Beyond Hot Flashes: The Real Story Of Perimenopause

It's not actually the classical hot flashes that I see in my practice that are the most bothersome for individuals. And I love that we're having this conversation because there's so many other symptoms that changes to your hormones and cause, but there is so much we can do.

in the perimenopause stage before we actually see changes to the menstrual cycles or absent menstruial cycles. I see so many individuals, women, and perimetopos thinking, these symptoms are so severe for me, they're not being taken seriously.

They've actually had to reduce their work hours to part-time. This is Doctor Talks. Today, I have an incredible guest who truly embodies what it means to be a high achieving woman.

She's a leader in the world of health and wellness, a doctor of naturopathy and a thriving entrepreneur, all while balancing motherhood and personal excellence.

By the age of 25, she had already earned an honors degree in biomedical sciences. Her doctor of naturopathy degree started a family and had built a successful business.

But she didn't stop there. She's on a mission to help women step into their power, feeling strong, looking their best, and achieving greatness in every aspect of their life.

Welcome, Dr. Breanne Kalanin. Well, Dr. Kalanin, I am so excited and grateful that you're here today. I'm excited to connect in real life. Thank you so much for having me.

Yes, it's definitely an important topic and I'm excited to be here talking about perimenopause. And you're absolutely right. It was kind of a topic that wasn't discussed very often, you know, in the last even five to 10 years, It's really been progressing.

Yes, and I'm excited too because we're going to look at this and through a bit of a different lens, of course, we'll touch on like hormone replacement and things, but I love that you want to emphasize other aspects of our physiology and just looking at our body from a global holistic standpoint and how we can best support it during this time.

But let's start with kind of the basics, the building blocks. Tell me some of most common symptoms that are associated with perimenopause. So the most common symptoms that we typically think of and hear of when it comes to perimenopause and menopausal is of course the classical hot sweats, right?

Night sweats. Hot flashes during the day. And that definitely the vasomotor symptoms are concerning for individuals. I don't know if you see this in your practice, but when individuals come to me, their main concerns are actually a little bit different.

it's the mood changes, it is the cognitive complaints. So the difficulty recalling what they're wanting to recall, the lack of concentration, sleep disturbances, even joint pain, tinnitus, anxiety, depression, vaginal dryness, increased urinary tract infections as well.

It's not actually the classical hot flashes that I see in my practice that are the most bothersome for individuals. And I love that we're having this conversation because there's so many other symptoms that changes to your hormones can cause.

Absolutely. And it is like, I feel like hot flashes are so loud and overt, like they're very noticeable. They're not subdued. You don't ease into them over time and only realize when they are super severe.

they kind of are pretty easy to notice, but some of the other hormones, the others symptoms you described are more subdued and they kind of slowly increase over time and I think people just dismiss them and don't realize it until they're profoundly significant and really really impacting their lives.

So I love this conversation because people can intervene a little bit earlier. Sorry, another misconception too that you just have to deal with these symptoms until your period stops and then you can get treatments.

But there's so much we can do in the perimenopause stage before we actually see changes to the menstrual cycles or absent menstruals cycles. Amen. This idea that women just sort of need to suck it up and suffer through in medicine until things are definitively one meet specific criteria is crazy.

It's absolutely crazy and I can only imagine you see the same thing, but I see losses of hormones like testosterone and progesterone and changes there.

so early, like so, so incredibly long before menopause that not intervening with them and helping support these systems really can have long-term implications in their quality of life, but even their health.

It impacts relationships, whether it's intimate relationships, relationships with friends and family, their children can impact their job. I see so many individuals, women in peri-metapods thinking, these symptoms are so severe for me, they're not being taken seriously.

They've actually had to reduce their work hours to part-time. And I'm just wondering, you know, how many individual are being missed and how much of this quality of life can we improve and the detriment to income and relationships that otherwise could be prevented.

Yeah, absolutely. Tell me some sort of red flags, yellow flags that women should be looking for, leading them to get a workup for perimenopause, and then tell me a little bit about what that work up looks like for you and for your patients.

Yeah, of course there's the big ones, like the obvious ones. Definitely you're having the hot flashes, the night sweats, irregular menstrual cycles. That's a great time to have a look at, is perimenopause a factor here?

But also the more subtle things that you talked about, loss of libido, vaginal dryness, increased urinary tract infection, new onset anxiety or depression that's not related to changes in your lifestyle or events that have occurred.

weight gain, all of a sudden your cholesterol goes up, your blood sugar is going up. You're having joint pain, tinnitus, hair loss. There's many, many symptoms that could lead us to want to really take a look.

Is this related to the changes that occur in perimetopause? Perineum menopause can occur 5 to 10 years prior to the onset of menopsis. And yeah, the average age of Menopaus 50, 51, 52, but it also can also occur earlier for individuals.

So I don't look at age as a defining factor, whether or not we're going to do a full hormone workup. I always look symptoms and what the individual is experiencing.

Blood testing can be helpful, although it's particularly challenging during perimenopause because it is not this nice, natural, easy decline in hormones until your period stops.

I think of it more as a hormone rollercoaster or a second puberty. So yes, I love as functional medicine doctor, looking at labs, testing, but we have to recognize because the hormones are so erratic during this time, one cycle we might get perfect labs and in the next cycle it could be completely different.

So it's not just about looking at the blood testing and what that says, but we have to look at both the patient's symptoms and the labs. I totally agree.

And I want you to… People get so confused about the lab thing. Like, they go and they get labs, and, like, oh, my labs were fine. But what they don't understand is the labor ranges are enormous, the fluctuations and hormones and importance of timing of labs and why that's difficult with perimenopause.

Can you extrapolate on that a little bit so that people can, because I think this is an aspect of medicine that is patient driven, meaning patients are going to their doctors advocating for themselves and being knowledgeable and empowered.

So they're driving the care that they need to receive. I want to really empower them with an understanding of this so they can kind of go a bit deeper.

Yeah, absolutely. And the common misconception that I hear for a lot of individuals is they'll say, well, my doctor won't run my hormones because hormones change all the time.

Yes, that's true, right? Our hormones as women will change throughout our menstrual cycle. But if we understand when you went for the labs in relation to your period, when your periods started, then where your next one came, we can definitely use that as information.

It's not definitive in terms of whether or not you would receive treatment, but it can help drive our treatment approach. I usually want to see our individuals ovulating.

And to get that information, I send individuals for their blood work about a week to 10 days before their next menstrual cycle. We can also look at an FSH.

If that's elevated, that can suggest perimenopause. But there's no one definitive blood marker that is going to say yes or no, you're in perimentopaus.

It's always important to combine individuals' labs with their symptoms. And also looking at other things that can cause similar symptoms to perimenopause, right?

So, you know, maybe it's not your hormones. Maybe it is an underlying thyroid condition or it your blood sugar that's throwing off your hormone or a nutrient deficiency that is causing your symptoms or issues with other hormones like cortisol.

We really have to take both the symptoms and the labs and interpret it very carefully. It's not just enough to say, oh, I hear this all the time, your hormones are normal, but the progesterone was tested on day three.

Progestrin is going to be low on Day 3. Yes, it's low for like 95% of your cycle and we need to know what it is at its peak when it actually showing up.

Exactly. Yeah. And, you know, sometimes it's not the absolute hormone level that's driving people's symptoms. Sometimes it just the dramatic fluctuations that we see.

Some individuals are very sensitive to the changes in those hormones. So it is more than just, blood work. It is just more looking at those big, broad, normal ranges.

We have to look at what is optimal. Actually, what's optimal is going to be different for each individual. Tell me some of the most common things, you kind of touched on this, but I'd love for you to explain on it, that you see in your clinical practice where people show up, they think their symptoms are perimenopause, maybe it ends up being something else and sort of what those symptoms in terms of their overlap.

So I definitely see everything as interconnected. And we do know that our hormones impact our blood sugar regulation, for instance. When we start to see declines in estrogen, we can start seeing insulin resistance increase.

We can also see inflammation increase, which can drive a whole host of other chronic diseases. It's almost like this chicken or the egg analogy. Is it the underlying conditions that are driving the changes to the hormones, or is it changes in the hormone that is leading to other issues?

It's hard to tweeze those out sometimes, what is causing what. Some individuals will come to me and like you said, usually the first hormones that I see to decline are the testosterone and the progesterone.

It's not always a complete absence in an estrogen that are driving some individuals. Sometimes their estrogen is actually higher relative to these other hormones.

