Chapter 11 - Six Real Life Rebalance Healing Journeys

If you’ve ever been told you’re “basically menopausal” while you’re still bleeding, or you’ve tried hormone therapy and somehow felt worse, this conversation will land hard. We walk through the Rebalance phase of the healing hierarchy using four real women’s stories from the clinic, each one showing how the right diagnosis at the right time can be the difference between relief and an ongoing spiral.

We start with Nina, whose online prescription of high-dose estradiol happened without the testing her body clearly needed. Her case opens up the real-world stakes of perimenopause care: PCOS history, heavy bleeding, progesterone dropping first, and why oestrogen metabolism pathways (including what a DUTCH test can reveal) matter for inflammation and longer-term risk. From there, we challenge the way “HRT” is used as a catch-all term, because perimenopausal hormone therapy is not the same thing as menopausal hormone therapy.

Amara’s story shows how perimenopause gets treated like menopause, and how a Mirena IUD (levonorgestrel, a synthetic progestin) plus added oestrogen can create an oestrogen storm with migraines, night sweats, weight gain and mood changes. We also unpack Sophia’s resistance to progesterone support despite clear biochemical burnout and hair loss, then finish with Clara, where stress, under-fuelling, and relationship strain prove that the body won’t heal in an environment that doesn’t feel safe.

If you’re navigating perimenopause symptoms, hormone therapy decisions, or just want sharper questions for your GP, press play, then subscribe, share with a friend, and leave a review so more women can find this support.

Transcript

Why Diagnosis Timing Matters

SPEAKER_00 0:00

Chapter 11 Six Real Life Rebalance Healing Journeys Don't ever compare your living, breathing, beautifully imperfect, and real life human self to someone else. As we begin to delve into Rebalance, the second phase of the hierarchy of healing, keep top of mind that much of a woman's health journey can hinge on one single detail the right diagnosis at the right time. This chapter consists of real-life case studies that present an archetype of women I see every day in my clinic. Within these women's health journeys, you may recognize yourself in one or more of their stories. My intention is to show how critical it is to receive the right diagnosis for the life phase your biochemistry is in. Perimenopause or menopause. I also want to make you aware of what can happen when the correct diagnosis isn't reached, you can risk rebalancing the wrong hormones for your particular life stage. Remember, perimenopause and menopause are two distinct states, and each requires a different approach to hormonal treatment. For a few of the women you will meet, a misdiagnosis, often due to a lack of testing, led to years of suffering, unresolved symptoms, and in some cases serious chronic issues, not to mention treatments that were ineffective or made things worse. But for some, the correct diagnosis of the actual transitional life phase they were in, and then rebalancing the right hormones truly changed everything about their lives. Why? Depending on whether a woman is perimenopausal or menopausal, which hormones need to be rebalanced and how they need to be brought back into alignment can look completely different. The right diagnosis and the right support at the right time can bring symptom relief, prevent the development of chronic conditions later on, and reclaim the vibrant woman you know is within. My hope is that as you listen, you feel seen, gain more clarity in your own health journey, and begin to understand what's really happening inside your body and what is possible in restoring your vitality when you're finally given the proper support. My aim is to empower you with the information you need to receive the most effective and supportive care through perimenopause. I want to begin with Nina and her transformative journey that began with a lack of understanding and proper testing.

