Early Perimenopause Signs Women Over 40 Should Know

Jolene: I'm going to tell you right now that you're going to want to share this with your friends, because we are going to bust so many myths, and I'm going to give you everything that your doctor should have given you in every single visit you've ever had but hasn't yet.

Nikkiey: What's going on, everybody? Hey, you guys. Welcome back to The WarriorBabe Show. Today I have an internationally renowned hormone expert, a nutrition scientist, and the founder of Dr. Brighten Essentials. She is a board-certified, I always fumble on saying it, naturopathic endocrinologist, a certified menopause specialist, a sex counselor. And I mean, what has she not done? She's also the best-selling author of Beyond the Pill and Is This Normal? Dr. Brighten is here today, everyone. She is on a mission to help women uncover the root causes of hormonal imbalances and reclaim their vitality through informed, science-backed choices. Today we're diving into all of the things: perimenopause, hormonal shifts, mood, libido, energy, and what it truly means to take control of your health through every phase of womanhood. I'm really excited for this conversation. Dr. Brighten, welcome.

Jolene: Thanks so much for having me. I'm very excited to jump in and talk.

Nikkiey: Everybody, she sent over some of the best questions.

Jolene: So I'm going to tell you right now that you're going to want to share this with your friends, because we are going to bust so many myths. And I'm going to give you everything that your doctor should have given you in every single visit you've ever had but hasn't yet.

Nikkiey: Amen to that, lady. I'm super stoked. Cool. So you've been one of the most trusted voices in women's health, especially when it comes to hormones and the silent symptoms that so many women experience. Before we dive into these questions, what first inspired you to get into this area of work?

Jolene: Oh, the biggest thing was the aha moment. I remember I was sitting in med school. I really thought, okay, I'm going to specialize in gut health. Nope. Because I had this epiphany that women's health is always done to them, not with them. The doctors are constantly gatekeeping information because they think they know what's best for the patient, and women weren't getting autonomy in making medical choices. They also weren't getting the truth about their bodies. And so I decided I was going to disrupt the system.

Nikkiey: Amen. Before I got into fitness and nutrition, almost eight, nine years ago, I worked in the healthcare field for nine years, and I worked in the emergency room for five. I love that you're bringing this message with your line of work, for the women that aren't able to advocate for themselves or stand up for themselves. Doctors are telling them they need to do this, need to do that, and it's not addressing the root problem. The solution is only fixing a symptom. So I'm really excited to unpack these things with you today.

Let's first start off in the bucket of hormonal imbalance, because as we mentioned, we're going to dive into many buckets here. For many women, perimenopause feels like it just sneaks up on them. I've learned that it can start as early as your mid-thirties, right? So what are the earliest signs of hormonal changes that women experience? What should we be paying attention to?

Jolene: Yes. What every woman needs to know about perimenopause is that hot flashes are not the first sign. Irregular periods are not the first sign. The very first hormone to decline in perimenopause is progesterone. Progesterone is only made after ovulation. The onset of perimenopause is when our savings account of eggs is running out. When you're out of eggs, you enter into menopause, which is 12 consecutive months of no period. The next day you're postmenopausal. So you've got a birthday of no periods. Yay, menopause. Next day, postmenopause.

But before that, what we see is that progesterone begins its decline. What do those symptoms look like? Worsening PMS. You're more irritable. Your partner chews their food loudly and you're like, I'm getting a divorce. I'm out of here. I can't be with this person anymore. I'm so irritable. Because what progesterone does is stimulate the GABA receptor in your brain. You make progesterone, or you take oral micronized progesterone, and your body converts that into allopregnanolone. That hits the brain. GABA lights up. GABA says, chill. You love this person. They're not that annoying. And we're going to get really good sleep. We're going to go to sleep and we're going to stay asleep throughout the night.

So if you're someone 35 or older and two, three, maybe even five days before your period you're having night waking, or you're waking up much earlier, so instead of waking up at six like you usually do, now you're waking up at four or five, that can be pointing towards a progesterone issue. The good news is that in the early perimenopause phase, there's still a lot we can do naturally to get the ovaries to work for you and help mitigate these symptoms.

Nikkiey: How? What can we do?

Jolene: Okay. We'll go right into it.

Nikkiey: Give it to us now.

