9 Steps for Wrangling a Complex List of Menopause Symptoms
How to prepare for an appointment
It’s not uncommon for me to get a message from someone with a lot of symptoms who sounds like she is at her wits’ end. This could be for a variety of reasons. Perhaps she has been dismissed by her health care provider(s), or her concerns have been taken seriously, but she is not receiving the standard of care. While it’s impossible in this format to tell any individual the best approach for their health, it is possible to consider the symptoms and provide some insight into how they could be approached. And so that is what we will do here, with the caveat that the information at hand is limited (in the office, I’d ask more questions, do a physical exam, have the medical chart to review, and might order some lab work) and of course, I am not the treating physician, so this is purely an exercise. However, I’m hoping when you see how I approach this kind of scenario, it might help you organize your thoughts and prepare for an appointment with your own provider(s).
The question:
Oh gosh - what do I do?!? I turned 45 but for the past year I have been experiencing perimenopause symptoms: night sweats, brain fogginess (I can’t remember what I was about to do or come up with a word at the tip of my tongue, or even forgetting I still have a patient I’m taking care of at work!) heartburn, adult acne, breast tenderness, joint pain (specifically plantar fasciitis) weight gain, FATIGUE, IRRITABILITY and MOOD SWINGS. I’ve been back and forth between my PCP and OBGYN asking to have my thyroid checked (I take levo for hypothyroidism) and hormone levels checked all to be told everything looks “normal.” So I’ve tried oral compounded progesterone which made me feel more tired and depressed and now my obgyn suggested estrogel whenever I start to experience the mood swings. I have an IUD. I’m a 5’6 and 146 lbs woman who exercises and eats clean and limits alcohol. I’m over this already, and the swings from feeling like myself to a person whom I don’t even recognize. Where do I start or who can I go see or what tests/labs should I push for?
For our purposes here, I’m going to assume we are discussing someone who is still having periods and is in the menopause transition (perimenopause), as there are some differences in approach for the menopause transition (before the last period) versus postmenopausal (after the last period).
STEP 1: Keep an Open Mind
Age 45 is the average age of onset of the menopause transition, so menopause transition is definitely on the table as a cause for some or many of the symptoms. However, other conditions can also produce many of the symptoms we are considering. In addition, menopause doesn’t happen in a vacuum, so it’s important to consider other factors, such as relationship issues, stress at work, and financial strain, to name a few, that could be amplifying some of the symptoms.
STEP 2: Know the Red Flags for Substandard Care
Knowledge is power, and while it’s not always possible to say which therapy is the best (often, there are several valid approaches), we can definitely identify some recommendations or therapies that are not evidence-based and not recommended. Some red flags for substandard care:
Starting and stopping estrogen from treating symptoms, as was recommended in our case above, to treat mood. Estrogen is not an on-demand therapy and should not be prescribed this way.
Compounded hormones, including hormone pellets.
Checking levels of reproductive hormones (estradiol and FSH) for people age 45 and older (read more about when hormone testing is and isn’t recommended here) or for people younger than 45 who are not skipping periods. This includes recommending the DUTCH test (read more about why that is a waste of money that tells you nothing useful here ).
Testing for the MTHFR variation.
I can’t fix all the systemic issues in medicine, but I can arm you with the knowledge you need to help you get better care, including spotting bad care. For me, a red flag is a sign it’s time for another opinion.
STEP 3: Make a List
Make a list of the symptoms that are bothering you. It can be a long list or just two things. Whatever you need. Think about the symptoms with the biggest bother factor and rank them first. Ensure your provider sees your list because something that doesn’t bother you (for example, irregular bleeding) might be of significant concern to them. Because the reader who asked the question put several of her symptoms in all caps, I will assume for the purposes of this exercise that they are the worst symptoms, so I have listed them first and in italics. THere is the list that we will be using:
Fatigue
Irritability
Mood swings
Night sweats
Brain fogginess
Heartburn
Adult acne
Breast tenderness
Plantar fasciitis
Weight gain
If being tired or fatigued is on your list, make sure you understand the difference between the two, as they are not the same, although people often use them interchangeably. Being tired is a lack of energy that improves with rest or sleep; fatigue is mental or physical exhaustion that affects daily life and doesn’t improve with rest or sleep.
When weight gain is a concern, check your medical records to know exactly how much you have gained and over what period, so when you see your provider, you can say, “I gained 10 lbs in three months or 10 lbs in six months or whatever it is). Menopause does not change metabolism and is not directly associated with weight gain (I know there are some doctors selling menopause diets that suggest otherwise, but they are incorrect. Metabolism doesn’t change until around age 60). Weight gained during the menopause transition is age-related and likely because people move less and possibly eat more. However, if weight gain is significant and/or over a short period, that might raise concerns for medical conditions that need to be explored.
STEP 4: Get the Baseline Tests
More tests may well be needed, but here are some tests that cover a wide range of symptoms on our list and what I order for anyone who may be in the menopause transition and who is coming to me to discuss their symptoms: