Chapter 10 - Rebalance Your Hormones

You can feel “not like yourself” for months and still be told everything is normal. We challenge that story by getting specific about what changes in perimenopause, why it is often a high and wildly fluctuating oestrogen state with low progesterone, and how easily that can be mistaken for menopause if you rely on a single blood draw or a rough timeline. We also clarify the clinical definition of menopause (twelve months and one day without a bleed) and why postmenopausal bleeding needs prompt medical assessment.

From there, we dig into why many guidelines in Australia, the UK and the US lean on symptoms alone and do not require routine hormone testing and where that approach can fall short when your body is more sensitive or your symptoms are complex. We talk about the “snapshot” problem of standard blood tests during a hormonal roller coaster, why physiology should guide interpretation, and how the timing of progesterone and other hormone tests can change the meaning of your results.

We broaden the lens beyond sex hormones into the foundations that can mimic or worsen perimenopause symptoms: a full thyroid panel, iron and ferritin, HbA1c and metabolic markers, lipids and vitamin D. Then we explain what comprehensive hormone testing such as the DUTCH test can reveal, including hormone metabolites, oestrogen metabolism pathways, progesterone metabolites, androgen conversion, cortisol rhythm, the cortisol awakening response, and melatonin, all linked back to real-world concerns like 3 am wake-ups, fatigue, anxiety and stubborn weight gain.

If you want clearer answers and a calmer path through perimenopause and menopause, hit play, share this with a friend who is struggling, and leave a review so more women can find it. What symptom would you most like proper testing to explain?

Transcript

Rebalance And Why Precision Matters

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Chapter 10 Rebalance For every reason you've been told you can't feel like yourself again, there is one better reason you can. Before we dive into rebalance, more specifically rebalancing your hormones, I want to take a moment to set the stage for this important chapter. In my clinic, today more than ever, it is so important to understand a woman's unique biochemistry, especially when entering perimenopause. Without the right testing, we can't know for certain what is really going on in her body. And when we don't know, we risk offering treatments that don't fully support what her body needs to heal and resolve. Or, at the very least, mitigate her symptoms and offer her some relief. In this chapter, I want to share with you why testing is so critical. Not only to measure your hormone levels, but also to gain a clearer picture of your biochemistry so that we can truly support you at this critical stage of life. Your body deserves precision. Let

Perimenopause Versus Menopause Basics

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me begin with a gentle reminder. Menopause and perimenopause are not bad. They are both natural, powerful transitions, but they are also distinctly different phases that require different approaches to care. More and more women come into my clinic and, on their intake forms, tick the box that they're a menopausal. But when I take the time to dig a little deeper into their stories and their symptoms, they'll also mention not having a period in four months, irregular or heavy bleeding, and tender breasts. If you remember from earlier, the hormonal patterns are completely different because perimenopause and menopause are two different stages in your life. Research has shown that perimenopause is characterized by high and fluctuating estrogen levels combined with low progesterone, while menopause is defined by consistently low estrogen levels. And the reason is perimenopause is not yet menopause. Yet, so often, both GPs and the women themselves don't correctly identify which phase of life they are in, which can result in improper treatment that results in real and lasting consequences. One more important reminder menopause is officially defined as going twelve full months and one day without a bleed. An important side note any postmenopausal bleeding must be promptly evaluated by a healthcare professional to rule out serious underlying causes, including endometrial pathology. But what I hear so often is that a woman will have gone two, three, four, six, even eight months without a period, and she'll think, right, I'm in menopause now. And once she believes she's menopausal, she may be more inclined to accept a diagnosis or treatment from the traditional medical model that isn't actually appropriate for her, or for the stage of life she's truly in. The truth is, until you've hit that 12 months plus one day mark, you're still in perimenopause. Your ovaries are still active, your hormones are still fluctuating, and that means your treatment plan needs to reflect that reality. That's why this distinction between perimenopause and menopause is so crucial. Getting the diagnosis right. Knowing whether you're a perimenopausal or menopausal can mean the difference between receiving truly supportive care or continuing to struggle for years with symptoms that may never resolve. You will see this firsthand in the next chapter when I share the health journeys of six women