Nina And The Cost Of Not Testing

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Chapter eleven point one Nina The Cost of Not Testing As soon as Nina entered my office, she sat down and immediately blurted out I've started hormone replacement therapy. But I heard the concern in her voice, and I leaned in to listen more closely. You see, I'd seen Nina a few years before, so I was familiar with her health history. A bit of important background to know about Nina. She has always been very proactive about her health. The first time I saw her, we decided to do the Dutch test to establish a baseline for her progesterone, estrogen, and testosterone levels. Part of our decision was based on her previous diagnosis of POS, as she did present with symptoms including irregular ovulatory cycles, meaning she was still ovulating but not with every cycle, insulin resistance, due to her body's struggle to properly manage her blood sugar, which could set her up for prediabetes, fluctuations in her weight. All of these symptoms are very typical of PICOS. However, the one insight from her PICOS diagnosis that stayed top of my mind was that it confirmed Nina might present with higher estrogen levels. In other words, her estrogen levels had the propensity to already be high. With her medical history in mind, I continued to listen. Nina explained that as she began to experience hot flushes, unexplained weight gain, and some brain fog, she sought help from a physician who could treat her symptoms online. My heart beat a bit more quickly with worry, and I thought, so she's been prescribed hormone therapy without testing or physically being seen by her doctor. Nina had been prescribed Sandrina gel, containing estradiol, a form of estrogen. Knowing her Picos diagnosis, I held my breath, hoping she was also taking progesterone in addition to the estrogen. Thankfully she was, but she was taking a standard dose of 100 milligrams of oral micronized progesterone. Here's where I became a bit alarmed. The standard starting dosage of Sandrina, the estrogen gel, is 0.5 milligrams to 1 milligram. Nina was taking nearly four times that amount. And for Nina, who was most likely already experiencing a high estrogen state, this additional higher Sandrina dose could have a significant impact on her health. Learning about Nina's prescription, it started to make sense as to why, since she began her HRT, she experienced the following extreme mood swings, hemorrhagic bleeding, severe breast tenderness to the point where her partner couldn't touch her, significant weight gain despite increased physical exercise, severe joint pain resembling rheumatoid arthritis that resulted in an ER visit, skin changes, extreme redness like a sunburn, cracked lips, and due to the inflammation, most likely originating in her gut, and the deficiency in her progesterone, extreme puffiness. As Nina continued to speak, my concern grew, given her previous history of Picos, an iron deficiency and anemia, which would only be exacerbated by the heavy bleeding she was experiencing. At the time of Nina's first Dutch test, she had presented with adequate estrogen levels, her testosterone levels were a bit high, and her progesterone level was moderate, but nothing was concerning at the time. Given the severity of her symptoms, even before we did her second Dutch test, I believed her progesterone levels had fallen significantly. But instead of the online doctor prescribing progesterone alone to treat the deficiency, she was put on an extremely high dose of estrogen, which in all likelihood was the root cause of many of her current symptoms. In addition, Nina's heavy bleeding told me she was still in perimenopause, which by definition is an estrogen excess state, as progesterone is the first hormone to leave the scene. In a sense, the last thing Nina needed was more estrogen. More alarming to me was Nina's increased cancer risk, given her Picos. Women with PICOS have a 2.7 to 5fold increased risk of developing endometrial cancer due to prolonged anovulation and exposure to unopposed estrogen. If she was already in a higher estrogen state, much depended on how her body was metabolizing that estrogen, and more specifically which pathway it was being sent down for elimination. Was it moving through the more protective pathway or the more inflammatory one? As we discussed in the last chapter, that distinction can make all the difference.

PCOS, Oestrogen Pathways, Cancer Risk

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Picos, estrogen and cancer risk. What you should know? With a Picos diagnosis, a woman often won't ovulate regularly, which means she produces less progesterone. Without enough progesterone to keep estrogen in check, the body can end up in a higher estrogen state, increasing the risk of endometrial cancer over time. As we've discussed, it's not just hormone levels, it's how your body metabolizes estrogen. Some detox pathways are safer, while others are more inflammatory with a potential cancer risk. What I knew from Nina's previous Dutch test was that she metabolized a higher percentage of her estrogen via the four-hydroxyl pathway, the red pathway, named for the colour it appears in the Dutch results. Research has shown that if the metabolites from this pathway aren't properly detoxified, they can damage DNA and potentially increase cancer risk. As I listened further, I was stunned by the fact that without any prior testing, she was prescribed a high dose of estrogen. Both her actual estrogen levels and how her body was metabolizing that estrogen were completely unknown to the prescribing doctor. Do I think the doctor did the best they could for Nina with the tools she had while following the current medical guidelines? Yes. However, Nina's body chemistry is sensitive and has more complexity than what practitioners might normally see. So Nina needed a practitioner with a bigger toolbox in order to be treated effectively, starting with the correct testing. Nina is the perfect example of why I believe the current medical guidelines for identifying and managing perimenopause and menopause must be revisited and changed, so that testing is recommended beyond simply looking at a woman's symptoms. Every woman needs proper testing, along with continued monitoring through testing during treatment. This is to protect women who may potentially be misdiagnosed as menopausal when there are still perimenopausal, and who actually need perimenopausal hormone therapy, not menopausal hormone therapy.

Rethinking HRT Language And Dosing

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Which brings me to my next gentle challenge to the dominant medical narrative. The nomenclature around HRT. Hormone replacement therapy is traditionally meant for women who need hormone replacement due to hormone loss from surgical menopause, such as after a hysterectomy. What no one seems to talk about is the distinction between perimenopausal hormone therapy and menopausal hormone therapy, as we discussed in chapter 3. As we've established, these are two distinct phases of life, and each requires a different therapeutic approach to rebalance hormones. For Nina, who was perimenopausal and in a naturally estrogen-dominant state, combined with her PCOS history, her PhT, perimenopausal hormone therapy, should have involved higher doses of progesterone to modulate her higher estrogen levels. If we're truly talking about correcting hormone imbalances in both perimenopause and menopause, I believe this distinction in nomenclature is a critical missing piece of the conversation. I want to make clear again that I do believe in hormone therapy when it's used at the right time using the right dosage for the right person and their phase of life. It can be beautifully life-changing. As we leave Nina's journey, be assured that the first step in her healing protocol was to do a second Dutch test, so I could see the full picture of what was happening in her unique biochemistry. We also revisited any gut issues she was experiencing to ensure that the plumbing of her gastrointestinal tract was functioning optimally. That way, when we determined which hormones needed rebalancing and how best to treat the imbalance, her body would be ready to respond and able to properly absorb and utilize the hormones it needed. Because when you treat from the foundational health approach, supported by testing, beginning with repairing the gut, and you make sure you restump the house first, true healing can begin. Nina's story illustrates how critical it is to test not just once but also at key points along your hormonal journey. Even with a known propensity for higher estrogen state, her doctor and the prescribed therapy ignored this. Nina was still in perimenopause and her treatment was actually hurting her more than helping her.

Amara Misread As Menopausal

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Chapter 11.2 Amara When perimenopause is treated like menopause. In this chapter you will meet Amara. She's a single mum, caretaker, and a woman with a deeply compassionate heart, whose story is equally powerful, but for a different reason. When Nina's treatment went wrong due to improper testing, Amara's care was what many would describe as a misdiagnosis from the very beginning. Amara was misdiagnosed as menopausal when she was still clearly in perimenopause. Her story, although a cautionary tale, is also one of healing. This beautiful woman walked into my clinic for a second time asking for help. Like Nina, I have a history with Amara. She first came to see me with a tender request. She was a single woman in her forties who wanted to have a baby. So together we checked her hormone levels and even thumbed through sperm donor profiles. Today she has a beautiful little boy, and her boy has become her moon and stars. Amara is an Italian mum who is completely dedicated to her son, and whose entire world revolves around his smile. She is an incredible single mum and a consummate caregiver to oil. Amara is the salt of the earth. So when Amara returned to my clinic at fifty one, truly beside herself, dealing with health issues, I knew something was deeply wrong. My concerns were confirmed when she said, I feel absolutely shocking. Something's just not right. She described a myriad of symptoms we'll touch on later, but the most concerning physical symptom was that she had a very heavy bleed, similar to Nina, who was also experiencing the hemorrhagic bleed. Then two months later, Amara suffered another episode. A heavy bleed in perimenopause can indicate endometrial hyperplasia, caused by high estrogen thickening, the uterine lining, which can be the precursor to endometrial cancer. I recognized Amara would benefit from progesterone to lighten the flow. Although her physical symptoms were worrisome, what alarmed Amara most was her growing propensity to be short with her little boy, suddenly raising her voice. I can tell you Amara's shortness was completely out of character. Before coming to me, Amara had already searched for a way to change her behavior and deal with the heavy bleeds. Like so many women who are suffering from perimenopausal symptoms, Amara listened to a few recommended podcasts that suggested hormone therapy might be what she needed to correct a potential hormonal imbalance. And so, off she went to see her doctor. At 51, it's understandable that her doctor might have thought Amara was menopausal. With her cycles changing, becoming more irregular, Amara also thought she might be in menopause, so she was quite happy to accept the doctor's diagnosis. Because like many women, she didn't know the clinical definition of menopause. You see, the diagnosis of menopause is retrospective. If you recall, you have to go 12 months and one day without a bleed to be in menopause. Had the doctor asked Amara a few more questions, he would have learned that Amara had bled five months prior to her visit. By definition, Amara had not graduated to menopause. She was still bleeding, meaning she was still in perimenopause. As you know by this point, that meant she was in an estrogen dominant state. However, without comprehensive functional testing to diagnose her proper life phase, her doctor prescribed a merina and some estrogen to prevent her heavy bleeding. Merina is a hormonal interuterine device, RUD, often used for contraception and to manage heavy menstrual bleeding. Inserted into the uterus, it slowly releases a synthetic hormone