And that's where looking at the labs and the symptoms all together and really teasing out what is causing what, is really important. there are some secondary effects that can happen with perimenopause.

So some women will actually see heavier cycles, and their cycles come more frequently. And this can lead to iron deficiency anemia. In perimentopausal, I'm always screening patients for iron-deficiency anemone because that could lead things like the hair loss, the fatigue, difficulty concentrating, So, is it the iron or is the hormones?

And this is where, you know, I see individuals and I seek clinics just focusing on the hormone, which is an important piece, of course, but there's so much else that goes into it, especially when we're looking at taking a holistic approach.

Absolutely. Tell me kind of your, if someone is struggling with perimenopause symptoms, tell me the three steps that you feel like people should know to take, whether it's first getting tested and then looking at these other factors.

Tell my kind a stepwise fashion that people could proceed through to be able to garner this information clearly on what they need to do to informed and empowered.

So step one is I always take a thorough history. So I'm so lucky that I get to spend an hour, hour and a half with individuals really reviewing what is so bothersome with these symptoms.

Where did they start? What was your past medical history? what else have you had going on? Do you have any other comorbid conditions that we need to know about?

So, I also take full thorough health history first. Then I explain that the current guidelines do not recommend that we test hormones, and I explained why the guidelines don't recommend we do.

I still run them because I do feel they're a very important piece to my practice, but I like individuals to be educated on why their doctor might not have recommended it.

I don't necessarily agree with all of those guidelines. I do think that the testing is really important, but I think individuals sometimes they feel misunderstood.

They feel dismissed because it's just not being explained to them, right? So we can say perhaps hormone testing was denied for you before because yes, it is true that hormones do change.

Yes, It's true there's going to be great fluctuations in perimenopause. But I still think it was valuable to run them. and we have a look at what those labs say.

I always look all the hormones, the estradiol, progesterone, testosterone free in total, but I also include other blood panels, so looking for insulin resistance, overall metabolic health, a full thyroid panel that you talk a lot about.

nutrient deficiencies because there's more often that's at play than just the hormone piece. And it's interesting this study that came out showed that individuals who have impaired insulin sensitivity, this could actually potentially influence the severity of their menopausal symptoms.

So more severe hot flashes, more frequent night sweats. Looking at the body as a whole I think is very important. Then what I do once we have those labs back is I'm really big on doctor as teacher.

So I go through what those lab mean, what i feel is the optimal range in terms of what see clinically when individuals feel best, and then I like to review all of the different treatment options.

I am trained in naturopathic medicine, so I have education on supplements and herbal based options, but I also like use an evidence based approach. So I will go through what our current literature has to say on supplements and herbs, as well as bioidentical hormone replacement therapy.

I do a lot of education on the misconceptions with hormone-replacement therapy, where did those misconceptions come from? How was data misconstrued in the past?

And what is the difference between the new therapies that we have? And then with all of that information, I leave it up to the individual to make the informed choice of which treatment they want to start with.

And them we monitor, right? We make sure that their symptoms are improving, most importantly, but I also want see that they're metabolic health is improving because that's really where we're looking at reducing chronic disease risk, heart disease, cardiovascular disease which I feel is huge in our population right now.

Absolutely. And seems to significantly increase, you know, I mean, the marker of time where people are studying it and increase incidences is postmenopausal or at menopause, right?

Where we become really, really vulnerable to metabolic dysfunction and heart disease and inflammation and all of these things. But no one's studying during perimenopas because it's just such a confusing time.

that medicine doesn't invest a whole lot into the study of what's happening in our physiology during that perimenopause. Go a little bit deeper if you can, if, you know, have some insight into this, but the role between hormones and insulin resistance and peri-menopaus and menopau, or just the breakdown of our metabolism during this season.

So one of the great benefits with estrogen is it's anti-inflammatory, and we know that there is a big connection between inflammation and the metabolism and immune system even at that point.

And the overall increase in inflammation, there's studies that we see not only can predispose you to insulin resistance, but even alter your gut microbiome, which is a new area of research that I'm particularly fascinated in because there seems to be so much that the gut mycobiome can influence from our overall health.

When you have insulin-resistance, the way I explain it to individuals is essentially your body's having to work extra hard to control your blood sugar.

