On a Hormonal Rollercoaster?

Your Support Team Is Waiting for You

Most women first notice perimenopause through changes they cannot quite place. Cycles that ran at twenty-eight days start arriving at twenty-two, and the next one may come at forty-five. Sleep breaks in the early morning hours, either with a wave of heat or with a mind that starts working through the next day's tasks. Irritability becomes harder to manage, word recall slips, and some women experience anxiety for the first time in their forties. Because these changes arrive gradually and unevenly, it is often unclear whether they are connected to each other or to hormones at all.

Many women spend months wondering whether what they feel is hormonal, stress, age, or something else entirely, and the usual route to an answer does not always provide one. Blood tests are often unhelpful during perimenopause, because estradiol and follicle-stimulating hormone (FSH) swing widely from one week to the next, and a single blood draw can come back in the normal range while symptoms are at their worst. For that reason, clinical guidelines in the UK advise diagnosing perimenopause in women over 45 on symptoms alone.

We see many women in this position at Root & Branch, and most of them arrive having been told, in one form or another, that this is normal and that they will get through it. As far as advice goes, its not wrong but its not exactly helpful. What most of them really want though is practical help with the changes in their lived experience. They want to sleep. They want help with temperature. They want to be less irritable and feel like they used to.

What Is Shifting

Perimenopause is the transition leading up to the final menstrual period. It commonly begins in the mid-forties and lasts several years, often four to eight, and menopause itself is defined in hindsight as twelve months without a period, at an average age of about 51 in the United States. During the transition, ovarian hormone output becomes erratic. Ovulation grows irregular, so progesterone, which is produced after ovulation, falls off early and unevenly. Estradiol swings in both directions, with some cycles producing higher peaks than a woman saw in her thirties and others producing very little. The rollercoaster image in the title is a fair description of the physiology.

Hot flashes and night sweats affect a majority of women during the transition, and in the long-running Study of Women's Health Across the Nation (SWAN), they lasted a median of about seven and a half years in total. Sleep disruption, mood changes, new or worsened anxiety, joint aches, and trouble with concentration and word recall are also common, and they tend to travel together. Stress amplifies much of this. Lost sleep raises next-day stress reactivity, and women who report higher anxiety also tend to report more frequent hot flashes, with each appearing to feed the other.

Chinese medicine's account of this transition begins in the first chapter of the Sùwèn 素问, part of the Huángdì Nèijīng 黄帝内经 (compiled circa 100 BCE to 100 CE), which traces a woman's life in seven-year cycles and places the end of menstruation at seven times seven, age 49, when tiān guǐ 天癸, the substance that initiates and sustains reproductive capacity, is exhausted. The tradition treats the years that follow as a period of consolidation, with resources that once went to the monthly cycle now held in reserve, and the same chapter is concerned with how a person reaches tiān nián 天年, the full natural span of life.

In clinic, perimenopause almost never presents as a single pattern. The most common picture involves Kidney Yīn deficiency, shèn yīn xū 肾阴虚, in which the body's cooling and moistening reserves run low and heat surfaces at night as hot flashes, night sweats, and dryness. It is often joined by xīn shèn bù jiāo 心肾不交, Heart and Kidney not communicating, the pattern behind the racing mind and palpitations that keep someone awake once she has woken. Liver qì stagnation, gān qì yù jié 肝气郁结, accounts for much of the irritability, breast tenderness, and premenstrual intensity many women notice in their forties, and Spleen deficiency, pí xū 脾虚, shows up as fatigue, foggy thinking, and digestion that has become less reliable.

Two women with the same hot flashes can have different patterns underneath, and they need different treatment. The full mix of symptoms a woman describes is what tells us where treatment should start.

What Working With Us Looks Like

A first visit at Root & Branch runs long, and most of it is conversation. We ask about your cycle over the past few years, how you are sleeping and at what hour you wake, when heat comes and what it feels like, how your digestion and mood have changed, and what you have already tried. We look at your tongue and take your pulse. We check your abdomen. If you are working with a physician, taking menopausal hormone therapy, or considering it, we want to know, and we work alongside that care.

The center of treatment is a custom herbal formula built for your pattern. A formula for Kidney Yīn deficiency with heat looks different from one for a Liver and Spleen picture, and most perimenopausal formulas address two or three patterns at once, with some herbs carrying the main work and others directing or moderating it. We typically revise the formula every few weeks in response to changes in sleep, heat, mood, and cycle. Research on Chinese herbal medicine for menopausal symptoms is still developing, with some trials suggesting benefit for hot flashes and sleep and others inconclusive. In our clinical experience, sleep is often the first thing to shift, and once sleep improves, much of the rest becomes easier to manage.

Acupuncture supports the herbs. Treatment appears to shift the nervous system toward parasympathetic activity, and many women find their mind settles during the session in a way it rarely does at home. Some studies suggest acupuncture can reduce the frequency and severity of hot flashes, though results across trials are mixed.