Jolene: Okay. So if you are experiencing increased PMS, you're having breast tenderness before your period, you're irritable, you're having insomnia or sleep issues, there are several things that can help. Number one, we increase our vitamin C, whether that is coming from diet or through supplements, and vitamin B6. With vitamin B6, we're looking at about 20 to 25 milligrams a day. Those are going to support the corpus luteum, the temporary endocrine structure that's left behind post-ovulation to produce progesterone. There's an herb known as chasteberry, or vitex. We typically use that at 200 milligrams. That can also help with supporting ovarian production of hormones, and it can help during that luteal phase.

Now, the other thing we've got to look at is stress. Stress is absolutely the number one thing that will rob you of a really easy period. The reason is that when the brain perceives stress, your body, wanting to survive no matter what, says make stress hormones, survival hormones. Don't make reproductive hormones, the expensive, potentially-gets-us-pregnant-in-a-scary-environment hormones. We need to survive. So your body, being really wise, is going to shift in that way. The problem is the modern woman is living under chronic stress day by day by day. And evolutionarily speaking, the way your entire hormonal system developed does not match what is happening in your environment.

So what can we do with that? We have to look at where we can mitigate stress and where we can cut out stress. You cannot control all stress, but you can control your response. I have several articles on drbrighten.com, and one I would recommend people check out is on vagus nerve stimulation. I also have a podcast episode going through ways that you can stimulate your vagus nerve. There are certain breathing exercises. There are massage exercises. The vagus nerve runs from your brain. It innervates your heart and it innervates your gut. This is a way that we can access the rest-and-digest aspect of our nervous system. We can hum, we can sing out loud, we can do deep breathing. That will shift us to more resilience against stress.

And then I ask people in my practice to do basically a stress inventory. I just want you to brain dump all of the things that are causing you stress. Then I want you to look at what you are unnecessarily putting on your plate. Because we do that. We think, oh, I'm the only one who can do this best. Does it really have to be you? Do you really have to sign up for that PTA thing again? Do you really have to volunteer for this extra thing? Where can you offload stuff? And then I want you to look at what is perceived stress and what is actual stress. Because sometimes when we write something down as a source of stress and we look at it, we're like, actually, I'm making that up in my head. That's not real stress. I need to let that go.

And then there's my favorite one. Everybody talks about a detox diet. I'm like, detox the people in your life who are toxic. Take a look at that. If there are people in your life that, when you spend time with them, you feel more exhausted and drained, you go home, you think about the interactions, you hate on yourself about things, those people have got to go, especially if you're in a healing phase of life. That doesn't make them bad people. It makes them not the right people for you and your hormones.

Nikkiey: Wow.

Ladies, are you feeling frustrated with body changes you're experiencing during menopause? It's time to take control. If you're between 45 and 65 years old and tired of struggling with body fat and muscle loss, WarriorBabe is here for you. At WarriorBabe, we've helped over 18,000 women just like you lose body fat, build toned muscle, and understand their bodies better with personalized plans based on hormone and thyroid testing and more. Imagine knowing exactly what your body needs to see real results, and results that last. Don't wait anymore. Take charge of your health and join our community of strong, empowered women. Visit warriorbabe.com/apply today to start your transformation. That's warriorbabe.com/apply. All right, let's get back to the show.

That's good advice already, so far into this episode. I'm sure many people are going to rewind and listen to that back, and you should, because that was a great, powerful answer. So my brain goes to: how can women differentiate between normal life stress and these hormones actually shifting?

Jolene: That's such a great question. So there's normal life stress, right? You have a stressful event. You feel the surge. Cortisol is going to go up, epinephrine, norepinephrine, so stress hormones are going to go up. We can always look to nature. When the gazelle gets chased by a predator, it has a stress response, comes away from that, shakes it off, actually shivers, moves its body, works out that stress, and then it's back to a calm state. Can you do that? Can you find your practices? Maybe it is dancing and shivering and shaking. Maybe it's something else. And then you come back and you feel a sense of calm. You feel a sense of ease.

If that's not happening and things are prolonged, sometimes we have a genetic issue. I'm one of those people that have what's called poor catecholamine clearance. We were the defenders of our tribe. Genetically speaking, we were made to defend the tribe, and you can say thank you to people like this because we're the reason this species exists. However, in modern society, we clear it much slower. So we're going to feel the effects of stress much longer, which also means every cell in our body is feeling it much longer.

