Perimenopause, and Why the Test Says Nothing

Amy Green: From MyMaya Health, this is It's Never Just Hormones. I'm Amy Green. I'm a therapist. I've spent two decades in the chairs sitting with women who had been told that it was stress or hormones or just what motherhood feels like and watching them fall through the cracks of a system that kept answering a different question than the one that they were asking. Eventually, I stopped waiting for that system to fix itself. and built the one I wish I could have had to refer them to. This show works the same way that room did. Every episode starts with a woman's story told on her terms. Then someone who knows this territory helps me trace it back to what was actually happening in her body, in her mind, and in the system around her.

There's a note on her phone she's been adding to since February. It doesn't have a title. It's just a list. And it's long enough now that she has to scroll. Woke at two. Awake until four. Woke at two again. Forgot the word invoice in a meeting. Heart pounding at my desk for no reason. Cried in the car in the parking garage. Forgot invoice again. I'm angry. I'm so angry at everyone. Nowhere on that list is the word perimenopause. She's 46, and nobody said it to her. She got promoted 14 months ago, the job that she has worked for her whole career. And somewhere in that year, she stopped sleeping through the night. She now does the math every single night.

It's 2 14 a.m. The alarm is at six. That's three hours and 46 minutes if I fall asleep right now. but she never falls asleep right now. And then she gets up and does the whole day anyways. And she's still doing them well. It's just costing her three times what it used to. Eventually, she takes that list to her doctor. She scrolls through it on her phone in the exam room. They run her labs, and four days later, there's one line through the portal. Your hormone levels are within normal limits. It's that one word, normal. She decides that the problem is her. She doesn't open that note again for a long time. She isn't one woman.

She's a version of a story I've heard so many times with the details changed. When she asks what's wrong, the answer is normal. But the honest answer is that for most of the history of American medicine, nobody has been looking. Today, why the test comes back normal when nothing feels normal? What's actually happening to a woman's brain in the years nobody warned her about? And why we know so little? and it's honestly a bit of a scandal. My guest is a scientist who found out how little we know by going to look for the data and finding out it didn't exist. Dr. Amy de Varana has a PhD in biomedical sciences and spent seven years as a data scientist before she started a company.

Amy, would you like to introduce yourself for a minute? Sure, yeah. My name is Amy. I'm the CEO and founder of UVaq. OOVET is an at-home hormone testing platform, and we currently help women navigate fertility, perimenopause, hormonal imbalances, or really anything that has an underlying hormonal condition. Before we talk about mental health, can you explain, what's actually happening hormonally during perimenopause for us? So if you think about women's health overall, right, we have menstrual cycles for the most part, assuming that we haven't had a hysterectomy or any other surgery to prevent that. and they're driven by a hormonal balance, right? So these hormones that we're always talking about, estrogen, progesterone, luteinizing hormone, FSH, they all work in this synergy together to help us progress through the menstrual cycle, right?

Now, what happens is if one of those hormones kind of gets imbalanced or goes out of whack, it has a downstream effect on all the other conditions, and then that leads to a lot of symptoms. So by definition, perimenopause is that period before menopause. Menopause is a moment in time. It is the day you have gone 365 days without a period and anything after that is postmenopause, anything before that is perimenopause. So what happens during perimenopause is that our hormones get a little imbalanced and that's what starts to send things into haywire. But the real big thing is that your estrogen and your progesterone start to become really unpredictable. And until you can kind of get a sense of what they're trying to tell us, it can become quite difficult to manage.

And unfortunately, ⁓ perimenopause can last anywhere from seven to 10 years. That's from a 2015 study, and it's the median duration of hot flashes. 7.4 years, or 10.1 for black women in that study. Perimenopause isn't the end of anything. It's the transition into it. So we're not talking about something you could just kind of sweep under the rug and deal with at some other point, and then separately taking over a big chunk of your life. I kept thinking of a roller coaster because I was like, that's really what you're on. You're a journey where like one hormones tanking, it's going to tank the other one at the same time. just, and then it comes back and then you feel fine for two seconds and your sleep normalizes again.

