarily on tracking symptoms and menstrual changes over time.
Healthcare providers typically use tools like the Greene Scale, which evaluates the presence and severity of common symptoms, along with a detailed medical history and symptom journal. Some newer diagnostic approaches include serial urine testing over multiple days combined with symptom tracking apps, but these are still being validated. The lack of a definitive test often leads to delayed diagnosis and treatment.
Dr. Ray Peat describes using prolactin to assess estrogen status. Absent a tumor in the pituitary gland, high prolactin levels indicate high estrogen, low thyroid activity. Ideally prolactin is at midrange and progesterone is effective in lowering prolactin. Women who have had surgical removal of the uterus and ovaries are given estrogen only as hormone therapy and urged to continue to use estrogen to protect the bones. However, high prolactin can increase parathyroid hormone which will then increase pulling calcium from the bones.
5. How does the timing of menopause affect a woman's health risks?
The age at which a woman experiences menopause significantly impacts her health risks, with early menopause (before age 45) associated with increased risks for multiple conditions. Research shows that women who experience early menopause have higher risks for cardiovascular disease, osteoporosis, cognitive decline, and overall mortality compared to women who reach menopause at the typical age of 51.
Conversely, later menopause (after age 55) is associated with longer life expectancy and lower risks for certain conditions, likely due to extended exposure to estrogen's protective effects. However, later menopause may slightly increase risks for certain hormone-sensitive cancers. The timing of menopause can influence treatment decisions, particularly regarding hormone therapy, as earlier menopause often creates a stronger case for hormone replacement.
It would make sense that the longer a woman has a menstrual cycle which includes ovulation and the release of abundant amounts of progesterone from the corpus luteum, the better off she would be. Rather than create a construct about “timing” it is more important to pay attention to the signs and symptoms of low hormones and proceed accordingly. Bioidentical hormone support is a pillar of the medical groups concerned about successful aging.
6. What are the key differences between natural menopause and surgical menopause?
Natural menopause allows for a gradual transition as hormone levels slowly decline over several years, giving the body time to adapt. In contrast, surgical menopause, caused by removal of both ovaries (oophorectomy), creates an immediate and dramatic drop in hormone levels. This sudden change can lead to more severe symptoms and greater health risks, including a 28% increase in overall mortality rate if left untreated.
Surgical menopause also carries specific risks that natural menopause doesn't: a 33% increase in heart disease rates, 62% increase in stroke risk, 60% increase in cognitive impairment risk, and 50% increase in osteoporosis risk. These heightened risks make hormone therapy especially important for women who undergo surgical menopause before the natural age of menopause, unless there are specific contraindications.
In the US 600,000 to 700,000 hysterectomies are performed yearly. Most of these hysterectomies are based on long term progesterone deficits. (see hysterectomy substack). Women are often left unassisted until their symptoms are unbearable. They are promised a hysterectomy will solve all their problems but the reality is that the old imbalances are still there and the surgery causes new problems.
7. How do genetics and family history influence menopausal timing and symptoms?
Genetics serve as the primary influence on when a woman will experience menopause, with family history being the strongest predictor of menopausal timing. Women often experience menopause around the same age as their mothers and sisters, and the genetic variants linked to later menopause have also been connected to longer life expectancy, highlighting the profound influence of genetics on reproductive aging.
Beyond timing, genetic factors can also influence symptom severity and specific health risks during menopause. For example, women with certain genetic variants may be more susceptible to bone loss or cardiovascular changes during menopause. Family history of conditions like osteoporosis or heart disease becomes especially relevant during the menopausal transition when estrogen's protective effects diminish.
It is no longer your mother’s menopause. We know that 90% of genetic expression relies upon the environment (epigenetics). It’s time to stop believing that we are fatally tied to our DNA and nothing can be done. Our mothers never had the chemicalization of our air, water and food we have now. Women who reach menopause who are symptomatic are really in “adrenopause”. After the ovarian cycles stop, the adrenal hormones provide the sex hormone functions. When we reach menopause with the adrenal hormones depleted, we essentially hit the wall.
8. What makes the timing hypothesis important in understanding menopause treatment?
The timing hypothesis suggests there's a critical window during which hormone therapy provides the greatest benefits with the least risks. This window is typically within ten years of menopause onset or before age 60. Research has shown that women who start hormone therapy during this window experience significantly better outcomes, particularly regarding cardiovascular and cognitive health.
Understanding the timing hypothesis has revolutionized how healthcare providers approach hormone therapy. Women who start hormone therapy early in menopause show reduced risks of heart disease, cognitive decline, and overall mortality compared to those who start later. However, beginning hormone therapy more than ten years past menopause may actually increase certain health risks, making the timing of treatment initiation crucial for optimal outcomes.
The so called “Timing Hypothesis” restricts the use of “hormones” after 10 years post menopause. This hypothesis was based on data from the Women’s Health Initiative. The Women’s Health Initiative used Premarin and medroxyprogesterone acetate as the “hormone therapy”. Premarin is a collection of many steroids and is not just estrogenic. The physiology is appropriate for horses but not humans. The horse estrogens equilen and equilenen accumulate in the human body since these are foreign chemicals. Medroxyprogesterone acetate is altered from progesterone and has been implicated in producing strokes. We spent a lot of taxpayer money examining the consequences of using chemicals which do not belong in the human body. We should restrict the use of these drugs. Premarin and medroxyprogesterone acetate should have no place in treating age related hormone deficiencies.
9. How do androgens (testosterone) affect women during menopause?
Women's bodies produce androgens, including testosterone, primarily in the ovaries and adrenal glands. During menopause, androgen levels typically decline, though not as dramatically as estrogen. This decline can contribute to decreased libido, reduced muscle mass, and changes in energy levels. However, some women may experience a relative increase in androgenic effects due to the more dramatic drop in estrogen, leading to symptoms like unwanted hair growth or acne.