Misdiagnosis And The Real Consequences

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who came to my clinic seeking treatment. Misdiagnosis at this stage of your life isn't just frustrating, it can lead to years of inadequate care. In clinical practice, women in perimenopause who are incorrectly treated as if they're a menopausal may experience worsening symptoms, including increased anxiety, breast tenderness, and irregular bleeding. On the flip side, I also see women between the ages of 35 and 45 who resist the possibility that they could be in perimenopause, and I get it. For many women, there's still this outdated and limiting idea that perimenopause means you're suddenly dried up, old and no longer fertile or lush, that it marks the end of your vitality, your sexuality, your relevance. Nothing could be further from the truth. Perimenopause is a powerful transformative time. It's a time to reclaim yourself, to step into your truth, to see things differently, to stand taller, to speak up, to set boundaries that you may have never dared to before, to rediscover your own magic and discover your strength. Shed the layers of expectation and people pleasing that may have built up over the years. This is the part of your life when you start to care less about the things that don't serve you, less about what others think, less about being the good girl all the time. You start to care more about what truly matters to you, your health, your relationships, and your purpose. So I invite you to step into this

Reframing Perimenopause As Transformation

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liminal space between two important phases in your life. To see perimenopause not as something to dread or deny, but as a powerful upgrade, an opportunity for deep transformation, allowing you to transition successfully into the peace of menopause. My intention is to provide you with the tools to take care of yourself in a way you never have done before, so you can fully receive the gifts this phase of perimenopause has to offer. And here's the one thing I really want you to hear. The sooner you come to terms with the possibility that you are in perimenopause, the sooner you can receive the therapies and support that can make this transition not just bearable but graceful, enjoyable, and even peaceful. Because what is the alternative? Dragging yourself through each day feeling exhausted, moody, and disconnected? Embarrassed by your overreactions, the aggro? Struggling with sleep and hot flushes? Frustrated by the unexplained weight gain? You deserve better than that experience. This phase of life isn't here to break you, it's to awaken you, and I promise you that when you embrace it, it can become one of the most powerful, joyful, and liberating transitions of your life. In terms of rebalance, emerging science shows that timely, individualized hormone treatment in perimenopause can support cardiovascular and metabolic health, may help preserve cognitive function, and can reduce central fat gain. When appropriately prescribed within the window of opportunity, the risk-benefit profile is generally favorable. The sooner you make peace with the life phase you're in, perimenopause or menopause, and receive the therapy that matches this moment in your unique biochemistry, the better your chances are of transitioning into menopause without the chronic health issues and challenges so many women are left to face when they don't get the care they need. Because menopause is not a disease. It is not the end. It's a doorway. And you deserve to walk through it with clarity, confidence, and care.

Starting With Comprehensive Testing

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So, where do we begin? It starts with proper testing. That's where we can start to understand exactly where your unique biochemistry is during this important transition to find out which stage you're in, perimenopause or menopause. As discussed earlier, I begin this phase of testing with full foundational bloods and the Dutch test. This is where more comprehensive testing, like the Dutch test, becomes invaluable. Not because it is required for a diagnosis of perimenopause, symptoms alone can do that, but because it gives us precision. It helps us understand not just what your hormone levels are at in one isolated moment, but how your body is processing, metabolizing, and clearing those hormones over time. That level of detail allows us to create a treatment plan that is truly tailored to your unique biochemistry. Women come in after being told their blood work is fine, even though they're struggling with debilitating symptoms. They're told their estrogen is normal, but no one is checking how their body is metabolizing that estrogen or whether it is being converted down problematic pathways that increase cancer risk. No one is looking at their progesterone metabolites to see if their body is actually using the progesterone it is producing. No one is tracking their cortisol pattern throughout the day to understand why they lie awake at 3 a.m. or wake up exhausted. The problem with standard testing. I want to pause and talk about something I believe is very important.