That's a great thing because your body wants to prevent you from developing pre-diabetes and type 2 diabetes. So it is to a degree a protection mechanism because yes, higher blood sugar is damaging, right?

It can damage our eyes, our nerves, or kidneys, and we don't want that. But on the other hand, when we have higher amounts of insulin, that creates the symptoms that we do not want.

That causes concerns with weight gain. We can see triglycerides go up, non-alcoholic fatty liver disease, food cravings, fatigue. Insulin resistance plays a role in hair loss as well.

All of a sudden this worsening of androgenic alopecia cases in perimenopause and menopausal, where it was otherwise quite controlled for them. There's definitely a big connection between when hormones start to change, it can absolutely alter our ability and our resilience to how we manage our blood sugar, as well as cortisol, right?

Our ability to handle the impacts of cortisol or stress is altered when we don't have optimal hormone states too. And from a symptomatic perspective, what I hear patients telling me is, I am more overwhelmed.

I'm more easily aggravated. Sounds and smells just seem to bother me so much more than they otherwise did. And even that lack of sleep. So if you don't have this great rise in progesterone that helps you sleep, If you're sleep deprived, it's going to be really hard to have good energy and good blood sugar control as well.

So it is very much integrated together and it comes down to the chicken or the egg analogy, right? I don't think we can separate it. I think the hormones declining plays a negative role in our metabolism.

But those metabolic changes can also alter our hormones too. And I love that you brought in the adrenals because you know what I see in my clinical practice is stress, really high levels of stress even chronic thyroid dysfunction leading to poor adrenal function.

Then in turn I find shortens sort of the timeframe before women hit perimenopause or at least until their testosterone, their progesterone start to drop.

And that adrenal dysfunction then worsens the perimenopause experience or makes it onset a little bit sooner. Do you find a similar pattern? Absolutely.

And cortisol, I think we really downplay the effects that stress can have. And I think we just assume, well, everybody's dealing with this, right? Everybody's stressed.

This is just our normal, and it's absolutely not the case, And it definitely can be leading to lower levels of progesterone, not ovulating as consistently.

And stress raises inflammation. Stress impacts our blood sugar, so stress in short-term amounts is really great for us. We need that cortisol response.

But it's when this chronic stress response over time builds and builds that it really starts to impact our hormone-based symptoms. So I always tell individuals that there's no magic pill.

There's not magic supplement for cortisol. Yes, there are B vitamins, magnesium, adaptogens, things like that. But we also have to look at the lifestyle piece.

How is your diet contributing to elevated cortisol? What exercise routine are you doing? Are you getting four to five hours sleep so that you can wake up and do that early gym class that your dragging yourself to and you feel really inflamed and your not recovering well?

Is that something that we need to have a look at? So it's not just the mental emotional stress that definitely plays a big role but it is also the stress our diet, our sleep routines and our exercise routines even have on our bodies.

Amen. Yeah, people think they boil adrenals down so much to just the cognitive stress piece, but our physiology, I mean, even thyroid dysfunction, right?

Like not fixing your thyroid appropriately is going to tax your adenals and everything else you mentioned. It's so important to have the perspective that it's not simply psychological stressors that tax you advenals.

And I love this kind of segues perfectly into the idea of what can people do in terms of their lifestyle to support their physiology through perimenopause?

What are some lifestyle things that anyone can do on a day-to-day basis that can help them? I definitely think looking at diet and lifestyle is going to be a game changer for individuals.

So look at the amount of processed foods. I have my patients track their foods because sometimes we don't realize, you know, the kid's snacks here, this takeout here.

We don' really appreciate how significant it is. So looking at how much processed foods are you consuming? How much alcohol are your consuming, breads, pastas, white sugars, all of the big things that everybody can agree probably aren't the healthiest for us.

Removing processed food, alcohols to the best of your ability, 80-20. It doesn't have to be 100%. It does not have cause more stress for you to follow this really rigid nutrition plan.

But make sure that you're getting the basics, like your protein, your healthy fats. You're not chronically under eating. That's stress on the body too that we need to look at.

Really take an objective look of your nutrition. And oftentimes once individuals track all their nutrition, we'll come back and review it and we will say, yeah, you are probably deficient here.