And then it's off the deep end again. And it can be a wild journey and ride without a lot of support. Yeah. So you imagine a roller coaster where it's kind of in a loop because you are still technically cycling. It's just irregular. But then somebody, some person in the hungry games board. is like dropping in a new hill or a new loop in that roller coaster. So the next time you go through that loop or that cycle, it's slightly different. And you have no way of knowing or being able to predict necessarily what that new event is going to be. So really understanding what your baseline is and then figuring out what's changing from that baseline is so critical to helping you navigate this journey.

So it's not surprising that we suddenly all out of nowhere develop anxiety or anxiety symptoms, right? Not at all. mean, these hormones, do influence our serotonin and our dopamine, GABA receptors, sleep, everything. We actually ran a survey last year where we asked women that were navigating perimenopause what the most common symptoms were that impacted their life the most. And when you think of perimenopause, you often think like hot flashes, night sweats, that's what's discussed the most. But actually, anxiety, mood changes and sleep disturbances. were in the top five symptoms that women were reporting. And the knife sweats and huff flashes were also mentioned, but they were all the way at the bottom of the list.

So what that tells us is that the most debilitating symptoms are often not associated with perimenopause and are more importantly, often misdiagnosed. So Amy, if hormones are causing these symptoms, why are so many women told that hormone tests are normal? Because that's really confusing. Yeah, 100%. And I mean, it kind of makes sense, right? If you look at what the guidelines currently say for perimenopause, they don't really rely much on hormones. But why is that? You're talking about making a decision or drawing a line of treatment from a single snapshot measurement that you get from blood work. Unfortunately, as we've been talking about, these hormones are fluctuating. You really can't see those changes that are happening from a single blood draw.

You need to be able to see how these hormones behave in a trend or on a daily basis. And so with something like UVA, we do test these hormones every day and we are able to see that imbalance. You can see how your estrogen and your progesterone are behaving day to day. And that imbalance is so critical to understanding, did I experience a symptom? Is it in my follicular phase? Is it in my luteal phase? Is it like you get to start to uncover and peel this onion back quite nicely with every additional piece of data that we capture. What tracks with depression in the season? isn't how low your estrogen goes, it's actually how much it moves.

There's an eight-year study of women who had never been depressed, and what predicted depression symptoms wasn't the level. It was the variability around each woman's own average. So she can have a reading that sits comfortably inside of a normal range on the day that you draw it, and at the same time be living inside of a swing that is just taking her apart. seeing patients every day that are coming in for various types of therapy. What is the most common thing that they're reporting? I think that they just don't feel like themselves anymore and that they're very disoriented because the way that they're used to operating or the way that they're used to, whether it's, you know, the way that they're used to eating or being able to lose weight or the way that they're, you know, able to manage their emotions, the things that worked before just don't work anymore.

And I think that one of the most kind of jarring ⁓ changes is, you know, this lack of buffer, like space between my decision and my action. And you can pause and take a breath. And oftentimes with perimenopause, that like buffer space gets reduced significantly. And so that irritability or that kind of fire that comes up makes you feel like you're just reacting. And so we find ourselves being irritable and flipping out and losing our mind with... people that we love and care about in situations that we never thought we would lose our mind in. And so there's this really big disorientation of who am I now? What is my body doing? How do I understand myself?

And then how do I try to find a pathway forward? I mean, even things, Amy, like the way that I used to enjoy sex, right? Those things change significantly. And so we are in this seven to 10 year process of, you know, kind of unraveling who we understood ourselves to be and grieving her. Trying at the same time to lean in and be curious and try to get excited about who's going to coming. Yeah. I think that that's like a hard thing too. Like it's hard to feel excited about something you don't know or can't define yet, you know? Given that, like I'm glad that we're talking about how you're kind of ending up having to mourn yourself and being aware of this, right?

Of this new rebirth of your own self. But why do think so many women end up on SSRIs during this phase? I mean... so many of the reasons that we just talked about Amy, right? The hormones when they shift, ⁓ mean, progesterone and estrogen impact your GABA receptor significantly. And so when you aren't able to ⁓ produce the same type of input to these very important hormones for our brains that feed our brains, nourish our brains, nurture our brains, but also give us that calming sensation, that smoothing sensation, they help to make us, again, have that buffer room and that space, you know. I think of an SSRI as almost that bridge kind of holding our hand as we get through the season to get to the other side so that we feel a bit more access to our coping skills or to regulation.