Guidelines And The Limits Of Bloods

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How perimenopause and menopause are currently identified or diagnosed in the traditional medical model, and why that matters for you. It might surprise you that in the UK, the US, and Australia, the official medical guidelines for diagnosing perimenopause and menopause do not actually require hormone testing at all. In the UK, the National Institute for Healthcare and Excellence, NICE, which sets the standards for medical practice, states that perimenopause and menopause should be diagnosed based on symptoms alone for women over 45. No blood work is needed. In the US, the North American Menopause Society, NAMS gives similar guidance. For women over 45 with classic symptoms, no testing is required. For younger women, FSH testing may be used, but even NAMS acknowledges that hormone levels fluctuate wildly during perimenopause, making single blood tests unreliable. In Australia, current practice guidance from the Australasian Menopause Society aligns with these international standards. Their practitioner toolkit advises that for women over 45 with typical symptoms, a clinical diagnosis based on symptoms is sufficient, and routine hormone testing is not necessary. Now, I understand the reasoning behind this approach. In a resource-strapped healthcare system, it makes sense to rely on clinical symptoms rather than expensive tests, especially when those tests may not be reliable during the perimenopause transition. But here is the problem. Standard hormone testing, done via single blood draw, the kind of through most GP surgeries or conventional labs, typically measures only FSH, LH lutinizing hormone, and sometimes estradiol. It's not capturing all hormones together in symphony, and it is important to see all hormones and how they are all working in the body. If you're in perimenopause, your hormone levels are all over the place. They can swing wildly from one week to the next, even from one day to the next. So, a single snapshot in time does not tell you much. You could have your blood drawn on a day when your estrogen happens to be high and your doctor might say everything looks normal, but two weeks later your estrogen could have plummeted, your progesterone could be non-existent, and you could be feeling absolutely terrible.

Physiology First With Fluctuating Oestrogen

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Understanding the physiology comes first. Something I believe to be absolutely critical, something that can make the difference between getting the right diagnosis or being misdiagnosed for years, is that your practitioner needs to understand the physiology of perimenopause before they interpret any blood test result. Let me explain why this matters so much. I have shared that Professor Gerald and Pryor's landmark research over three decades has established that perimenopause is not a state of estrogen deficiency, as many people assume. Instead, it is frequently a hyperestrogenic, low progesterone state. During perimenopause, estrogen levels are often higher and more erratic than normal. This is a paradigm shifting insight. Perimenopause is a high estrogen, low progesterone state, whereas menopause is a low estrogen, low progesterone state. The treatment for each is entirely different. Imagine this scenario. A doctor orders a blood test and catches your estrogen at a low point, say after it's just crashed from a high peak to the bottom of the cliff. They might look at the number and think her estrogen is low. She must be menopausal. But that would be wrong. If that practitioner does not understand the full physiological picture, as you do by now, that estrogen surges wildly during perimenopause before it crashes, they may misdiagnose perimenopause as menopause. That misdiagnosis leads to inappropriate treatment that can make you feel worse, not better. This is where clinical wisdom must override laboratory values. If you're experiencing heavy bleeding, breast tenderness, mood swings, and bloating, all signs of estrogen dominance, a knowledgeable practitioner should recognize that you are in a high estrogen perimenopausal state, even if one random blood test shows low estrogen. Your symptoms tell the story. The blood test is just one piece of data, and it is capturing only a moment in time.