Mirena, Progestins, And The Estrogen Storm

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called levanogesterol, a synthetic progesterone, over several years. Although we touched on progestins versus bioidentical progesterone in chapter 6, I want to provide more detail here so you have a full understanding of the differences between the two and why not all progesterone are what they seem to be. What you should know about the marina IUD. By its definition, the marina RUD is helpful. It acts as an effective contraceptive and it helps reduce the hemorrhagic bleeding, one of Amara's chief complaints. The synthetic progesterone the Marina IUD releases is designed to act like progesterone to keep the diva estrogen in check. However, levinogesterol, the progesterone in the marina IUD, has a molecular structure derived from testosterone rather than progesterone, which means it can have androgenic effects that natural progesterone does not. This matters when we consider how progesterins may impact other parts of your body, like your brain, your bones, and your breasts. We simply don't have a full understanding yet. Now compare bioidentical progesterone, which is molecularly the same as the progesterone your body naturally makes. That means your body recognizes and responds to it just like it would to the hormone your body produces on its own. Whereas a synthetic progesterone, like what's found in some birth control or the marina IUD, is man-made and not identical in molecular structure. So your body may respond differently and sometimes unpredictably to this synthetic hormone. In women who are already presenting with a higher estrogen state like Amara, adding a synthetic progesterone to the mix can cause more problems than it solves. The marina IUD might decrease the heavy bleeding by thinning the uterine lining, but it certainly doesn't offer the beautiful, calm, cool, anti-inflammatory, and protective effects that bioidentical oral micronized progesterone offers a woman's body. If you're currently taking progesterone, take a few minutes to check what exactly you're being prescribed. Is it a bioidentical progesterone or a synthetic progesterone? To explain the differences between bioidentic progesterone and synthetic progesterone to patients, I often use a fruit analogy. Imagine you were hungry for a piece of fruit and you were offered the choice of an orange or a pear. As you contemplated your choices, what if you were told that we didn't really understand how the orange would behave in your brain, breasts or bones, and there was a small risk of it causing breast cancer? Then for the pear it was explained that your body will recognize and respond well to the pear with no adverse health issues. Wouldn't you choose the pear? When it comes to bioidentical progesterone versus synthetic progesterine, I believe there's a huge blind spot in clinical practice in general. We, as practitioners, need to stop and think about why we're not offering women a safer, natural option first when bioidentical progesterone is anti-inflammatory, calming, and data suggests a safer breast cancer risk. If you were taking progesterone and haven't yet checked exactly what you've been prescribed, please take a minute to do so, and then you can take further questions to your GP. Now I want to turn our attention back to Amara. Within four to six weeks of getting the marina IUD, which introduced progestin into her system, Amara began to suffer from severe migraines, hot flushes, night sweats, constipation, and unexplained weight gain. Symptoms she hadn't experienced before. Remember, the doctor also prescribed estrogen. So now the sweet perimenopausal woman, who by definition already presents with a higher estrogen state and a progesterone deficiency, is taking more estrogen, creating what I would describe as an estrogen storm. This resulted in her severe symptoms, including her heavy bleeds. It's like the additional estrogen put fuel on the perimenopausal fire, and every one of her symptoms indicates higher levels of estrogen. As Amara and I put together her treatment protocol, it became evident that she blamed herself for her symptoms. She thought that something was wrong with her body. And what broke my heart was how she beat herself up for her shortness with her son. In fact, there was nothing wrong with her body, she was not broken, and her mood swings could be explained and mitigated. Amara is an example of a woman who sought the appropriate therapy, but due to being misdiagnosed as menopausal, when she was clearly in perimenopause, experienced all of these negative side effects. Amara's treatment.

Amara’s Reset With Testing And Foundations

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Of course, we began with Dutch testing to get a clear picture of Amara's hormone levels. Due to her heavy bleeds, I also wanted to test for a potential iron deficiency, as I do with every patient. I began her treatment by beginning with her foundational health to bring it back into alignment. We started with healing and sealing her gut using my heal, seal, and repair protocol. I also Ordered a full thyroid panel to test for hypothyroidism and the possibility of insulin resistance, which both would help explain the extra 10 kilograms Amara was carrying. I believe information empowers every woman to ask the right questions of her practitioner. Learn from Amara's cautionary tale so you can avoid a misdiagnosis of your phase of life. Be fully informed about progestin versus progesterone. And finally, ask for foundational health support. Perimenopause is often the overlooked transformational phase of a woman's life. But I believe if you have the right information you can ask the right questions so you can receive the right treatment to rebalance your hormones, to bring them back online and feel amazing.