But to your question of how do you know, I think what you're asking is whether there's dysregulation in that stress system. The hypothalamic-pituitary-adrenal axis is what it's called. That's how your brain speaks to your adrenal glands. If you are exhausted when you go to bed, your body is just ready, down for the count, but the brain won't shut up, you're wired and tired. That's a sign we've got HPA dysregulation. This is a big one: somebody walks into a room and you are constantly startled. You're scared of everything. You're just jolting. Your nervous system is on edge. It's primed to respond. If you find you're waking up with headaches, or you slept eight hours and you're not waking up feeling completely rested, you're like, I know I got sleep, but it doesn't feel like it was restorative. If you are noticing you have blood sugar crashes: when our blood sugar gets low, cortisol responds to that. So if you're constantly having blood sugar crashes and you're on that roller coaster, that's bad for your insulin and bad for your cortisol levels.

So there are signs that we've got that dysregulation, and we can test that. We can do salivary cortisol or we can do urinary cortisol. One of the common tests that practitioners use is called the DUTCH test, because that's going to look at cortisol and cortisone. In my book, Is This Normal?, I have a quiz for your hormones and I talk about low cortisol. When people say they have low cortisol, what it often actually is, is they've had high cortisol for such a long period of time that their body is either inactivating it, taking it to cortisone, or the receptors are no longer responding to it because it's system overwhelm. So if you're somebody who's like, I'm just dragging through the day, I'm getting sick all the time, these can be signs of what we would call low cortisol. But it isn't in fact that your cortisol is low. It's that your system is protecting you. So we've got to go back to that stress piece of what's going on there.

I will also say that if you have dysbiosis in your gut, an imbalance of gut flora, a chronic gut infection, chronic Epstein-Barr virus, an autoimmune disease, you've got a chronic inflammatory state. Your adrenal glands are the ones that produce cortisol to keep that inflammation in check. But if you do not address that, you're going to end up with HPA axis dysfunction.

Nikkiey: Wow. So much good information there. To piggyback off what you said about recognizing the differences, are there other physical changes that may happen? If stress is too high and the hormones internally are off, outside of being wired and tired or waking up not feeling rested even though you slept eight hours, are there other symptoms we could see as women that tell us maybe this isn't just normal stress, this is more the hormonal shifts going on?

Jolene: Definitely the morning headaches I talked about, and getting sick all the time. Like, I'm constantly sick, I'm the one who gets everything. I think those are really important to pay attention to. Sometimes people are just like, I'll pop some Advil, drink more water, I'll try to overcome this. But that's a really big thing to be thinking about if you've got that adrenal issue going on.

I think it's also really important that we understand that you're not going to just have adrenal hormone issues. We're going to see that affect your insulin. So maybe you're someone who's starting to have insulin dysregulation. Maybe you're even starting to have insulin resistance showing up. We do need to look at what is going on with your stress.

The other thing I would say: if you've ever encountered somebody who has had a spouse pass away, lost a parent, something that is a major, tremendous stressor in their life, getting sued, we know that's a big one, isolated to the United States, we need to figure that out. But when people look at them and they're like, whoa, they aged rapidly, that's cortisol. Cortisol, this stress hormone, is going to age us at the cellular level. If you're like, I think I'm getting more bags under my eyes, my skin looks like it's aging a lot more, I'm getting more gray hair, I'm having brain fog, I can't keep a word in my head, I'm having a major impact on my cognition, my brain is struggling. We know that extended periods of heightened cortisol exposure can delete brain cells, but it also can act as a neurotransmitter that makes it hard for us to focus, hard for us to retain our memory, and hard for us to stay emotionally stable.

Nikkiey: God, such good advice, especially on the cortisol aspect. How about hair thinning?

Jolene: Definitely. Oh my God. Hair loss is so annoying because it can be literally almost any hormone in a woman's body. There are some really key players, though. You can definitely have hair loss from acute stress, and that hair loss can happen a couple of months after the acute stressor. It happens rapidly. Your hair's falling out all at once. Then your hair will grow back. So that's a temporary hair loss. We see a lot of people who contract viral illnesses and get really sick have that kind of hair loss, and of course people who are going through a very heightened period of stress in their life.