Okay, You are not eating enough here, let's start with that. Because those are really easy things that are going to add up to big improvements in your overall health.

Sleep is a big one too. If you're not sleeping, we need to figure out why that is and how we can support you. I had sleep deprivation after I have my kids and it is awful to have to go through.

It's like a form of torture in my opinion. We need make sure that we get you sleeping and its gonna help with your energy, its going to help your mental clarity, your ability to exercise and workout is going be better.

And then also looking, I'm big on iron deficiency. I see so many patients with iron deficiencies and I am like, it's so simple. We can so easily correct that for you.

And not having enough iron and, and not talking like mild iron-deficiency that I've seen. Like I have seen ferritin of 5 and 12 and that's been progressed for years and years.

Your body is not properly getting oxygen to these vital organs. That's a stress on the body too that we need to look at. So running the basic labs, making sure that you are sleeping, having a solid foundation with your nutrition, but not going too crazy with it.

And then also looking at what are you doing for fun? Like I asked individuals, what do you do for fine? What are your hobbies? And so many times individuals are taken back like, I don't have any hobbies.

I Don't know what I like. That's an area that you need to explore too because if you're spending eight hours a day at a job that You don t really like and then you re coming home to do all the X Y and Z to-do list things and there's no joy and no things that your looking forward to, that's not really an environment for your body to thrive either.

Yeah. I couldn't agree more. And we forget about that, right? The play part of our life, which is huge, too, on our adrenal function. Like, it really can reset so much from that to an inflammatory perspective, all of it.

Well, and then tell me too, your thoughts on the hormone replacement piece in all of this. Is that something that you really advocate for? Do you find that it really changes people's lives in a pretty significant way?

And then just reiterate too the timeline of that. Does it need to be when we're officially in menopause? How often or how useful is it in the perimenopausal phase?

Yeah, so hormone replacement therapy, I'm a big advocate of individualized therapy. So you want to understand is there anything else that's contributing to your symptoms that is unrelated to hormones and correct that at the same time.

I think a great time to initiate hormone-replacement therapy is for individuals where their quality of life is really affected. And that oftentimes is more so in the perimenopause state, because you have this rollercoaster of emotions too, but of your hormones up and down, and the hormone replacement therapy can really help level that out for individual.

So for patients who they're worried about their weight, right, they have a weight loss goal. But their hormones are really erratic. They're having heavy painful menstrual cycles.

It's lowering their iron. they're not sleeping as well. it's like how are you going to have the energy and the capability to do all the right things when it comes to the exercise that you know you should do and you want to and the meal plan that you know you should do and you want to do.

When your hormones are really the obstacle in the way that's leading to the success of those things that many of my patients are trying really, really hard to accomplish, and they're putting a lot of pressure on themselves to Hormone replacement therapy, you do not have to wait until your period stops to initiate that treatment.

Some individuals, they do really well starting with testosterone. Other individuals may start with progesterone. And we always use the lowest most effective dose first, but that might not be right for you.

So working with your practitioner to figure out what is the dose of HRT that's going to be the most beneficial for your and recognizing too that it's gonna be a journey.

Things are going change as you go through perimenopause and menopausal. And the guidelines are that hormone replacement therapy can be continued as long as the benefits outweigh the risk.

And working with your practitioner to decide specifically for you your lifestyle, your family history, you're conditions that you might already have, that's really going to be the best approach because it's not a one size fits all.

It's just not like here's your bag of HRT, come back when you are 60 kind of thing. it does need to ever be evolving and the dose often needs to adjusted.

Absolutely, I couldn't agree more. Well, this was incredibly insightful. I would love for you to share with everyone where they can find you outside of this, where can learn more from you if you have anything that's coming up soon that maybe they would be interested in.

Tell us where to track you down. You can find me on social media. My handle is my name, Brianne Kalanin. You find my Instagram and TikTok. I do a lot of education over there.

And then every week I live videos over on TikTok with educational topics, whether it's hair loss or perimenopause, as well as every couple of months I run a webinar.

If you're interested in the past webinars on my YouTube channel, same name. I have recordings on thyroid, perimenopause, hair loss, insulin resistance.

So there's lots of different resource for individuals. I love it. Well, thank you so much for being here today, for sharing your wisdom, and for shedding so light on this really misunderstood topic.

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