The role of testosterone replacement in menopausal women remains controversial, largely due to limited FDA-approved options for women. While some studies show benefits for sexual function, muscle mass, and energy levels, concerns exist about proper dosing and long-term safety. Current evidence suggests that physiologic testosterone replacement may help some women with specific symptoms, but requires careful monitoring and individualized dosing.
The FDA has twice refused to approve testosterone products for women. So practitioners who wish to help their patients have to use smaller doses of the products approved for men or have testosterone prepared by a compounding pharmacy. Progesterone is the most abundant sex hormone in women, followed by testosterone and then estrogen. Testosterone is critically important for all protein synthesis in the body. Oddly this book as well as others imply that only estrogen is critical. Testosterone can be the solution for urinary tract leakage common in perimenopause and menopause, relief from pain in the vestibule of the vagina and prevent the atrophy of the clitoris. Susan Davis from Australia has produced a large volume of studies on testosterone in women which does not apply in the US. Ironically, the FDA had no problem continuing the sale of Premarin MT (methyltestosterone) and similarly Estratest when the methyltestosterone had been shown to be highly liver toxic. The spectre of this liver toxicity still remains and wrongly applied to testosterone when it was the altered chemical methyltestosterone that produced the damage.
Research Excellence: trialling women's testosterone therapy | NHMRC
10. Why do some women experience menopause earlier than others?
Early menopause can result from various factors, including genetic predisposition, autoimmune conditions, exposure to toxins, or medical treatments like chemotherapy. Lifestyle factors such as smoking, certain medications, and being underweight can also contribute to earlier onset. Additionally, having never given birth or experiencing menarche before age 11 significantly increases the risk of early menopause.
Medical procedures, particularly those affecting the ovaries or uterus, can trigger early menopause. Even a hysterectomy that preserves the ovaries can lead to menopause about 4.4 years earlier than average due to disrupted blood flow to the ovaries. The impact of early menopause makes it crucial to identify risk factors and implement appropriate preventive strategies, especially regarding bone and cardiovascular health.
Reiterating. Symptoms of menopause are really “adrenal pause”. When the body suffers so much stress, hormone production is compromised.
11. What distinguishes normal aging symptoms from menopausal symptoms?
While aging and menopause can share some common symptoms, menopausal symptoms typically appear more suddenly and cluster together during the perimenopausal transition. The key difference lies in the underlying cause - menopausal symptoms result directly from declining estrogen levels rather than the gradual physical changes of aging. For example, while muscle mass naturally decreases with age, the accelerated loss during menopause is specifically tied to hormonal changes.
Many symptoms mistakenly attributed to normal aging - such as joint pain, cognitive changes, or skin alterations - may actually be driven by menopause-related hormone fluctuations. The distinction becomes clear when considering that hormone therapy often improves these symptoms, indicating their hormonal rather than purely age-related origin. Understanding this difference is crucial because it opens up treatment options that wouldn't be relevant for normal aging processes.
During the menopause transition, many hormone systems are involved. This is not just declining estrogen. Progesterone declines first, adrenal DHEA steadily declines from its highest during the 20’s, insulin and glucose become dysregulated, bile is not produced properly, testosterone declines, cortisol may be high for a while and then drop, vitamin D may be depleted. Thyroid and the metabolic rate declines and pituitary hormones TSH, LH and FSH which are inflammatory increase. It is a huge mistake to put all attention to estrogen which is just a piece of a much bigger puzzle.
12. How do the different types of hormone therapy compare in terms of risks and benefits?
Hormone therapy comes in various forms, from oral pills to transdermal patches, gels, and vaginal preparations. Oral estrogens pass through the liver first, which can increase clotting risks and affect blood pressure. Transdermal options bypass this "first-pass effect," potentially offering a safer cardiovascular profile. Local vaginal preparations, while effective for genitourinary symptoms, don't provide the systemic benefits that might be needed for other symptoms.
The choice of progesterone type also matters significantly. Synthetic progestins may carry different risks than bioidentical progesterone, particularly regarding breast health and mood effects. Compounded hormone preparations offer customization but lack the rigorous quality control of FDA-approved products. The optimal choice depends on individual factors including symptoms, risk factors, and personal preferences.
It becomes very easy to address hormone deficiencies when using only the hormones with the same molecular configuration as the human body makes. There is a lot of money spent to convince people that the altered chemicals are safe. A simple rule of thumb to never put foreign chemicals masquerading as hormone therapy into the human body can eliminate much of the mismanagement of hormone deficiencies.
13. What are the key differences between bioidentical and synthetic hormone treatments?
Bioidentical hormones are structurally identical to those naturally produced by the body, typically derived from plant sources and modified in laboratories. These molecules match human hormones exactly, potentially allowing for more natural interaction with hormone receptors. Synthetic hormones, while similar, have chemical structures that differ from natural hormones and may interact differently with body systems.
FDA-approved bioidentical hormones offer standardized doses with proven safety profiles, while compounded bioidentical preparations provide customization but less consistency and oversight. Both types can effectively treat menopausal symptoms, but their different molecular structures may influence side effects and risk profiles. The choice between them often depends on individual response, availability, and cost considerations.
There is no sound reason to use anything other than bioidentical hormones. This author takes considerable time to criticize compounded hormone preparations. This language is directly from the PhARMA run groups mentioned above in their position papers. Compounding pharmacies are the most regulated part of the medical profession and are often required to adhere to standards more stringent than the FDA approved manufactured products. Dr. Haver’s own medical office would likely fail to meet the standards that compounding pharmacies must do.