SSRIs are a tool. They don't have to be the only tool. They're one of the tools. And I think that they're a profound tool, especially if you're finding yourself having a ton of anxiety that is keeping you up in the middle of the night, these intrusive thoughts. that just stay on loop or on repeat, you know, being able to get out of that depression. Yeah, absolutely. And it can kind of be a launchpad, right? Like, let's get things kind of under control and then we'll start to wean ourselves off of this. I think what can be so powerful about it, though, is that, you know, to have access to myself and to try to get myself to understand and feel excited about this next person that I'm becoming, I might need that support.

And so... you know, the invitation I think in this season is where can I be supported as I go through this transition and how do I need to invite that in? That could be, again, an SSRI. That could be an honest conversation with my partner about what our sex life needs to look like during this season. It could be an honest conversation with ⁓ the support people in my life saying, you know what, I actually need a hell of a lot more help with my kids or my work or my whatever so that I can. Do it. could be, you know, coming up with new strategies and skills to try to remember things and write things down and make to-do lists because my brain is just not the same brain, you know?

And the other thing to keep in mind is that perimenopause isn't just one thing. So as we're navigating the seven to 10 year journey, what you experience on day one is not what you're going to experience on year 10. It's going to change. And we need to understand how our hormones are really underlying that and what those changes are driving. So there's a massive gap when it comes to longitudinal hormone understanding. And that's what we're trying to fill right now. Tell me more about that, because that is something that blew my mind when I learned about the gap in menopause and perimenopausal research and tracking our data. I was like, what do you mean we have never tracked menopause in data sets for women?

And then we've prescribed medications and we've done all these decisions for women and their bodies. And God, mean, Alzheimer's medications, diabetes medications, GLP-1s, none of them have any sort of menopause data set to it. So we don't know if the dosage is right. We don't know how it impacts based on the time of the month. It's just pretty profound information to not have. Yeah, absolutely. It's kind of, it's sad, but it also kind of makes sense once you... understand this component. So when you're thinking about doing a women's health study, you are going to try to remove any outliers. So you are going to try to find women that have a 28-day cycle that aren't going through menopause, that still have a uterus, that still have their ovaries.

Like, try to make this the best patient pool so that you can get clean results. Well, the problem is when you're impairing menopause, you don't have a 28-day cycle. Your cycles are by definition irregular, and you are going through a transition. postmenopause, you no longer have a cycle. So in both those cases, you're most likely going to be excluded from any of the women's health research that's happening. And that's why we have such little data when it comes to perimenopause. It isn't a conspiracy. It's in fact much more ordinary than that, which sometimes is worse. What I find really exciting though is when we look at UVEZ data, because now we have a massive amount of perimenopausal hormonal trends that we can look at.

My happy place is going into our data set and seeing like what can we find. And it's exciting but sad that no matter what we find, it's groundbreaking because no one has been able to look at data like this before. We're starting to see how can we actually educate consumers and then also clinicians on the findings that we're having. So seeing very clear patterns when it comes to your estrogen behavior and sleep quality. Now I know we have this partnership with Aura, which I think is going to be game changing for the industry. You're not looking at how many hours I'm saying I slept. My device is telling me this. We can trust it a little bit more.

And I think it's we're going to start to really uncover some meaningful hormonal underlying patterns that are going to inform what symptoms we're experiencing. And then hopefully we can close that data gap too. It's the coolest thing ever. Amy, is that something really interesting? Like how we do start to not feel like ourselves and you end up becoming somebody new. And as I mentioned, like one of the more common symptoms of women are experiencing is anxiety. Now, what if someone discovers or accepts that they're starting to experience anxiety in their 40s? What would be one of the first things that they should do? So, I mean, this is where I think the therapy or even just some of the mindfulness practices can come into play.

So even just starting with calming your body down, giving your body time to rest, I think one of the most interesting things again is like our our workplaces and our God, our society is built on this nine to five rhythm. And a nine to five rhythm may not be a woman's internal rhythm or need for that season. And so where are there ways that we can invite in? Again, if I'm not sleeping from three to six in the morning, guess what? I need more sleep. And it might be from six to 10. And so where can I invite in a different rhythm within my workday, within my, you know, my life of just when am I working out?