We also see a very common cause of hair loss due to testosterone, and specifically a form called dihydrotestosterone. For everybody that is in perimenopause and menopause, if you're losing your hair, go to drbrighten.com. I've got an article that's just about that and what you need to know for your hormones. One of the most common causes of thinning of the hair, where your hair shaft gets thinner and thinner until it cannot grow, is that conversion of testosterone to DHT. That happens via the 5-alpha reductase enzyme. There are a couple of drugs for men. For women, we can use minoxidil. Usually we're using that orally. Or we're using things like saw palmetto, which is an herb that helps with that conversion. You need some DHT. It's important for your libido. But we don't want such potent DHT that we're losing our hair. Spearmint tea, or even spearmint leaf as a supplement, can be really beneficial for this.

And when we've got this excess testosterone, we want to look at whether the underlying issue is PCOS. And if so, is it insulin resistance driving the production of testosterone? Is inflammation involved in the hair loss as well? So it can be multifactorial. High estrogen can be another cause of hair loss. We know that cortisol can affect the hair follicle itself. And in other cases, sometimes there's a fungal element to this. This is where meeting with a dermatologist can be really helpful for you to go through all of that.

And then really simple ones you can do on your own: vitamin D, iron. If your iron is getting low, if you have heavy periods, you're going to lose your hair. If your ferritin, which is the storage form of iron, gets below 50, we're going to see hair loss in a lot of cases. So iron, vitamin D, and a lot of your minerals overall support hair growth. Zinc is another one that can support, because it can help with testosterone as well. So you really want to look at the whole picture and not just isolate it to hormones, because sometimes it's hormones and fungal, sometimes it's hormones and nutrient deficiencies, and sometimes it's all of the things and you've got to peel back those layers and address it.

Nikkiey: Okay, got it. Cool. So tons of variables could be at play here. That's why it's really important to get your blood work, saliva. What do you say? Do you back the DUTCH test? Because I know a lot of people have various thought processes behind that.

Jolene: Yeah. I think it's really important for people to understand that you can't just decide you're going to make a medical test and have it have no efficacy behind it and no checks and balances. The DUTCH test has done that. There's also published data on the DUTCH test. I find it really useful. People who often criticize the DUTCH test do not understand that estrogen has metabolites that we can test for, and those are really important.

What is actually interesting to me is that there are people who call themselves hormone experts who have never even been trained to prescribe hormone replacement therapy. They have only been trained to prescribe the birth control pill, and that's it, and maybe make a referral to a reproductive endocrinologist. And they will come out and criticize this and say there's absolutely no reason to be running these tests. Yet we know that these metabolites of estrogen can play a role in cell proliferation, which is what we think of for cancer. They also can play a role in protection against cancer. So we want to understand that. We also want to understand estrogen clearance. How well are you able to clear your estrogen? There is this idea in medicine that we're all supposed to be exactly the same, that there are no genetic variations. And yet those do exist, and that matters. It matters at any stage of life, and certainly when we are prescribing hormones that are coming in exogenously, because we've got to know how well you actually clear those and how this is going to affect your system.

The other thing you can see on a DUTCH test, but you can also run this in blood work, is testosterone and DHT, and you can see that 5-alpha reductase activity. So women, listen up. It's not just total testosterone. Via blood work, you want total testosterone, free testosterone, sex hormone binding globulin, DHEA sulfate, and you're going to get that DHT, dihydrotestosterone. On the DUTCH test, we're going to see all of that but not the sex hormone binding globulin.

What I also like about the DUTCH test is, again, we can see the cortisol-to-cortisone ratio. That is so important. If I was to order blood work for you, I'm going to order an ACTH. That's the brain hormone that speaks to the adrenal glands. And I'm going to order an 8 a.m. cortisol. I am not going to send you back to the lab to get stuck four times in a day to measure what your cortisol is like throughout the day. So seeing that curve can be really helpful. I do like using the DUTCH test. I also meet people where they're at. If we have to run blood work, we're going to start there. And if we can do the DUTCH test, I think that's fantastic for getting that data and really understanding where your hormones are at and those different layers. There aren't a lot of labs that will do the 2, 4, 16 hydroxyestrone testing to understand your estrogen metabolites, and I think that is something we really need to be understanding in women.