Sophia’s Burnout And Progesterone Resistance

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Chapter eleven point three Sophia When you ignore what your biochemistry is telling you Sophia's story is a bit different from Amara's because her journey wasn't one of misdiagnosis or a lack of testing, but one of resistance. Resistance to the truth about her biochemistry and that at the young age of forty three, she was, in fact, perimenopausal. As you will see, her resistance was to the therapy and treatment that could help ease her symptoms and support her through this very important transition. Sophia was not yet willing to listen to what her body was trying to tell her, resisting the very therapy that could have brought relief to her most severe symptoms. In doing so, she was, I believe, missing a beautiful invitation to see periomenopause not as something to resist, but as the springtime of a new and transformational phase in a woman's life, and something to fully embrace. Sophia is a stunning 43-year-old woman who is tiny in stature but feisty in her spirit. She is tremendously talented at her fast-paced, high stress job while balancing the busy mum life where she takes care of three children. But when Sophia came to see me, it became clear very quickly that she didn't want to be in perimenopause, even though her biochemistry was providing irrefutable evidence that she was already well into this transition. Her resistance is not uncommon. Women often struggle to embrace the fact that they are aging. At forty-three, Sophia believed she was too young. Sophia didn't want to be in perimenopause. When she came to me, Sophia described severe exhaustion. In addition to the high stress of her job, she attributed a lot of her fatigue to being micromanaged by a boss whom she described as having narcissistic tendencies. Without knowing the full extent of her situation, I suspected that as a result, her cortisol levels, the stress hormone, were going to be off the charts. When cortisol is elevated for a prolonged period of time, the body often shifts hormone production to keep up with the stress demands. In Sophia's case, I thought her high levels might be suppressing progesterone while upregulating androgen pathways, meaning her body was producing more androgens. The hormones like testosterone that can cause symptoms including hair loss, acne, and weight gain. This made sense. Another one of her main complaints was her hair loss. Once we did the Dutch testing, my suspicions were confirmed. Her results showed true biochemical burnout. She had been in such a high stress state for so long that her stress response system, her HPA access and adrenals, was clearly dysregulated and running on empty. Another significant piece to Sophia's health issues was her long history of restricting calories, which resulted in years of hypothalamic amenorrhea. This condition occurs when your body stops ovulating and your periods can go missing, not because you've entered menopause, but because your brain temporarily puts communication with your ovaries on pause. It's your body's way of saying, I don't feel safe enough to support a pregnancy right now. HA is reversible, but it's definitely a sign that your body needs more nourishment, rest, and care. For Sophia, who was now in perimenopause, her long-standing history of hypothalamic amenorrhea only added to the hormonal challenges she was already facing. This earlier disruption in her foundational health meant her system was especially sensitive to the natural hormonal turbulence of perimenopause, with more frequent anovulatory cycles and intensifying symptoms like fatigue, insomnia, anxiety, and hair loss. The very symptoms she came to me to help address. When we sat together and talked through what she was experiencing, we came up with a full list of her symptoms dysregulated cortisol pattern due to chronic stress, resulting in exhaustion, increased anxiety, low libido, sleep disturbances, brain fog, hair loss and shorter cycles. Of course, her hair loss was a major concern for Sophia because it was very visible. But there were two additional components to her health picture that confused her and added to her resistance to the fact that she was in perimenopause. First, Sophia was still cycling, meaning she was still bleeding every month for four to five days. So she assumed that with every menstrual cycle she was also ovulating. But for perimenopausal women, this isn't always the case. As your ovaries age, they sometimes skip the release of an egg, which is called an ovulation, even though the rest of the menstrual cycle occurs. Without ovulation, the body isn't producing the usual surge of progesterone that typically follows the release of an egg. Once we did Sophia's Dutch testing, her extremely low progesterone levels confirmed that her ovaries were beginning to retire, meaning that even though Sophia was still bleeding regularly, she wasn't ovulating in every cycle. I tried to share with her Professor Geraldine Pryor's description of perimenopause. It is the ovaries grand finale, the releasing of the final eggs. It is like that last fiery display at the end of a fireworks show. This finale can present challenges, but with proper hormonal support it can lead to the beautiful calm of menopause. The second point of confusion for Sophia was directly related to her anovulatory cycles, her high levels of androgens, the male hormones, or androgen excess. The results of her testing confused her because she wasn't presenting with some of the typical high androgen symptoms, like facial hair or extreme aggro, severe mood swings, but she did have the hair loss directly related to increased androgen levels. The reason for her increased levels was because when progesterone leaves the scene in perimenopause, it no longer modulates and keeps the androgens in check. Although I do understand some of Sophia's confusion and frustration with the test results and the information I shared with her, what she couldn't quite get her mind around was this fact. Her resistance to proper treatment was actually prolonging her symptoms and pain. Boosting her very low progesterone levels would have helped relieve many of those symptoms, including her hair loss. But she refused to consider this possibility. However, Sophia had one more treatment barrier. She didn't want any prescriptions that weren't botanical medicines. Treatments made from plants, herbs, roots, flowers, or leaves that support the body's natural healing processes. Even though the goddess progesterone can promote healthy and vital aging, Sophia, like so many women, had been influenced by the findings of the Women's Health Initiative study in 2002, which reported that certain hormone therapies could increase the risk of cancer. So Sophia was not only afraid of taking perimenopausal hormone therapy and preferred botanicals, she also wished she weren't in perimenopause at all. For Sophia's treatment and her desire to only utilize botanical medicines and adjustments in her diet, my hands were a bit tired when it came to delivering the results she wanted in the timeframe she had hoped for. There's only so much you can do with botanicals to reduce testosterone and its metabolites, which can actually be three to four times more androgenic, or male hormone-like, than testosterone itself. From her Dutch testing, I knew we were dealing with high levels of two specific metabolites, etioconalolone and androsterone. Add to that her strikingly low progesterone levels, levels I would only expect to see in a post-menopausal woman, not a 43-year-old. We had a clear picture of the contributors to her hair loss. From the perspective of Sophia's foundational health, our first step was to recolonize, heal seal, and repair the microbiome in her gut. We also needed to support her sluggish thyroid and reduce her elevated cortisol levels, all of which were also playing a role in her hair loss. My recommendation to Sophia, and one that wasn't received well, was this. If we were to use bioidentical progesterone therapy, we could try to re-establish her ovulatory cycles and increase the likelihood that she'd ovulate with each bleed. I also believed that three months of progesterone therapy could significantly reduce, if not stop, her ongoing hair shedding. I explained that I'd be happy to integrate perimenopausal hormone therapy when it was needed alongside a botanical solution. I tried to appease some of her fears by explaining the safety profile of bioidentical progesterone. She has a good safety profile with few significant side effects. She carries a much lower breast cancer risk than synthetic progestins. She's calm, cool, and collected. She helps your sleep. She's anti-inflammatory. She protects your bones, your brain, and your breasts. She downregulates certain autoimmune conditions.