When am I moving? When am I eating? When am I sleeping? And how can I be supporting myself with that, knowing that this is, a season I'm going to be in for some time. Then again, when I come back to therapy, know, therapists are an incredible resource, especially CBT ⁓ and CBTI. So cognitive behavioral therapy for insomnia is a tool, and it's a very well-researched evidence-based tool that can be such a powerful kind of reset to how and when we sleep and just trying to get our body back. regulated over and over again. CBTI. There's six to eight sessions, it's a protocol, and there's no medication. In a trial of 150 women past menopause with chronic insomnia, 54 % were in remission at the end of treatment.

And at six months after the sessions had stopped already, it was 68%. CBTI kept working after it ended. And so CVTI really works on how can I change my habits up? And so, you know, whether that's getting up and out of bed and going and reading a book or listening to a guided meditation in the middle of the night or just finding something to do. I mean, if you're wide awake and you want to move, great. And CVT works similarly. So with anxiety, it's how do my thoughts affect what I do and what I feel and how do I challenge an intrusive thought or how do I stop? ⁓ a worry cycle or a negative thought cycle.

How do I have compassion with myself in this season when I just, again, feel so out of control? That's great. I mean, I think that's one of the toughest things, right? Giving yourself that grace to be able to actually go through these motions and then also being able to accept that this is happening to me. So what does it look like ⁓ and what should women do on the hormone side then, Well, I think one of the things that we touched on is that One of the biggest complaints that women experience is they don't feel like themselves. That's a really hard thing to walk into your doctor's office and be like, I don't feel like myself.

The doctor's not going to know how to treat that. There's no like CPT code for them to use to help figure out what that protocol should be. So what we're trying to do is how do we provide you as the patient with enough resources to be able to go into your doctor's office and have a two way conversation and be able to speak the language that a doctor can actually understand and then more importantly, treat. you don't feel like yourself, great. Let's start to track those symptoms. Well, when are you actually having trouble sleeping? Is it in your luteal phase? Is it in your follicular phase? Is it when your estrogen is dropping? So what I would recommend is that you start tracking your symptoms.

You also track your hormone patterns on top of that because doctors understand hormones. They know what they are supposed to do and this is not a foreign language to them. So now if you're mirroring those symptoms with the hormone patterns, all of a sudden you're bringing something really objective. that a clinician can understand and then more importantly, use to figure out a personalized treatment protocol for you. And the solution isn't always just jump into HRT. It could be, it's a very valid solution, but there are other interventions that people were just touching on that are appropriate. And you can have a really meaningful discussion with your doctor to see what is the right path for you, what are the concerns that you have, and then make sure you get on the right treatment protocol for yourself.

Like having the information. and being able to take the information and data to actually say this is what's going on is such a different conversation than I'm snapping at my husband. I don't know. It's really hard. like, I'm feeling like I'm sure I'm going through perimenopause right now. But like, my patients are like, I don't think you've ever irritated me as much as you are right now. And overall, pretty happy marriage. I'm like, I just don't want to be around you. It's just gone, the buffer, it's gone. Yeah, going for a walk is actually quite a good solution to help with not only your mental health, but also with your marriage, I'll be honest. That's a good relationship, good advice.

It's too real. I want to be upfront with you about where the science runs out, because this is a field where a lot of people are selling certainty. Tracking your own hormones over time is the right design. The literature supports measuring a woman against her own baseline instead of a population's average. What we haven't shown yet is that at-home hormone tracking changes an outcome. That's a legitimate place for technology to be. It just isn't the same yet as proven. But it has to start somewhere, right? So we can either sit here in the dark hole and be like, ⁓ there's no research out there, no one's doing any work. Well, that's not true. People are trying to do the work.

It just takes time. There's always going to be more research about ED than there is about perimenopause. Accept it, let's start to feel it and put more people in the research space to have more papers and research on perimenopause. That's my ask for the industry right now. That if you're doing the work, like put the data out there and let's get some new findings to help move this field along. Coming to our partnership, because I'm just so stoked to talk through this with you. Why did Uva and Mamaya decide to work together? I'd love to hear your perspective and I'm happy to share mine too. This really shines in perimenopause, like honestly, it's not limited to just perimenopause.