14. Why might some women not be candidates for hormone therapy?
Clear contraindications for hormone therapy include current or suspected breast cancer, recent arterial thrombotic disease, undiagnosed abnormal genital bleeding, and active severe liver disease. Women with a history of estrogen-sensitive cancers or blood clotting disorders typically cannot safely use systemic hormone therapy, though vaginal estrogen might still be an option.
However, many commonly cited exclusions are actually misconceptions. For example, a family history of breast cancer or cardiovascular disease doesn't automatically disqualify someone from hormone therapy. The decision requires careful individual risk assessment, considering factors like age, time since menopause, specific health conditions, and personal preferences.
All of these cautions should not be considered absolutes. Until the whole metabolic profile is taken into consideration and relationships between hormones are considered, then there may be a cautionary time. However, when throwing off the burden of synthetic analogues of hormones, there are much fewer issues to consider.
15. How has the understanding of hormone therapy safety evolved since the Women's Health Initiative study?
The initial interpretation of the WHI study in 2002 led to widespread abandonment of hormone therapy due to perceived cancer and cardiovascular risks. However, subsequent analysis revealed that the risks were overstated and heavily influenced by the age and health status of study participants, who were on average 63 years old - much older than typical hormone therapy users.
Modern understanding emphasizes the "timing hypothesis" - that hormone therapy started within 10 years of menopause onset or before age 60 generally provides more benefits than risks. The absolute risk increases found in the WHI were actually quite small, and newer studies show potential benefits for bone health, cardiovascular disease prevention, and cognitive function when therapy is appropriately timed.
The Women’s Health Initiative left us with a lot of data for drugs that should not be used in the human body. It’s a pity that medical practitioners completely abandon their premed training in physiology and biochemistry and accept the lies and fiction repackaged as standard of care.
16. What role do supplements and alternative treatments play in managing menopause symptoms?
Supplements and alternative treatments can provide support for specific menopause symptoms, particularly for women who cannot or choose not to use hormone therapy. Evidence supports the use of certain supplements like omega-3 fatty acids for inflammation, vitamin D and calcium for bone health, and specific probiotics for metabolic health. However, supplement quality and purity vary significantly, making careful product selection important.
Many alternative treatments lack strong scientific evidence but may still offer benefit through lifestyle modification or placebo effects. The most reliable non-hormonal options typically combine multiple approaches, including dietary changes, exercise modifications, and stress management techniques. These can be used alone or as complementary treatments alongside conventional medical approaches.
Practitioners rarely spend time enough to teach these approaches. But readers are cautioned to use alongside conventional therapies.
17. How do delivery methods for hormone therapy differ and why does this matter?
Hormone therapy delivery methods include patches, gels, creams, oral pills, vaginal rings, and pellets, each with distinct advantages and considerations. Transdermal methods (patches, gels) bypass liver metabolism, potentially reducing clotting risks and providing more stable hormone levels. Oral medications offer convenience but undergo first-pass liver metabolism, which can affect their risk profile.
Local treatments like vaginal rings or creams provide targeted relief for genitourinary symptoms with minimal systemic absorption. The choice of delivery method can significantly impact treatment success and side effects. Factors like skin sensitivity, absorption rates, convenience, and cost all play roles in determining the most appropriate delivery method for each individual.
When hormones are applied locally into the blood stream, the area near the application site has the greatest concentration of hormone to use. Avoiding the first liver pass has nothing to do with protecting the liver. It is an opportunity to get more active ingredient into the body than the oral absorption would allow. You can protect the liver by avoiding using foreign chemicals.
18. What are the most effective strategies for managing hot flashes and night sweats?
Management of vasomotor symptoms requires a multi-faceted approach, with hormone therapy being the most effective treatment when appropriate. For women using hormone therapy, relief often occurs within weeks. Environmental modifications like keeping the bedroom cool, using layered clothing, and avoiding trigger foods (spicy foods, alcohol, caffeine) can provide additional relief.
Non-hormonal medications like certain antidepressants, gabapentin, or the newer neurokinin 3 receptor antagonists can help when hormone therapy isn't an option. Lifestyle modifications including regular exercise, stress reduction techniques, and dietary changes may also reduce frequency and severity of hot flashes. Cognitive behavioral therapy has shown promise in helping women cope with these symptoms.
Dr. Jerilynn Prior just published a paper (cited above) on the effectiveness of progesterone with vasomotor symptoms. The vasomotor symptoms show up when progesterone starts to fall. Adrenal instability and insulin glucose swings are also involved. Vasomotor issues are very easy to correct and will disappear quickly.
19. How does menopause affect bone health and what are the best preventive strategies?
The dramatic decline in estrogen during menopause accelerates bone loss, as estrogen plays a crucial role in maintaining bone density. Women can lose up to 20% of their bone mass in the five to seven years following menopause, significantly increasing fracture risk. This loss occurs because estrogen helps regulate the balance between bone breakdown and formation.
Prevention requires a comprehensive approach including adequate calcium and vitamin D intake, regular weight-bearing exercise, and resistance training. Hormone therapy, when started early in menopause, can help prevent bone loss and reduce fracture risk by 20-40%. Regular bone density screening becomes crucial during this time, and additional medications may be needed for women at high risk for fractures.
Dr. Jerilynn Prior’s (cemcor.ca) work on osteoporosis in young female athletes demonstrates how important hormones are. Progesterone is particularly important by stimulating osteoblast driven new bone. By nourishing the body with the hormones that have become deficient along with ensuring all the raw ingredients of protein and minerals are ingested, digested and are available is another key to restoring not only the bones but the entire body. Alan Gaby “Preventing and Reversing Osteoporosis”. The biphosphanate class of drugs is extremely debilitating. These drugs are designed to freeze bone remodeling leaving only old bone which can splinter and break easily. Another class of drugs called proton pump inhibitors designed to turn off stomach acid production inhibit the breakdown of dietary protein and stop the absorption of minerals.