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So I asked Sophia what I now want to ask you.

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Why wouldn't you want this goddess on board? I recognized Sophia was holding on tightly to her fear of hormonal treatment and her denial about the phase of life she was in. But it broke my heart that she was refusing the one treatment that could help her most. My clinic is first and foremost patient-centered care, so I respected her request to try the botanical route first, but I also explained that this path would prolong seeing any results or mitigation of symptoms. The botanical therapies would take at least three months to begin working and likely another three months before we could assess whether they were actually making a difference. Sophia's story is a clear example of how earlier foundational health disruptions, like her history of restrictive eating that led to hypothalamic amenorrhea, can impact the perimenopausal transition. Her resistance to accepting this life phase became one of the biggest barriers to her journey to heal, rebalance her hormones, and ease her symptoms, preventing her body from receiving the support it needed.

Clara And The Body Keeps Score

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Chapter 11.4 Clara How the Body Keeps Score during perimenopause. Clara shares some of the issues we've seen in the other women's stories irregular anovulatory cycles, mood swings, and exhaustion. Also androgenic acne. But hers is a journey that encapsulates the inseparable relationship between the psyche, the mind, and the soma, the body. Clara's health journey demonstrates that in perimenopause, healing is not just about bringing the hormonal chaos into balance. It requires working with her biochemistry, her psychology, and her social experience, all at once and as a whole. For those of you who've read or even just heard of Dr. Bessel von der Koelk's best-selling book, The Body Keeps the Score, Brain, Mind, and Body in the Healing of Trauma, you'll notice I leaned a bit into his title for Clara's case study. I chose to do so because his book so profoundly emphasizes the psychosoma connection and how traumatic experiences can leave lasting imprints on our mental, emotional, and physical health. Clara's story is a cautionary tale of what happens when life circumstances and biochemistry collide. Clara was 35 when she came into my clinic. She was married, but she and her husband had no children yet. Due to changes in her family's circumstances, Clara had to step into the workforce as a high powered professional in a high stress environment, becoming the main breadwinner. This was a major shift in her life, and one I sensed she felt she hadn't signed up for, and deeply resented. That instinct proved true as I learned more about the tension and disappointment she carried towards her husband. Clara didn't want to be working 60 hour weeks. Clara didn't want the job she had. As we reviewed her medical history and she shared her symptoms, it became clear that Clara was experiencing a perimenopausal-like transition at the young age of 35. She wasn't ovulating due to frequent anovulatory cycles. She was severely underweight with a long-standing history of an eating disorder, and similar to Sophia, she'd experienced hypothalamic amenorrhea, an absence of her menstrual cycle. Since the age of 20, for more than 15 years, Clara experienced irregular or absent ovulation, leading to a consistent progesterone deficiency. When we went through the perimenopausal self-assessment quiz together, Clara checked off 23 of the 30 symptoms listed. Clinically, this strongly suggests she was in perimenopause, but like Sophia, she was both resistant to the diagnosis and deeply unhappy about it. Among the most significant physical symptoms Clara reported were the following Androgenic acne, pointing to high levels of androgens, the male-like hormones like testosterone or its metabolite, hair thinning, bloating and constipation exacerbated by low fiber intake, exhaustion and mood swings, loss of libido, emotional numbness and symptoms of depression, insomnia, fatigue, longer and more painful cycles. In essence, Clara was 35 years old, experiencing a profound perimenopausal-like transition, with a history of irregular or absent ovulation. Based on her symptoms and before testing, I suspected she had a significant progesterone deficiency layered on top of her physical challenges. Clara felt bitterness that she had entered perimenopause in what should be her fertile years, and still had no children. The difficult question of whether pregnancy was still possible weighed heavily on her. Before we go further, we need to go back to the beginning of Clara's story and to the root of her unresolved resentment, unspoken and unmet needs, and the relentless pace of her life. All of