Nikkiey: I appreciate you sharing your opinion on that and your truth behind it. There's so much information you're sharing already, and it's really good stuff. Before we move into the next bucket, I want to ask you: what are the most common myths and misconceptions you hear from your patients about perimenopause and hormone health?

Jolene: Actually, I hear this one from other providers. It's that perimenopause and menopause are just natural, so if you're having symptoms, you just need to ride it out. And you know what I find really funny? I've been prescribing hormone replacement therapy, or menopause hormone therapy, for over a dozen years. This is part of my core training and my background in medicine. And so many of these doctors, primarily gynecologists, have been out here telling women to just raw dog their way through menopause. Suck it up, get through it. It's natural. Don't use these hormones, they'll cause cancer. Some of them sent me nasty messages, like, what are you trying to do, kill this patient, giving them HRT? I'm like, no, I'm trying to give them back their life and let them not lose their mind and actually enjoy a fully lived life.

Nikkiey: Or feel like a stranger in their body.

Jolene: Yeah. And now these people are like, oh my God, sign me up, I want this HRT and I'm also going to be an expert in it. And I'm like, could you just for a minute recognize the fact... I mean, there are a few gynecologists out there in the menopause space who I think are doing a great job, and they do talk about how they had no background, no training, and they did a disservice to their patients. We have to have that dialogue to build trust with patients, because the people out there that you denied hormones to absolutely remember you.

So I think that's one big myth in that space: it's natural, so you should just deal with it. You don't have to just deal with it. And you don't have to use hormones if you don't want to. That's one option. There are a lot of natural therapies we can use. Nutrition and lifestyle go so far. And I will be the one to tell you, HRT is not enough. I don't care about these people singing it like it's the gospel that's going to save your life. It is not enough. You have to be looking at nutrition and lifestyle as well. The way you show up every day to live your life has such a tremendous impact on your outcomes. And anytime we put basically a paywall between people and optimal health, like you have to see a provider, you have to get a prescription, it's very disempowering, because there's a lot you can do now with or without hormones. And there are also other medication options we can use if you're like, I don't want to go the hormonal route, I'd rather try something else. So you shouldn't just suffer through it. There are lots of options, lots of things we can do.

The other myth is that perimenopause is a new phenomenon, that it wasn't even a thing until this generation of millennial women started talking about it, when really it's been documented for hundreds of years. Perimenopause has always existed. And then there's the concept that our ancestors didn't have this, therefore you don't need hormones. I hate to tell you this, but our ancestors died in childbirth a lot. A lot. And they also didn't make it past their fifties. Our life expectancy has been extended. And so with that, we have to pivot and look at how to support women much better.

Nikkiey: Hey, while you're listening, if you're getting value from this episode, take a moment to tap that review button or share this podcast with a friend. It's a small gesture that goes a long way in helping more women find their way to feeling stronger and more confident in their skin. I appreciate you so much for taking the time to support this show.

Jolene: The other myth is that if you take hormones, you're going to get cancer. That's a big one. There was a study called the Women's Health Initiative. They used much older women than we initiate HRT with these days, and they already had the onset of certain disease processes. We weren't going to reverse those. Hormones aren't going to reverse those. But the concept that these hormones cause cancer, we have to really peel that back. As the new research comes out, what we're seeing is that progestin, which you find in hormonal birth control, tends to be the one that's more associated with cancer than the bioidenticals we use today. Premarin, which is estrogen we extracted from the urine of pregnant horses, is also not great. But using your own biological hormones doesn't show the same risk as we saw with the synthetic hormones we were using.

I just released a podcast episode, and I have several where we talk about estrogen and breast cancer. The latest one, with Dr. Felice Gersh, is great because she talks in so much detail about how estradiol, the form we use in hormone replacement therapy, actually helps glue the cells together so that you don't get metastasis, which is what kills us in breast cancer. I know there are going to be people commenting, yes it does cause cancer and you're going to kill people, because this myth has been so perpetuated by the media. But medicine got it wrong and science got it wrong to make that blanket statement.

And I want women to understand that smoking, drinking alcohol and binge eating ultra-processed food are higher risk factors for breast cancer than using a very small dose of estrogen hormone replacement therapy with progesterone. They've got to be balanced out. And when it's done right, we're using the lowest dose to support your body. We are not trying to get your period back or get your levels back to what they were when you were still menstruating.