Dietary guidance is specific to your pattern as well. A woman with heat signs at night is usually asked to go easier on alcohol, afternoon coffee, and heavily spiced food, while a woman whose fatigue and foggy thinking point to the Spleen is steered toward warm, cooked, regular meals. Most of the recommendations use food from a regular grocery store.

Many of the women we see are also managing demanding jobs and caring for children or aging parents. We follow each patient across months of treatment and expect the picture to change along the way, which matters when symptoms shift as often as they do in perimenopause.

Something to Do Tonight

Stress deserves its own attention during perimenopause, because it feeds nearly everything else. We have recorded a short guided tapping video for the moments when it spikes: before a hard conversation, partway through a hot flash, or after waking early and being unable to fall back asleep.

The technique is Emotional Freedom Techniques, usually called EFT or tapping. You tap lightly with your fingertips on a sequence of points on the hand, face, collarbone, and upper body while naming what you are feeling, then repeat the round until the intensity drops. EFT was developed in the United States in the 1990s and is a modern technique, though several of its points sit on or near acupuncture points used in Chinese medicine.

A 2016 meta-analysis found that it reduced anxiety compared with both no treatment and active control conditions, and later reviews have reported similar results, though many of the trials are small and the mechanism is debated. Some of the effect likely comes from what tapping shares with other calming practices, including slower breathing, rhythmic self-touch, and steady attention on a feeling you might otherwise push away. Those effects help a stressed nervous system whatever the mechanism, and tapping takes a few minutes, costs nothing, and can be done in bed.

Try it once a day for two weeks, ideally at a predictable time, and again whenever stress spikes. Pay attention to how quickly you fall back asleep and how fast a wave of irritability passes. Tapping will not stop hot flashes on its own, and it does not replace treatment of the patterns underneath them. If you are experiencing persistent low mood, panic attacks, or thoughts of harming yourself, talk with your physician or a mental health professional. New depression and anxiety are common during perimenopause, and they are treatable.

If you are in the middle of this transition and have been managing it on your own, we would be glad to see you. The first visit is unhurried, and you are welcome to bring your questions, any symptom notes you have kept, and a list of what you have already tried.

Ready to have your support team step in?

Notes From Dr. Rudio

Hormone Therapy, Honestly

Few topics in women's health come loaded with as much fear and as much outdated information as menopausal hormone therapy. A lot of what people think they know traces back to a single set of headlines from 2002. Here, Dr. Olivia Rudio, our women's health specialist, works through what the evidence shows, what the risks actually are, and where Chinese medicine fits, whether or not hormones end up being right for you.

Q: Let's start at the beginning. What is hormone therapy for menopause, and what is it supposed to do?

Dr. Rudio: When a woman begins the transition toward menopause, the ovaries gradually change the way they produce reproductive hormones, particularly estrogen and progesterone. During perimenopause, these hormones can fluctuate considerably. After menopause, ovarian production of estrogen and progesterone drops dramatically, leaving the body with much lower levels of these hormones.

Because estrogen and other reproductive hormones act throughout the body, these changes can affect many different systems. Some women may experience few to no symptoms, while others experience significant changes in their sleep, temperature, mood, vaginal and urinary tissues, and bone strength. Hormone therapy for menopause is one option used to replace some of the hormones that are declining and, depending on the formulation and the individual, can help relieve hot flashes, vaginal dryness, and recurrent UTIs. But the fact that hormone levels decline during menopause does not mean that menopause itself is a disease or that every woman needs to replace what has been lost.

Hormone therapy has changed over time. One of the best-known early forms was Premarin, a preparation of conjugated equine estrogens made from estrogens collected from the urine of pregnant mares. Menopausal hormone therapy today covers a range of formulations, with different types of estrogen, different ways of administering it, and different doses. The appropriate approach depends on the person's symptoms, goals, age, whether they have a uterus, and their individual medical history and risk factors.

Q: I grew up hearing that hormone therapy causes cancer. Where did that come from?

Dr. Rudio: In the 1960s, estrogen supplementation was strongly encouraged as a way to help women stay young and feminine "forever." Robert A. Wilson, a gynecologist, published a bestselling book called Feminine Forever in 1966, arguing that menopause amounted to a hormone deficiency and that supplementing with estrogen could help women remain feminine and healthy. In the 1970s, however, the pendulum swung when researchers discovered that unopposed estrogen appeared to increase the risk of endometrial cancer. This is why women who still have a uterus are generally given a progestogen alongside systemic estrogen to protect the uterine lining. By the 1980s, hormone therapy was also being promoted for its potential benefits for bone health.

Despite these broader claims, the FDA-approved indication for estrogen therapy was treatment of menopausal symptoms such as hot flashes and urinary problems. Culturally, however, hormone therapy had taken on a much bigger role as a kind of preservation tool, based on the idea that menopause itself was a hormone deficiency. That idea eventually helped lead researchers to ask whether replacing hormones might also protect women against cardiovascular disease. This led to the infamous Women's Health Initiative (WHI), which began in the 1990s. In 2002, one arm of the study was stopped early after researchers reported that women taking a commonly used form of combined hormone therapy had higher rates of breast cancer, stroke, and blood clots.