these factors began to show up as symptoms in her body, and they ultimately contributed to why she walked into my clinic. Clara's story of a body keeping score. As a young couple, Clara and her husband married in Australia. He got an incredible job as a war correspondent with a major TV newsroom. Her husband's role required that they move to the UK, far away from family and friends. As you'd expect, he travelled constantly. Imagine the stress of a job where the phone might ring in the middle of the night calling your husband into a war zone somewhere across the world, while you're left alone to hold down the home without the support of your family or friends you grew up with. Clara described her experience this way. Even though she felt physically safe in their London home, it was as though she was the wife left behind with her husband away at war. I would suspect that his long absences sent Clara's biochemistry into a kind of war zone too. If the person that she loved most in the world and the father of the children that she planned to have was in a war zone, her body wouldn't feel safe. When you layer on her restrictive eating, low body weight, and loss of her menstrual cycles, is it any wonder that Clara's body wasn't prepared to fall pregnant? Eventually, the couple returned home to Australia, and for a while everything seemed to fall into place. Her husband had the big job that he wanted and was making a lot of money. Clara was at home doing a bit of work with her health practice. With her husband as the breadwinner and Clara ready to stay home with the children they planned, life appeared to be unfolding exactly as they had agreed. Until it wasn't. And this is when Clara's biopsychosocial experience went further into misalignment. Clara's husband was assessed by a therapist and diagnosed with PTSD due to the effects of his time out in the field and the difficult things he witnessed. The therapist recommended that he slow down and reduce the stress in his life, including finding a different, less demanding job. Basically, he was told to take it easy. The entire equation in their marriage shifted. He focused on looking after himself, going to the gym every day and eventually taking a lower stress job with significantly less pay. Then, with interest rates rising and her husband no longer earning the same income, the couple struggled to pay their mortgage. Suddenly, Clara had to go out into the workforce. Not only was her new job in a very male-dominated industry, but the high stress and fast pace quickly began to take its toll on her physically and mentally. This was not at all the life Clara signed up for. So when Clara walked into my clinic, her biochemistry was in chaos. She had moved from hypothalamic amenorrhea straight into a perimenopausal-like transition, yet she still desperately wanted children. When I viewed Clara's life through a biopsychosocial lens, I saw a complex picture. Emotionally, I saw a woman who was feeling deeply disappointed in and resentful of her partner, whom she no longer respected or felt protected by, experiencing a loss of libido and desire for intimacy with her husband, leading to an almost complete emotional shutdown, and emotionally resistant to the reality of her perimenopausal transition and grieving because she may not be able to have children. Socially, I saw a woman who was living with a husband who had been a big-time war correspondent, but now was checked out and emotionally unavailable, leaving her feeling unsupported and unseen. Working in a masculine role, both professionally and personally, as the main income earner, which disrupted her sense of partnership with her husband, and living in a state of chronic stress and emotional isolation. And clinically, I saw a woman whose biochemistry mirrored her emotional state. Her body didn't feel safe, and as a result, it often would not ovulate. Hormonal chaos was driving many of her physical symptoms, including a tendency toward low progesterone caused by chronic anovulation, higher estrogen levels contributing to perimenopausal symptoms, and elevated cortisol levels impacting her ability to ovulate and her overall stress response function. And chronic stress and emotional disconnection had led to what's known as a kind of neuroendocrone shutdown, meaning Clara's body had been under stress for so long, physically and emotionally, that her brain and her hormones had shifted into survival mode, shutting down to protect her from the added burden of pregnancy. Having heard Clara's full story, gaining an understanding of how deeply her biology, psychology, and social experience were impacting her health, I could finally begin to design a protocol that would be supportive and nourishing to her body. You see, I didn't believe her biochemistry was broken. Her body was simply trying to protect her. My approach to her treatment.

