Everything You Need to Know About Perimenopause—From an OB-GYN

By Dr. Kristin Markell, Board-Certified OB-GYN & Integrative Medicine Specialist

If you've ever thought, "What is happening to me?" during your 40s, you're not alone—and you're probably in perimenopause.

This transition isn't just hot flashes and mood swings. It's a full-body hormonal shift that can throw everything from your sleep to your sex drive into chaos. And most doctors? They either skip over it or wait until you're officially in menopause to bring it up.

As a board-certified OB-GYN and integrative medicine specialist, I want to change that. Because perimenopause is real, it's happening before menopause, and it's not something you have to suffer through.

Let me break it down.

What Is Perimenopause?

Perimenopause is the 4 to 10 years leading up to menopause (which is officially diagnosed after you've gone 12 months without a period). But here's the truth: it's not a gentle winding down of hormones. It's hormonal chaos.

Estrogen levels don't just slowly decline. They spike and crash unpredictably. One month might feel relatively normal. The next? You’re hit with intense PMS, night sweats, brain fog, and random bouts of rage. These spikes can happen at the "wrong" times in your cycle, or not at all.

According to the North American Menopause Society, perimenopause can begin as early as your mid-30s, though it most commonly starts between ages 40 and 44. What makes this transition so difficult is that your body starts producing inconsistent signals—the brain and ovaries are no longer in perfect sync.

And yes—you can still get pregnant during this time. Ovulation doesn't shut off on a schedule. Just because your period is irregular doesn’t mean you're infertile. If you aren’t trying to conceive, you still need protection.

How Do You Know If You’re In Perimenopause?

Perimenopause is a clinical diagnosis. That means there's no single blood test to confirm it. Your symptoms tell the story. And those symptoms often fall into distinct clusters:

1. Physical Symptoms

Heavier or irregular periods
Breast tenderness
Fatigue and exhaustion
Headaches
Weight gain, especially around the belly

2. Emotional & Cognitive Symptoms

Anxiety or low mood
Mood swings
Brain fog and memory issues
Trouble concentrating or making decisions

3. Sexual & Pelvic Health Symptoms

Vaginal dryness
Pain during sex
Changes in libido
More frequent UTIs or urinary urgency

You might experience a mix from different clusters, or just one set more intensely. That’s why it’s so confusing—and why it’s often missed.

Why "Balance" Is a Moving Target

We love to talk about "hormonal balance," but here's the reality: balance isn’t a fixed point. For cycling women, hormones naturally rise and fall each month. But in perimenopause? The rhythm becomes erratic.

Dr. Markell explains that the old medical model suggested estrogen and progesterone simply declined over time. But now we know that in perimenopause, estrogen can spike to very high levels, then plummet unexpectedly—often within the same cycle.

That means some months, your ovaries and brain might "remember" how to communicate, leading to ovulation. The next month? Misfire. This is why your moods, sleep, libido, and energy can feel wildly unpredictable.

And this is also why you can still get pregnant. Even if your cycles are irregular or spaced out, ovulation may still occur unexpectedly. Fertility declines with age, but it doesn’t disappear until menopause is confirmed.

How to Support Your Body Through Perimenopause

Supporting your body during perimenopause doesn’t require a complete life overhaul, but it does require understanding what your body needs now.

1. Nutrition That Supports Hormones

Protein, healthy fats, and fiber become non-negotiables. Blood sugar regulation is key. Skipping meals or overdoing caffeine and sugar only worsens symptoms.

2. Movement That Protects Muscle and Mood

Strength training and walking are your best friends. You don’t need intense workouts—you need consistency. Maintaining muscle mass protects your metabolism and keeps your body strong for decades to come.

3. Sleep (Even If It’s Hard)

Perimenopause can disrupt your sleep big time. Start with a wind-down routine, limit screens before bed, and be mindful of blood sugar dips that wake you up at 3 a.m.

4. Herbs & Supplement Support

Plant-based support can go a long way—especially when it includes ingredients like:

Ashwagandha (to calm cortisol swings)
Red Clover (a phytoestrogen that mimics estrogen gently)
Chaste Tree (supports progesterone production)
Magnesium (for sleep, mood, and muscle relaxation)
Vitamin B6 (for serotonin production and energy)

A well-formulated supplement can be a powerful ally during this transition. One example is The Baseline—a daily, naturopath-formulated blend designed specifically for perimenopause. It combines the right ingredients, in the right doses, to help women feel more balanced, supported, and in control.

Do You Need Hormone Therapy?

Hormone therapy (HRT) can be a game-changer for some women—especially those dealing with intense hot flashes, sleep disturbances, mood shifts, or long-term concerns like bone density and brain health.

As an integrative OB-GYN, I always emphasize that you don’t have to wait until symptoms are unbearable to consider HRT. In fact, starting the conversation early can lead to better outcomes. Many women are told they have to be in menopause before starting hormones, but that’s a myth. HRT can absolutely be part of a perimenopause support plan.

That said, HRT is not one-size-fits-all. It often takes time—sometimes up to 6 months—to find the right formulation and dosage for your body. As hormones continue to shift throughout perimenopause, your treatment may need to shift too. It requires some patience and ongoing adjustment, but for many, it provides significant relief.

For others, a combination of supplements, herbs, and lifestyle changes may offer solid support. What matters most is having a care plan tailored to your body, your symptoms, and your goals

How to Advocate for Yourself With Your Doctor

If you’re heading into an appointment, here’s how to get the most out of your time:

Come prepared with a list of symptoms (broken into clusters can help!)
Write down questions in advance so you don’t forget them
Say the word "perimenopause"
Ask clearly: Could this be hormonal? What are my options?
Don’t be afraid to say: "I’d like to talk about treatment, including herbs or hormone therapy."

In traditional settings, doctors often have 10-20 minutes with each patient. When I practiced in a traditional setting, I loved when patients brought their questions on paper or in their phone—it made the visit more efficient and impactful.—it made the visit more efficient and impactful.

If you don’t feel heard? Find someone who takes this seriously. There are providers who specialize in midlife hormonal health.

Final Thoughts

You are not broken. Your hormones are not betraying you. Your body is asking for a new kind of support—and there are expert-backed, effective tools to help you feel good again.

This is a powerful season of life. And with the right information and support, it can be one of your best.

Dr. Kristin Markell is a board-certified OB-GYN and integrative medicine physician. She specializes in hormonal health and wellbeing for women in midlife and beyond.

📍 Learn more or work with Dr. Markell at KristinMarkellMD.com
📲 Follow her on Instagram @kristinmarkellmd

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