20. What causes the changes in body composition during menopause and how can they be managed?
Menopausal body composition changes result from hormonal shifts that affect fat distribution and muscle mass. Declining estrogen levels tend to promote visceral fat accumulation in the abdomen, while simultaneously reducing muscle mass and bone density. This shift occurs even without weight gain and can increase risks for metabolic disorders and cardiovascular disease.
Managing these changes requires increased focus on protein intake (1.2-1.6 grams per kilogram of body weight daily) and regular resistance training to maintain muscle mass. Hormone therapy may help prevent visceral fat accumulation when started early in menopause. Additionally, maintaining an anti-inflammatory diet and regular physical activity can help minimize unfavorable body composition changes.
What comes first? Metabolic disorder or hormone deficiencies? With drops in blood glucose, adrenaline is pumped out to restore the glucose to the brain. Cortisol can follow and is perhaps a moderator of excess adrenaline. These high cortisol levels are also thought to increase the visceral fat. In this unbalanced situation, progesterone is lost to cortisol, thyroid function is suppressed, androgen hormones such as testosterone are suppressed and estrogen becomes dominant. Dominant estrogen promotes fat cell storage and fluid retention. Encouraging the use of estrogen without the consideration of the metabolic effects of all the hormones is irresponsible.
21. How does menopause impact cardiovascular health and what preventive measures are recommended?
Declining estrogen levels during menopause significantly affect cardiovascular health by altering cholesterol profiles, blood vessel function, and inflammation levels. Women often experience increases in LDL (bad) cholesterol and decreases in HDL (good) cholesterol during the menopausal transition. This shift, combined with the loss of estrogen's protective effects on blood vessels, can accelerate the development of cardiovascular disease.
Prevention requires a multi-faceted approach including regular monitoring of cardiovascular markers like blood pressure, cholesterol, and inflammatory indicators. Early intervention through lifestyle modifications such as regular exercise, an anti-inflammatory diet, and stress management is crucial. For appropriate candidates, starting hormone therapy within ten years of menopause onset can provide significant cardiovascular protection, reducing heart disease risk by up to 40% in some studies.
Testosterone and thyroid are likely to be the most protective of the cardiovascular system. You can monitor cardiac markers all you want but if you miss the mark on not considering the entire metabolic system nothing is gained. Since the FDA refused to approve testosterone supplementation for women and the Endocrine Society has a history of sanctioning doctors who try to genuinely help patients with insufficient thyroid activity, emphasizing estrogen treatment over considering the whole picture is flawed.
22. What approaches are most effective for addressing sexual health changes during menopause?
Sexual health changes during menopause often involve multiple factors including vaginal dryness, decreased libido, and pain during intercourse. Local estrogen treatments can effectively address vaginal tissue changes and dryness, while systemic hormone therapy may help with broader symptoms including decreased desire. Regular sexual activity itself helps maintain vaginal health by improving blood flow and elasticity.
Beyond hormonal approaches, addressing psychological and relationship factors is crucial. Open communication with partners, use of lubricants and moisturizers, and pelvic floor physical therapy can all contribute to maintaining sexual health. Some women may benefit from testosterone therapy for libido issues, though this requires careful monitoring and individualized dosing.
Estriol is the most effective estrogen for vaginal dryness. Using 0.5 mg to 1 mg daily in the vaginal area can be restorative quickly. Estriol is provided by compounding pharmacies and some nonprescription products. DHEA in doses around 12 mg has been shown to be effective. Testosterone is hugely important. The vestibule of the vagina is the same as the urinary tract tissue and has large numbers of testosterone receptors. Local application of testosterone can relieve pain issues at the mouth of the vaginal, stop urinary leakage and restore an atrophied clitoris.
23. What are the most important questions to ask when selecting a menopause healthcare provider?
Essential questions should focus on the provider's experience and approach to menopause care, including their familiarity with current research and various treatment options. Key inquiries should cover their experience prescribing hormone therapy, their approach to symptom management, and their philosophy on shared decision-making. Understanding their menopause-specific training and certification status through organizations like the Menopause Society can provide insight into their expertise.
The provider's willingness to discuss multiple treatment approaches and their communication style are equally important. Questions about their typical treatment protocols, monitoring practices, and availability for follow-up care help ensure comprehensive support. Additionally, understanding their approach to non-hormonal treatments and lifestyle modifications can indicate whether they offer truly individualized care.
When I counsel women, I remind them to demand 100%. The question I would ask is how many women have you restored to full quality of life and prepared them for healthy aging? I wrote a blog about the tyranny of flow chart medicine.I don’t care what typical treatment protocols are. That this exists is a red flag.
Symptoms of Progesterone Deficiency - The Wellness By Design Project
24. How can women advocate for themselves effectively in medical settings during menopause?
Effective self-advocacy starts with thorough symptom documentation using tools like the Greene Scale and symptom journals. Preparing specific questions, bringing copies of relevant medical research, and clearly articulating treatment goals helps ensure productive medical appointments. Knowledge of current menopause guidelines and treatment options enables women to engage in informed discussions about their care.
Being persistent while maintaining professional communication is crucial, especially if initial interactions are dismissive. Seeking second opinions when necessary and being prepared to switch providers if current care is inadequate represents appropriate self-advocacy. Understanding insurance coverage and treatment costs also helps in advocating for preferred treatment options.
The most important thing is that women take charge of themselves. We have sadly been trained to give away so called health care to practitioners. When we have been in our bodies for decades it would be desirable to be able to observe and identify what is awry and know what to do accordingly.