Timing Plus Foundational Health Markers

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If blood tests are done, timing is everything. Keeping in mind physiology first, if you and your practitioner do decide to use standard blood testing, I want to share with you why timing is absolutely critical to getting accurate results. Hormones rise and fall throughout your cycle in predictable patterns. If you test at the wrong time, you will get falsely low or falsely high results that do not reflect what is actually happening in your body. Here is what I recommend in my clinic. For progesterone testing, progesterone should be tested between days 19 to 22 of a 28-day cycle, or about 5 to 7 days after ovulation, if you're tracking ovulation. Why? Because, as I've spoken to, progesterone peaks in the luteal phase after ovulation. If you test it earlier in your cycle, you will get a falsely low reading that does not reflect your true progesterone status. For all other hormones, estrogen, E2, testosterone, free testosterone, sex hormone binding globulin, SHBG, Lutinizing Hormone LH, and FSH should all be tested between days 1 to 3 of your cycle. I typically recommend day 2 as the optimal testing day. Testing at the wrong time means you might catch these hormones mid-surge or mid-crash, giving you inaccurate information. It is not just about sex hormones. And here's something else I need you to understand. Something I see overlooked time and time again in conventional medicine. It is not just about estrogen, progesterone, and testosterone. As I discussed earlier, there are foundational blood tests that are absolutely essential for understanding your health during perimenopause. These include a full thyroid panel, not just TSH, but free T3, free T4, reverse T3, and thyroid antibodies, iron studies, including ferritin, because iron deficiency is rampant in perimenopausal women, HBA1C to assess blood sugar control, lipid panels, and vitamin D levels. Why does this matter? Because thyroid dysfunction, iron deficiency, insulin resistance, and chronic stress can all mimic or worsen perimenopausal symptoms. You cannot effectively rebalance your hormones if your thyroid is struggling, your iron stores are depleted, or your blood sugar is on a roller coaster. This is why comprehensive testing, not just a quick FSH check, is so important. We need to see the whole picture. There is so much more to hormones than a blood level. What standard testing completely misses is the whole story of how your body is actually processing your hormones. To truly understand what is happening with your hormones during perimenopause, we need to look at where all of your estrogens are at E1 estrone, E2 estradiol, and E3 estriol, not just a single estrogen measurement. We need to see how those estrogens metabolize, which pathway they are taking, because some metabolites are protective, while others can increase cancer risk. We need to understand how your testosterone is metabolizing as this can explain symptoms like hair loss. We need to look at your cortisol awakening response, your dional cortisol pattern in relation to melatonin and dopamine, because these stress, motivation, and sleep hormones directly affect how you feel, how you sleep, and how your body responds to perimenopause. We also need to look at your insulin sensitivity because perimenopause affects how your body handles glucose and can shift you towards insulin resistance. This is why I appreciate the nuance and the depth of the Dutch test, dried urine test for comprehensive hormones, that I use in my clinic, alongside foundational blood tests. The Dutch test does not just measure hormone levels at a single point in time. It tells the entire story of how your hormones are being processed, metabolized, and cleared from your body over a 24-hour period.