The part that got lost in the headlines is who was actually in the study. The women were mostly in their sixties and seventies; the average age was around 63, and many were more than a decade past menopause when they started hormones. Since then, we've learned that when a person starts hormone therapy matters a lot, and understanding that has changed how we think about its risks and benefits.

Q: So was the study just wrong? What changed?

Dr. Rudio: First, I think it is important to point out that the goal of this study was to see whether hormone therapy could reduce the risk of diseases that become more common as women age, particularly cardiovascular disease, osteoporosis, and certain cancers. For its established use in treating menopausal symptoms like hot flashes, HRT has long been an effective option for the right candidate.

What a second look at this study generated was something called the "timing hypothesis."

The study was accurate for the women it actually looked at; the results reflected what happened in a population that was mostly older and further from menopause. The mistake was treating those results as the truth for every woman at every age. When researchers looked more closely at age and timing, a different picture began to emerge.

For women who start hormone therapy before about age sixty, or within ten years of menopause, the picture looks different. Research suggests that starting hormone therapy during this window is associated with a more favorable cardiovascular benefit-risk profile, particularly compared with starting it much later. Some studies have even found lower rates of coronary heart disease in women who begin hormone therapy closer to menopause. But this doesn't mean HRT is a treatment for cardiovascular disease or that it is protective for everyone. The timing matters. Starting hormones as an older woman, particularly one who already has significant cardiovascular risk, is a very different situation from treating a recently menopausal woman for symptoms like hot flashes. We had been asking one study to answer a much bigger question than it was designed to answer.

Q: So where does Chinese medicine fit into all this?

Dr. Rudio: I don't see Chinese medicine as being in competition with hormone therapy. If a woman has decided with her medical provider that hormone therapy is right for her, that doesn't change the way I practice.

Remember earlier when I mentioned that the original estrogen used in hormone therapy was derived from pregnant horse urine? I find that symbolically interesting as an acupuncturist and herbalist because, in Chinese cosmology, the Horse has a natural relationship with the Fire phase. Fire is Yáng 陽: warm, active, stimulating, and associated with the Heart, circulation, and the movement of qì 氣 and Blood through the body. The Heart, in turn, has a key relationship with the Blood.

I should be clear that there is no medicinal application of horse urine in any Chinese herbal formulas that I know of or studied in school. What interests me is the symbolism, because it opens up another way of thinking about what happens when the body has a lot of Fire and activity over a long period of time.

Fire has a limitation: it consumes Yīn 陰. Yīn is the more substantive side of the body, the Blood, fluids, tissues, and nourishing substances that give the body something to draw from and that anchor all that activity. When there is a lot of Yáng activity without enough Yīn underneath it, the body can begin to show signs of having been overdrawn: dryness, heat, hot flashes, and difficulty settling down and resting.

Modern life asks a lot of women. We live in a culture that already tends toward Yáng, with constant stimulation, productivity, activity, stress, and very little encouragement to slow down. By the time a woman reaches perimenopause, she may already be living with years of demands on her body and nervous system. Menopause doesn't simply happen in isolation from that history.

This is one reason the Blood is so important to assess in women's health concerns around peri- and post-menopause. Blood in Chinese medicine covers more ground than the blood we see in a lab test or the blood a woman loses during her period. It is part of how we understand nourishment, circulation, sleep, and Shén 神, the consciousness, mental vitality, and emotional presence of a person. Women who have a menstrual history have an advantageous insight into the quality and movement of their Blood based on what their menstruation looked like.

Q: What if I can't take hormones, or don't want to? Or what if I take them and still feel terrible?

Dr. Rudio: This is exactly where Chinese medicine earns its place, and it covers more women than you might think.

If hormones are off the table for you, whether because of a cancer history, a clotting risk, or your own considered choice, you still have options. Well-chosen herbal formulas can take the edge off hot flashes, improve sleep, steady mood, and ease dryness and fatigue, without touching your hormones. Acupuncture can support the transformation started by the herbs. Dialing in a formula takes longer than rubbing on some topical estrogen, and for many women even the modest changes early in treatment are enough to make the difference between coping and struggling. Given a few weeks, many women report a complete retreat of their symptoms.

The other big group who Chinese medicine can help is women who are on hormone therapy and still do not feel right. Maybe the flashes are better, but the sleep is still broken, or the mood is low, or the digestion is off, or there is a fatigue the hormones never reached. Hormones replace estrogen, and that is where their job ends. Tuning the rest of the system, the sleep and the mood and the digestion and the energy, is the work Chinese medicine is built for, and it sits comfortably alongside a prescription. You do not have to choose one team.

The decision about hormone therapy belongs to you and the clinician who knows your history. What the last twenty years have changed is the quality of the conversation you can have about it. The 2002 headlines are not the last word, the risks are smaller and more specific than most people were told, and both the form and the timing matter. Bring your own history into that conversation, including what your periods looked like, because that is information your clinician cannot get anywhere else.

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