25. What blood tests and screenings are most important during the menopausal transition?
Essential screenings during menopause include comprehensive metabolic panels, lipid profiles, thyroid function tests, and vitamin D levels. More specific tests like bone density scans become increasingly important, particularly for women at higher risk for osteoporosis. Advanced cardiovascular screening, including markers like ApoB and Lp(a), can provide deeper insight into heart disease risk.
Regular monitoring of inflammatory markers and blood sugar levels helps track metabolic health changes. While hormone level testing isn't typically useful for diagnosing perimenopause due to fluctuating levels, baseline hormone panels may be helpful when starting treatment. Screenings should be individualized based on personal and family history, symptoms, and risk factors.
Evaluating the entire hormone system and many of these tests should happen at the first sign of perimenopause. Discomfort caused by hormone deficiencies can be easily corrected and decades of misery averted.
26. How can women determine if they're candidates for hormone therapy?
Candidacy for hormone therapy depends on various factors including age, time since menopause onset, personal and family medical history, and current health status. The timing hypothesis suggests optimal benefits occur when therapy starts within ten years of menopause onset. Absolute contraindications include current breast cancer, recent blood clots, unexplained vaginal bleeding, or severe liver disease.
The decision requires careful consideration of individual risk factors and symptoms. Women should discuss their complete medical history, current symptoms, and treatment goals with their healthcare provider. Understanding both the potential benefits and risks allows for informed decision-making about whether hormone therapy is appropriate.
Left out of this equation is how risky it is to turn to altered chemicals to mimic the real hormones.
27. What role do primary care physicians versus specialists play in menopause care?
Primary care physicians often serve as the first point of contact for menopause-related concerns and can manage many common symptoms. However, their training in menopause care may vary significantly, and some may not feel comfortable managing hormone therapy or complex cases. They play an important role in coordinating care and managing overall health during the menopausal transition.
Specialists like gynecologists or certified menopause practitioners typically have more extensive training in hormone therapy and managing complex menopause-related issues. They often become involved when symptoms are severe, when hormone therapy is being considered, or when complications arise. The ideal scenario often involves collaboration between primary care and specialist providers.
Notice that collaboration with the individual is not included here. Practitioners do not want patients who demand to leave the flow chart they have created.
28. How should women prepare for their first menopause-related medical appointment?
Preparation should include detailed documentation of symptoms, their timing, and severity using tools like symptom diaries or the Greene Scale. Gathering a complete family medical history, particularly regarding cardiovascular disease, osteoporosis, and cancer, provides crucial context. Creating a list of current medications, supplements, and previous treatments attempted helps inform treatment planning.
Writing down specific questions and concerns ensures nothing is forgotten during the appointment. Bringing records of recent medical tests, information about menstrual patterns, and notes about lifestyle factors like diet and exercise helps create a comprehensive picture. Setting clear goals for the appointment and being ready to discuss treatment preferences facilitates productive dialogue.
Many women turn to their practitioners at the first sign of troubling symptoms at perimenopause. Most leave their appointments with no guidance and instruction. Understanding and treating menopause should start early.
29. What documentation should women maintain about their symptoms and experiences?
Comprehensive symptom tracking should include the type, frequency, and severity of symptoms, noting any patterns or triggers. Recording menstrual cycles, including changes in flow and timing, provides valuable information during perimenopause. Documenting the impact of symptoms on daily life, work performance, and relationships helps demonstrate their significance to healthcare providers.
Maintaining records of treatments tried, their effectiveness, and any side effects experienced creates a useful history for future care decisions. Tracking lifestyle factors like sleep patterns, exercise, diet, and stress levels can help identify connections between behaviors and symptom severity. Regular updates to this documentation support better treatment outcomes and help monitor progress over time.
The most important aspect is the “here and now”. What are you experiencing as uncomfortable? What are you doing about it now?
30. How can women navigate insurance coverage for menopause treatments?
Understanding insurance coverage for different treatment options, including hormone therapy, requires reviewing plan documents and often directly communicating with insurance providers. Many FDA-approved hormone treatments are covered by insurance, while compounded preparations typically require out-of-pocket payment. Knowing which specific tests and treatments are covered helps in planning care and managing costs.
Working with healthcare providers to properly document medical necessity can improve coverage likelihood. Understanding prior authorization requirements and appeal processes helps navigate denials. Exploring alternative payment options, including manufacturer discount programs or mail-order pharmacies, can help manage costs when insurance coverage is limited.
This is another huge problem with our medical system. We now only give our health care away to practitioners; we give it away to faceless business people to determine our choices or lack thereof. Sometimes, in order to improve our quality of life, we have to leave this system and be prepared to pay for the help we want. If you don’t have your health, you have nothing.
31. What dietary changes are most beneficial during menopause?
Anti-inflammatory nutrition becomes crucial during menopause to help counter the systemic inflammation that occurs with declining estrogen. The focus should be on consuming adequate protein (1.2-1.6 grams per kilogram of body weight), increasing fiber intake to at least 25 grams daily, and emphasizing foods rich in omega-3 fatty acids, antioxidants, and polyphenols. Foods like leafy greens, fatty fish, berries, nuts, and seeds provide essential nutrients that support metabolic health.
Limiting added sugars, processed foods, and excessive alcohol helps manage weight and reduce inflammation. Some women benefit from intermittent fasting approaches, which research suggests may help reduce visceral fat and improve insulin sensitivity. Timing of meals and protein intake becomes increasingly important for maintaining muscle mass and managing body composition changes.
It seems odd that we as human beings have survived so long and don’t know how we should nourish our bodies. It is important to have adequate protein intake to maintain our bodies. We have to ensure our digestive systems work as designed. We should not have to make dietary changes when we get to menopause. We should be feeding ourselves in the best possible manner our entire lifespan.