The DUTCH Test And Hormone Metabolites

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Why the Dutch test versus only a simple blood draw? A woman's hormone levels can fluctuate substantially even within a single day. And this is especially true during perimenopause. Do you remember why progesterone matters more and the antics we discussed in chapter 4 that come from Ardeva estrogen? Once progesterone starts to exit the scene, estrogen is left unmodulated. Her levels can soar to great heights and then crash back down. This often leaves your body feeling like it's stuck on a perimenopausal roller coaster. If you're listening to this book, I would venture to guess you've most likely visited your doctor or health practitioner to report symptoms like mood swings, sleep issues, hot flushes, or that relentless fatigue that just won't let up. And chances are the doctor ordered a blood test. That's what most GPs typically do so that they can check your hormones, estrogen, progesterone, perhaps FSH and sometimes testosterone. But here's the thing: the blood test is just a snapshot. It only tells you what your hormone levels are at the exact moment your blood is drawn. And during perimenopause, that moment can look completely different from the day before or even the hour before. That's why a simple blood draw may not tell the full story of what's happening in your unique biochemistry. The Dutch test offers a more comprehensive analysis of your hormones and their metabolites, meaning it tells your doctor how those hormones are being processed and cleared from your body over a 24-hour period. When we talk about hormone metabolites, we're referring to the byproducts your body creates as it breaks down and eliminates hormones like estrogen, progesterone, and testosterone. And those byproducts matter. We'll dive deeper into why this information is so vital in just a moment. But for now, what's important to understand is the Dutch test gives us insight, not only into how much of a hormone is present, but also into how your body is using it, clearing it, or possibly storing it in a way that can contribute to your symptoms. I trust the Dutch test because it can give you so much more information than a simple blood drawer. With a blood test, you don't see how estrogen is being metabolized. You don't see the downstream metabolites of testosterone. And yet, these two pieces of information are often the missing data points in a woman's hormonal picture. Before we go into more detail about the actual Dutch test, there's a bit of an elephant in the industry that I want to address. I want to share the reasons why I believe that health practitioners must test. Now here's where I step in. It's not that I disagree with the current guidelines, it's that I want I want to ask what I feel is an extremely relevant question. When we diagnose a woman as perimenopausal or menopausal, why aren't we testing her hormone levels comprehensively? Especially when we know in the medical community that every woman's biochemistry is unique. When her symptoms, her sensitivities, and her lived experiences are also unique. My intention in asking this question is so that it might act as a gentle disruptor and a respectful challenge to the current guidelines. Why? Because I want to advocate for the woman whose body may be more sensitive. The woman who's already been dismissed or misdiagnosed. The woman who may have other health issues going on beneath the surface. For her, I believe testing is not only helpful, it's critical. And please hear me, this is not about pointing fingers at other health practitioners. Most are doing their best, working within the system and guidelines they've been trained to follow. But that's exactly why I believe the guidelines need to be revisited, according to recent research in this periodopausal space. That's why we must be able to better evolve our practices to match the updated data that new research is allowing us to find. Even if not everyone in this field agrees with me, I believe it's time to shift toward testing. Here's why. Without proper testing, women are often prescribed hormone therapy guided by symptoms without the precise knowledge of what might be truly going on with their hormone levels or underlying issues, which then puts them at risk of receiving support that might not actually match the phase of life they're in. For example, if a woman is in perimenopause and is unknowingly in a high estrogen state, as you'll see in our next chapter with Nina, giving her additional estrogen without testing first can actually cause more harm than good. It is for this reason that the Dutch test is often my go-to tool when I treat women who have fallen through the cracks of the traditional medical model, which in my experience is far too many. I believe testing needs to happen, not only because every woman responds to and metabolizes hormones differently, but also because if primary care providers were to test more consistently, they'd see what I so often see in clinic. High estrogen in perimenopause, low or missing progesterone, and treatment plans that don't reflect what a woman's body truly needs. With all that in mind, let's take a closer look at the benefits of the Dutch test. This is the same information I provide to support each woman in my clinic through the rebalance phase of her healing journey. What the Dutch test really tells you. As I go over Dutch test results with a patient, I often describe them as not just a snapshot of your hormone levels. It's a clearer story of how your hormones are behaving, how they're moving through your body, and how your biochemistry is responding. Instead of a single snapshot, the Dutch test tracks your hormones over a 24-hour period using dried urine samples collected at specific times throughout the day. You do this in the comfort of your own home, and it provides a level of insight that a single blood drawer at your doctor's office simply cannot match. The sex hormones more than just the numbers. The Dutch test will show your levels of estrogen, progesterone, and testosterone, along with their key metabolites. And this is where things start to get interesting. Because it's not just about how much of each hormone you have in your body, it's also about how your body is metabolizing them, meaning processing each one, responding to each one, and whether each of them is working for you or against you. Estrogen the diva with three metabolic pathways. Estrogen is incredibly powerful. During perimetopause, as you know, she can become unpredictable. Some days her levels soar, some days they come crashing down. That's why it's not enough to just know your total estrogen levels. We need to know what your body is doing with the estrogen it's using. And here's where the Dutch test becomes so valuable. It looks at estrogen metabolism, which means it doesn't just measure how much estrogen is floating around in your system. It also shows how your body is breaking estrogen down and clearing it out using three metabolic pathways I will describe below. You see, with estrogen, it's vital that your body uses it and then loses it. This is incredibly important because the way your body metabolizes estrogen can affect everything, from your mood, sleep, and cycle symptoms to your long-term risk for hormone-sensitive conditions, like fibroids or even certain cancers. The Dutch test helps us answer the question, which pathway does my estrogen take on its way out of my body? And just as importantly, this test tells us how well you're clearing out those estrogen metabolites. Even the good metabolites need to make use of efficient elimination. If the estrogen metabolites stay around too long, they can exacerbate symptoms like bloating, breast tenderness, and irritability. Estrogen is primarily cleared or metabolized through three main metabolic pathways, meaning the roads your body is sending your estrogen down to lose it. The pathway your estrogen is being cleared through matters because one is more favorable and safer than the others. Two hydroxy pathway. This is the protective route. It produces estrogen metabolites that are less estrogenic and generally considered less inflammatory and more easily eliminated from your body. This is the route we want to favor. The four hydroxy pathway. This one can be more problematic. If the metabolites from this pathway aren't properly detoxified, they can damage DNA and potentially increase cancer risk. sixteen hydroxypathway This creates more active estrogen-like effects in the body. When this pathway is dominant, it's been associated with more proliferative estrogen effects, and in some studies, linked to things like heavy periods, fibroids, endometriosis, and estrogen sensitive cancers. It's important to note that while these pathway distinctions guide clinical practice, the clinical significance of estrogen metabolite ratios remains an active area of research, and not all studies have found consistent associations with disease risk.