Healing Through Safety, Nourishment, Reflection

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First, we had to address her nervous system and find ways to calm her HPA access, hypothalamic pituitary adrenal access. This access is the communication pathway between the brain and the adrenal glands, which regulates the body's stress response. Clara's system had been in an overactive state for so long that she needed to downshift from a constant state of fight or flight, reduce her cortisol levels, and guide her body back into a state of balance. Clara's nervous system had been stuck in high alert due to emotional stress, distress in her marriage, long-term calorie restriction, and the demands of overworking. Calming her HPA access was the first step in letting her body know you're safe now, you can begin to heal. I suggested acupuncture and herbal therapies as supportive tools and began educating her further about the impact of chronic stress on fertility and hormonal imbalance. Next, we needed to turn our attention to her nutrition and overall gut health. I encouraged Clara to increase her caloric intake and eat a more nutrient-rich diet. I also recommended a bioidentical progesterone hormone therapy. I explained that without the appropriate progesterone levels on board or proper nourishment, her body would continue to experience anovulatory cycles, making falling pregnant highly unlikely. What broke my heart, much like Sophia's case, was Clara's resistance to listening to the symptoms her body was communicating and increasing her food intake. What her body needed to restore hormonal balance and even open the door to the possibility of becoming a mum was within her reach, a more nourishing diet, and the return of the goddess progesterone. Finally, I had to have a very honest conversation about Clara's relationship with her husband and whether it was truly supportive of her healing. I gently pushed her to take an honest look at the resentment and disappointment she held for him. I asked her to think about doing therapeutic work to explore her core values, her true desires, and the life she wanted for herself. I explained to Clara that in the biopsychosocial environment she was in, both her biochemistry and her body were unlikely to feel safe enough to be vital, to thrive or to bring a baby into this world. I could help her tread water in this state, but because Clara's body was keeping score in perimenopause, I couldn't help her truly heal while she continued accepting so much less than she deserved in her life. Clara's journey is a cautionary tale that reminds us that you cannot address perimenopause and its symptoms purely through hormone therapy, supplements, and diet alone. One must look at a woman's health through a biopsychosocial lens, because a body simply will not heal in an environment that feels unsafe and misaligned. Healing happens when the psyche and the soma are treated as one. I want to leave you with a few reflective questions to ask yourself. Where in my life am I possibly overriding my own needs, physically, emotionally, or relationally? Like with Clara, is it possible that my body is trying to tell me something that I haven't yet allowed myself to listen to? If so, how is my body showing me which changes I need to make? In other words, is it possible your body is keeping score too, and you're not listening?