32. How should exercise routines be modified during menopause?
Exercise during menopause should prioritize resistance training to maintain muscle mass and bone density, which naturally decline with decreasing estrogen levels. A minimum of three strength-training sessions per week, focusing on progressively increasing loads, helps counter these losses. This should be combined with regular cardiovascular exercise for heart health and metabolic benefits.
Balance training becomes increasingly important to prevent falls and maintain functionality. High-intensity interval training can be particularly effective for managing weight and improving insulin sensitivity. However, exercise intensity and duration should be balanced with recovery needs, as hormonal changes can affect exercise tolerance and recovery time.
Here is another area where estrogen is getting emphasized but it is the androgenic hormones like DHEA, testosterone and growth hormone which become deplete and affect our body’s ability to continue remodeling itself. It’s important to explore the big picture of all the hormone systems and use your body accordingly.
33. What sleep strategies work best for managing menopause-related insomnia?
Creating an optimal sleep environment becomes crucial during menopause, with room temperature being particularly important (between 60-67 degrees Fahrenheit). Establishing consistent sleep and wake times helps regulate circadian rhythms, while avoiding blue light exposure from electronic devices for two hours before bedtime can improve sleep quality. Using lightweight, breathable bedding and sleepwear helps manage night sweats.
Cognitive behavioral therapy for insomnia (CBT-I) shows significant effectiveness in improving sleep quality. Stress reduction techniques, such as meditation or deep breathing exercises, can help calm an overactive mind. For some women, supplements like magnesium or prescription medications may be necessary, but these should be discussed with healthcare providers.
It’s odd that the sleep restoring hormone progesterone is not even mentioned here. Having trouble sleeping can occur early in perimenopause and easily restored with progesterone or correcting insulin glucose imbalance or thyroid deficiencies.
34. How does stress affect menopausal symptoms and what management techniques are most effective?
Stress during menopause can exacerbate symptoms by increasing cortisol levels, which can worsen hot flashes, sleep disturbances, and mood changes. High stress levels also contribute to inflammation and metabolic disruption, potentially increasing visceral fat accumulation and insulin resistance. The body's stress response becomes more sensitive during menopause due to changing hormone levels.
Effective stress management requires a multi-faceted approach including regular physical activity, mindfulness practices, and adequate sleep. Setting boundaries, prioritizing self-care, and seeking social support help manage emotional stress. Some women benefit from professional counseling or stress-reduction techniques like yoga, meditation, or breathing exercises.
Women can be too stressed to use all these techniques. One of the greatest offenders is insulin resistance which spurs on adrenaline excesses. Adrenaline Dominance by Michael Platt. Poor detoxification of adrenaline leads to persistence of anxiety, panic, and sleep disorders.
35. What role does protein intake play in maintaining health during menopause?
Protein becomes increasingly important during menopause for maintaining muscle mass, supporting bone health, and managing weight changes. The recommended intake increases to 1.2-1.6 grams per kilogram of ideal body weight daily, significantly higher than general adult recommendations. Protein helps preserve lean tissue during weight loss and supports recovery from exercise.
Distribution of protein throughout the day matters as much as total intake. Consuming 20-30 grams of protein per meal optimizes muscle protein synthesis. Sources should include both animal and plant proteins to ensure a complete amino acid profile and provide various nutrients. Higher protein intake also helps manage appetite and maintain stable blood sugar levels.
Protein intake is critical and so is the ability to digest it. Many have digestive issues so they turn to carbohydrates as their energy source. It’s not enough to say, “eat more protein”.
36. How can women maintain cognitive function during the menopausal transition?
Maintaining cognitive function requires a comprehensive approach focusing on brain health through lifestyle modifications. Regular physical exercise, particularly aerobic activity, supports brain blood flow and neuroplasticity. A Mediterranean-style diet rich in omega-3 fatty acids, antioxidants, and anti-inflammatory compounds helps protect brain tissue from oxidative stress and inflammation.
Social engagement, intellectual stimulation, and learning new skills help maintain cognitive reserve. Adequate sleep becomes crucial for memory consolidation and cognitive restoration. For some women, hormone therapy started early in menopause may offer cognitive protection, particularly for those at higher risk for neurodegenerative conditions.
There are so many issues that can disturb brain function. Dale Bredesen documents about 32 reasons for dementia and Alzheimer’s in his book The End of Alzheimer’s Identifying and replenishing all declining hormones is just one of these.
37. What lifestyle modifications help prevent weight gain during menopause?
Preventing menopausal weight gain requires proactive strategies focusing on both diet and exercise. Regular strength training helps maintain muscle mass and metabolic rate, while high-intensity interval training can be particularly effective for fat loss. Protein intake should be increased to support muscle maintenance, and meal timing may need adjustment to optimize metabolism.
Managing stress and sleep quality becomes crucial as both affect appetite hormones and metabolism. An anti-inflammatory diet emphasizing whole foods while limiting processed carbohydrates and added sugars helps prevent insulin resistance. Some women benefit from specific eating patterns like time-restricted feeding or Mediterranean-style diets.
A complete metabolic panel including all the hormone systems can point out the specific reasons each person is experiencing provoking weight gain. Before diets and exercise, correcting the hormone imbalance and other metabolic insufficiencies that created the problem in the first place should be foundational.
To Test or Not to Test? - The Wellness By Design Project
38. How can women protect their bone health through lifestyle choices?
Bone health protection requires a combination of proper nutrition and weight-bearing exercise. Calcium intake from food sources should be optimized, aiming for 1,000-1,200 mg daily, while vitamin D levels need regular monitoring and supplementation as needed. Weight-bearing exercises and resistance training provide crucial mechanical stress that stimulates bone formation.