Cortisol, Melatonin, And The Road Ahead

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Progesterone the calm, the cool, the collected. Your progesterone metabolites, A pregnanodile and B pregnanodile, help us understand how much progesterone your body is making. Much of this will sound familiar from earlier in the book, but as a reminder, progesterone is the goddess. She is your calming, steadying hormone. She also promotes and supports sleep, soothes anxiety and regulates your cycle. As you know, estrogen may get all of the attention. I would argue that progesterone matters more, especially during perimenopause, when progesterone is often the first to leave the scene and the party girl estrogen is left to her own devices. What you may not know is that in working in tandem with estrogen, progesterone plays a key role in the following. It may improve heart health through its antiinflammatory properties. Progesterone is a natural anti-inflammatory. It supports bone formation by stimulating cells that build new bone, thus protecting you from osteoporosis. When your progesterone levels drop, leaving estrogen unchecked, symptoms will often include the following sleep disturbances, trouble falling asleep, staying asleep, or waking up feeling wired and tired, anxiety, feeling more on edge, heavier or longer periods, thanks to estrogen running unopposed, irregular menstrual cycles. Your body's rhythm starts to feel off. Bloating or breast tenderness. The Dutch test measures not just testosterone but also DHEA, DHEAS, and DHT, as well as how testosterone is converting or aromatizing into estrogen. This helps explain symptoms like hair loss, low libido or unexplained weight gain. Even though these are often called male hormones, androgens, they matter deeply for women too. Again, we're not just looking at the total amount of testosterone, we're also looking at how your body is processing it, converting it, and whether your androgen balance is contributing to symptoms you're feeling now. Cortisol and your body's morning wake-up call. The Dutch test results will also show how your cortisol levels, your main stress hormone, rise and fall over a 24-hour period. One key aspect I focus on when I review these test results is the cortisol awakening response, or CAR. This refers to the natural rise in cortisol that occurs within the first 30 to 60 minutes after waking. It acts as your body's natural alarm clock, helping you transition from sleep to alertness. When your car functions optimally, you wake up feeling refreshed and ready to take on the day. However, if your cortisol levels are too low in the morning, you might wake up feeling tired, flat, and unmotivated. Conversely, if your cortisol is too high at night, you might find yourself feeling wired but tired, struggling to fall asleep, despite feeling exhausted. Understanding your cortisol rhythm is crucial to taking steps to properly rebalance your hormones, especially if you're experiencing symptoms like fatigue, sleep disturbance, burnout, or anxiety. Melatonin, your sleep hormone. The melatonin connection. The Dutch test also shows how well your body is producing melatonin. Low melatonin can explain why you're waking at 3 a.m. or struggling with sleep despite feeling exhausted. All this information collected from four simple urine samples over 24 hours in the comfort of your own home gives us a pretty complete picture of what is really happening in your body. I recognize I've leaned into the science behind why the Dutch test and proper testing in general is critical to rebalancing your hormones, but I wanted to share why this level of insight is so valuable when you're trying to get to the bottom of stubborn perimenopausal symptoms. This insight can be the difference between your practitioner announcing that your blood tests are in normal range as they dismiss your symptoms, even when you know your body doesn't feel right. Your hormones aren't random, they're part of a beautifully complex system. Standard blood tests offer a snapshot of them at a certain moment in time. But these standard tests often miss the nuances of what's actually happening in your body. With important bloods and comprehensive testing, like the Dutch test, we're able to gain deeper insights into your unique biochemistry, which allows us to rebalance your hormones in a way that supports your unique body so you can feel vibrant and balanced. This way you can step into the best version of you. The Journey to Rebalance. In my clinical practice, every woman I work with receives a treatment plan tailored specifically to her. This means the plan from repairing her gut to rebalancing her hormones is crafted based on her unique symptoms, history, and test results. An individualized approach is the essence of precision medicine. However, within the confines of this book, I can't provide a personalized hormone prescription for each listener. So to introduce the second phase of the hierarchy of healing, rebalance, I want to share six health journeys from real women. Their stories, or perhaps cautionary tales, describe the challenges each woman faced when proper testing was not done, nor was the proper diagnosis given, and then go on to describe the transformative power that rebalancing their hormones brought to their lives. I hope that somewhere in these stories you may recognize similarities you currently face in your own health challenges and gain valuable insights that will guide you towards reclaiming your vitality.