It's really all stages or seasons. I love how you call it a season that we go through as women. But our hormonal experience and these different phases are not separate from our mental health. They are very much intertwined. We know that there's a hormonal signal that drives anxiety, that drives the disturbances, that drives all these other things that ultimately can get you on a treatment course that may not be the right thing if you don't give your mental health. the appropriate attention that it needs. The intersection of those is so fascinating and we don't understand a ton about it yet, which I think is what I'm so excited about because this then gives us access to data that can help us to understand when I'm feeling sad, when I'm feeling mad, when I'm feeling more irritable, why those things are happening versus just I'm anxious and I have no idea what's going on.

Absolutely. I mean, I'd like to say that we're just really adding color or translating what our body's trying to tell us into a language that we can understand because sometimes the headaches don't really convey what's going on. They don't know they're just debilitating and annoying. My body is not separate from my brain. know exactly it shouldn't be treated as separate. And I think that when partnerships like this exist it brings that whole woman together and it brings the context to why she is experiencing what she's experiencing when she's experiencing it. she can be empowered with that data and information so that she can then make decisions about what type of support she needs. It's really about putting you back in the driver's seat of your own health.

I mean, I know when I was going through my own hormonal journeys, I didn't have the data or the wherewithal to advocate for myself. I was really at the mercy of my clinical team telling me what I had to do, what treatments I had to go on, and I was put on medications I didn't need to be on for an extended period of time. Amy's a woman. with a doctorate in biomedical science on medications that she didn't need for years. Being able to have data to not even, it's not to be combative. It's really to be able to ask empowered questions and make sure that whatever plan you're being put on, you are on board with as well.

And it's not just like, my doctor told me to do it. I'm blindly going to do this because nothing can be worse than what I feel like right now. What would your goal be, Amy, like if five years from now you look forward? ⁓ and Uva and Mamaya have done great work together. What, what would you like to see the outcome of that for women? Love for a woman to be able to not feel shame talking about her mental health. I feel like something is drastically wrong with her. And instead it's like, kind of like what you were hinting at, that if my hormones are doing X, then I know I'm going to be feeling anxious in this time.

So let me take the right steps. And we have worked together enough to say like, this is the protocol for a woman who has a hormone pattern like this, experiencing symptoms like you're reporting, and we have seen that this actually works for you because you feel better. It doesn't always have to end in a therapeutic. It can end with a lot of things that a woman can do on her own, as long as she knows when to do it and how to do it right. And so I do believe we can get to a world where we can really help women navigate that personalized mental health care ⁓ based on objective data. I'm so grateful for your partnership.

It's incredible. Thanks so much, Amy. All right, last thing. Let's talk straight to her, to that woman lying awake right now at 10 past two. Remember that list on her phone? The one with no title? We're gonna give it a title. For women, we diagnose perimenopause based on a pattern of symptoms. 60 to 90 days. Bleeding, sleep, mood, the 2 a.m. wakings, the days that you can't find words, those rage days, the irritability. and roughly where your cycle lands in each one. Most women in the season are keeping some version of that list somewhere, and nobody's ever told them that it's the data. So she opened that list again, and she gave it a title.

The second time that she went in, she didn't say, I don't feel like myself. She handed over her phone. Here's 90 days of data. Here's what my sleep has done. Here are the days that I can't find words. Here are the four days a month I can't even be around my own family. It's the same woman in the same body and probably the same labs with a different conversation. If this is your season, the one step is the list. It's free and you can start it tonight. If you've already been keeping it, you're further along than you think. What comes after now? There's therapy. There's hormone testing, hormone therapy. There are SSRIs and antidepressants and anti-anxiety medications.

There's CBTI and sleep treatment. It's a conversation now that you get to be in instead of one that feels like it's happening to you. If something in this found you where you live, here's what I want you to know. What you're carrying is real, it has a name, and it is more treatable than anyone has told you. At Mamaya, we measure every woman's progress, every single session, because the only way to know care is working is to actually check. Most women who come to us in the clinical range finish below it, and most of that change lands inside 12 weeks. Finding care built for your season takes one step. Visit us today at mamiahealth.com or visit the resources in our show notes.

If you're in a crisis, call or text 988. If you're pregnant or postpartum, Postpartum Support International is a great resource. And if there's a story you've never told about this season or any season nobody warned you about, the form is in our show notes. Anonymous is fine. Nothing airs without your okay. I confirm it with you first, every time. It's Never Just Hormones is from Amaya Health. Our senior producer is Emily Seiner. New episodes twice a month. I'm Amy Green.