Avoiding smoking and limiting alcohol consumption helps prevent bone loss. Fall prevention strategies become increasingly important, including balance training and home safety modifications. Regular bone density screening helps track changes and allows for early intervention when needed.
This is simplistic and ignores all the body systems that can degenerate and start failing to keep your body intact. A thorough review of all the hormone systems, blood chemistry, blood differential, lipids, iron metabolism, and inflammatory markers can help identify what areas need attention.
Comprehensive Wellness by Design Female Panel- Discounted Labs
39. How does early menopause differ from menopause at the typical age?
Early menopause, occurring before age 45, carries increased health risks due to premature loss of estrogen's protective effects. These women face higher risks for cardiovascular disease, osteoporosis, cognitive decline, and overall mortality compared to women reaching menopause at the typical age. The psychological impact can be significant, particularly for women still considering pregnancy.
Treatment approaches often differ for early menopause, with hormone therapy typically strongly recommended unless contraindicated. The duration of treatment may be longer, extending until the natural age of menopause. More intensive monitoring and preventive care may be needed to manage increased health risks.
Increased health risks occur when women are ignored when they report early disturbing symptoms and are dismissed. Each woman should be evaluated as the individual she is and correct the imbalances and deficiencies that have come up.
40. What special considerations exist for cancer survivors regarding menopause treatment?
Cancer survivors face unique challenges in managing menopause, particularly those with hormone-sensitive cancers. Treatment options depend on cancer type, stage, and time since diagnosis. While systemic hormone therapy may be contraindicated for some, local treatments for specific symptoms might still be appropriate. Each case requires careful individual risk assessment and close coordination between oncology and menopause care providers.
Non-hormonal approaches become particularly important for this group, including lifestyle modifications, specific medications for symptom relief, and complementary therapies. Regular monitoring for both menopausal symptoms and cancer recurrence is essential. Support for psychological aspects of managing both cancer survivorship and menopause often proves crucial.
This question is very problematic because very little has been studied. Dr. Avril Bluming in Estrogen Matters reports that even using Premarin and Provera are superior to nothing at all 5 years after breast cancer treatment. Our current medical protocols give a blanket warning to avoid all hormone therapies without sufficient documentation as well.
Breast Cancer Resources - The Wellness By Design Project
41. How should BRCA carriers approach menopause management?
BRCA carriers face complex decisions about menopause management, particularly regarding hormone therapy. Research shows that BRCA carriers who undergo risk-reducing bilateral salpingo-oophorectomy (RRBSO) before natural menopause can safely use hormone therapy until the average age of menopause without increasing breast cancer risk. The benefits of hormone therapy in this group often outweigh risks, as early surgical menopause can significantly impact quality of life and health outcomes.
The timing and type of hormone therapy require careful consideration based on individual risk factors and whether preventive surgeries have been performed. Regular screening and monitoring become especially important, and treatment plans often need adjustment over time. A comprehensive approach including lifestyle modifications, bone health protection, and cardiovascular risk management is essential.
The emphasis on “risks” involved with BRCA genes comes into question when research shows that the genes do not initiate cancer and that cancers are 90% linked with epigenetics. This BRCA gene spectre generates income for the cancer industry and involves extensive mutilation to heathy women and should be suspect.
42. What workplace accommodations might be helpful during menopause?
Workplace accommodations during menopause might include temperature control options, flexible work schedules to accommodate sleep disruption, and access to cool drinking water and rest facilities. Research shows that menopausal symptoms contribute to productivity losses of over $150 billion globally, making workplace support both an employee wellness and business performance issue.
More employers are beginning to implement menopause policies that include manager training, access to fans or temperature controls, flexible working arrangements, and educational resources. These accommodations can help maintain workplace performance while supporting women through the menopausal transition. Some companies also provide access to occupational health services or employee assistance programs specifically trained in menopause support.
That the menopause transition causes so much disfunction that workplaces consider accommodation serves to illustrate how much our medical system fails women. Better information and care for women transitioning would avoid all these issues.
43. How can women manage menopause symptoms while maintaining professional performance?
Managing menopause symptoms in the workplace requires proactive strategies and planning. This might include keeping a change of clothes at work, scheduling important meetings during peak energy times, and using stress management techniques throughout the day. Documentation of symptoms and their impact on work can help when discussing accommodations with supervisors or healthcare providers.
Professional performance can be maintained through strategies like breaking tasks into smaller segments, using memory aids or organizational tools, and scheduling regular breaks. Some women find that discussing their experience with trusted colleagues creates understanding and support. Seeking appropriate medical treatment, including hormone therapy when suitable, can significantly improve workplace functioning.
This is accommodating for health disturbances that in reality can be easily remedied again speaks to the failure of our medical system.
44. What unique challenges do women face with surgical menopause?
Surgical menopause creates an abrupt hormonal change rather than the gradual transition of natural menopause, often leading to more severe symptoms. Women experience a sudden 90% drop in hormone levels, which can cause intense hot flashes, mood changes, and sexual symptoms. The psychological impact can be significant, particularly for younger women or those who haven't completed their families.
Health risks are also more pronounced with surgical menopause, including increased risks for cardiovascular disease, osteoporosis, and cognitive decline if hormone therapy isn't initiated. Women who undergo surgical menopause before age 45 typically need more aggressive treatment approaches and closer monitoring of health outcomes. The decision about hormone therapy becomes particularly important for this group.
Yes, women are consistently given only estrogen after a surgical menopause if they are given anything at all. They must take estrogen to “protect their bones”. However, excess estrogen was the main problem leading to the surgery in the first place. High estrogen, low thyroid can increase prolactin which in turn can increase parathyroid hormones which pulls calcium from the bones and into the blood stream.
Hysterectomies are Profitable - The Wellness By Design Project
45. How does menopause affect women with preexisting health conditions?
Preexisting health conditions can complicate menopause management and may be exacerbated by hormonal changes. Conditions like autoimmune disorders, thyroid dysfunction, or diabetes often require careful monitoring and adjustment of treatments during the menopausal transition. The inflammatory effects of declining estrogen can worsen certain conditions and create new challenges in disease management.
Treatment approaches need careful coordination between healthcare providers to ensure all aspects of health are properly managed. Some women may need modification of existing medications or additional treatments to manage the combined effects of their condition and menopause. Regular monitoring becomes especially important to track changes and adjust treatments as needed.
All of these preexisting condition mentioned should have been remedied long before menopause.
46. What developments in menopause research show the most promise?
Recent research developments include new understanding of the timing hypothesis for hormone therapy, improved delivery systems for hormone replacement, and better recognition of the role of testosterone in women's health. Studies are also exploring new treatments for specific symptoms, such as neurokinin 3 receptor antagonists for hot flashes, which represent the first new class of medications specifically developed for menopause symptoms.
Emerging research areas include the relationship between menopause and brain health, the role of the gut microbiome in menopausal symptoms, and personalized medicine approaches based on genetic factors. There's also increased focus on understanding racial and ethnic differences in menopause experience and developing more inclusive treatment approaches.
We don’t have to create exotic new chemicals to run our biochemistry. Identifying the deficiencies and removing the blocks to our biochemistry will go a long way to better health. A basic understanding of human physiology and biochemistry is lacking in medical practitioners. Rote learning of drug use predominates.
47. How can women build effective support systems during menopause?
Building effective support systems involves multiple layers of assistance, including healthcare providers, family members, friends, and possibly support groups or online communities. Educational resources and menopause-specific social media communities can provide valuable information and connection with others sharing similar experiences. Partner education becomes particularly important for maintaining relationship quality during this transition.
Professional support might include assembling a healthcare team that includes primary care, menopause specialists, and other providers as needed. Some women benefit from working with mental health professionals or lifestyle coaches during this transition. Creating connections with other women experiencing menopause can provide practical advice and emotional support.
Women are desperate for solutions when their health goes awry. There’s an explosion in social media sites where women learn more from each other than medical practitioners. This is a very positive advance with individuals taking charge of monitoring and adjusting their decisions.
48. What resources are most helpful for menopause education and support?
Evidence-based educational resources include materials from organizations like the Menopause Society, professional medical associations, and certified menopause practitioners. Online platforms and communities moderated by healthcare professionals can provide reliable information and peer support. Books written by menopause experts offer comprehensive guidance for navigating this transition.
Tracking apps and symptom journals help women monitor their experiences and communicate effectively with healthcare providers. Educational programs focusing on lifestyle modifications, such as nutrition and exercise for menopause, provide practical strategies for symptom management. Resources should be evaluated for scientific accuracy and updated medical information.
And oddly enough, social media platforms. Here you can find the failures. Many practitioners think they may be doing OK with their patients not knowing that they have left for somewhere else because this advice was not working. Here you can find successes and community too.
49. How is the medical field evolving in its approach to menopause care?
The medical field is gradually shifting toward more comprehensive and individualized approaches to menopause care. There's increasing recognition of the need for specialized training in menopause management, with more providers seeking certification through organizations like the Menopause Society. Understanding of hormone therapy safety has evolved, leading to more nuanced treatment recommendations.
Healthcare systems are beginning to develop dedicated menopause clinics and integrate menopause care into primary practice settings. There's growing emphasis on preventive care and early intervention to optimize health outcomes. The field is also becoming more inclusive, with greater attention to diverse populations and varying needs during the menopausal transition.
This paragraph illustrates a swing from complete disregard to an opportunity to medicalize menopause. Both extremes are problematic. If only bioidentical hormones are used in practice suddenly the complexity disappears. If only practitioners were well trained in physiology and biochemistry and had a better basis in understanding the human body, problems can be identified early and solutions used before a lifetime of misery occurs.
50. What role do community and social support play in menopause management?
Community and social support significantly impact how women experience and manage menopause. Strong support systems can reduce isolation, provide practical coping strategies, and improve overall well-being during this transition. Women who feel supported often report better outcomes and more successful adaptation to menopausal changes.
Online communities, local support groups, and educational programs create opportunities for shared learning and mutual support. These connections can help normalize the menopause experience and provide valuable resources for managing symptoms. Social support also plays a crucial role in maintaining emotional well-being and resilience during this significant life transition.
The partner relationship is left out of this paragraph. One client remarked “Nothing my husband says bothers me anymore.” This was after sufficient progesterone for her needs. The ramifications on the quality of relationships is simply breathtaking. So many men are long suffering and patient when women are floundering with hormone issues.
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I never knew there were so many issues with menopause. How did women get through this before the medical industry started treating it?
I never thought about it much, but I suppose I should now that I am in my 40s. Is it also possible to get through it without taking anything (provided that the symptoms are not unmanageable of course), or will my health be ruined then?
Surprised to see no mention of histamine sensitivity in this discussion. A lot of women demonstrate symptoms of histamine sensitivity with increasing age — symptoms that are nearly always misdiagnosed as anxiety, panic attacks, heart-related issues, etc. In my experience, many medical professionals aren’t even aware of it, or even flatly deny it, and will run a patient through a whole gamut of “specialists” trying to figure out what’s happening, only for all the tests to return as “normal” and then just write a prescription for anxiety meds (which won’t work). Look up histamine intolerance and MCAS in menopause.