Nikkiey: Oh gosh, thank you. That information right there, I think a lot of people overlook it, or believe the media, believe what people have to say about this, especially people with status who are sharing it. So I love that breakdown, because it helps us really understand that we're working with your body, not just giving you things that are going to make things worse. And the call-out on nutrition, which I'm going to dive into next with you: the little dose you're going to give somebody is not what's going to make the difference, or it's going to help them. But if people are overeating, consuming alcohol, smoking, doing all these other things, those are greater risk factors for causing cancer.

So you often talk about food being a powerful tool for hormone health, and I love that. That's where you and I align big time. We focus on the nutrition aspects inside of WarriorBabe, and on strength training and building muscle. So what are some go-to nutrition recommendations you share with your patients?

Jolene: Oh gosh, there's so much. I've written whole books. I have so much to say on this. I think as women, some of the most important things we can do is structure our day so that every meal we try to hit 30 grams of protein minimum, throughout the entire day we're hitting 25 grams of fiber minimum, and we are limiting added sugar. Not fruit. I'm talking about added sugar. Check your yogurt. I hate that yogurt has so much sugar in it. But not more than 25 grams. So we want to hit 30 grams of protein every meal, 25 grams of fiber in the day, and we want to get below 25 grams of added sugar. That is one way we want to structure things.

Now, when we look at a plate, and I did this whole diagram in Is This Normal?, you take a plate and split it in half. Half that plate is going to be plants. When I say plants, I'm talking about fruits and vegetables, whole foods showing up there. Even if it's frozen, even if it's canned, if you're getting those in, you are way ahead of the curve just in doing that. Then we take the plate and cut it in half again. We're going to have a section that's protein. That's going to be about the size of the palm of our hand when we're talking about meat. We want to be looking at that protein component and being mindful of it at every single meal.

If you're a vegetarian who eats eggs and fish, you're going to be fine. But if you're vegan, you may very well need more protein than that, because your protein source does not have all of the amino acids. I'm always like, you can be a vegan, but you've got extra work to do in life. You've got to make sure you're getting complete amino acids. Otherwise you can just sign yourself up for loss of skeletal muscle. That's coming for you. And when you lose that, you lose insulin sensitivity. You're staring down diabetes and cardiovascular disease, and I hate that for you. So let's not do that.

Now, the other section of our plate is going to be our carbohydrates. If you eat grains, great. Whole grains. If you don't, or perhaps there's a reason you just don't feel good with those, or it's the evening and you're like, I need to get more fiber, maybe we're looking at a sweet potato, carrots, turnips, more of those root vegetables. Bonus tip: if you make potatoes, I don't care what kind they are, cool them in your fridge and eat them as a leftover. You just built resistant starch. Resistant starch is so good for your gut health. It supports the gut bacteria that make short-chain fatty acids. Short-chain fatty acids are so great for modulating inflammation and for helping our brain health. They're going to support your hormones overall as well. So that's how we want to structure a plate throughout the day.

If you can get some cruciferous vegetables in daily, fantastic. If not, most days a week I want to see some cruciferous vegetables. I always recommend cooked. Why? Because it's so much easier on your digestive tract. Onions, garlic, and cruciferous vegetables are very hard for our human body to digest and break the bonds of. So they're often better cooked, and you're still getting the benefits. The other thing I want people to know about cruciferous vegetables is that you're not going to eat enough of them to inhibit thyroid function. There's this myth about goitrogens. Yes, goitrogens exist in cruciferous vegetables, but your gut wouldn't allow you to eat the amount of raw cruciferous vegetables it would take to disrupt thyroid health, because you would be the gassiest, most bloated person in the world and you would hate life. So you're not going to get there. But I still recommend cooked because it's just easier on the digestive tract.

Broccoli, kale, cauliflower, Brussels sprouts, arugula: these are examples of cruciferous vegetables. These are so important for women's health because they support the metabolism of estrogen through the liver so that we get the healthiest forms of estrogen. All forms of estrogen can be problematic, but we want the healthiest version. And if you're someone who's like, I can't do broccoli, broccoli sprouts are going to be a great source of sulforaphane, which we know is really beneficial when it's coupled with mustard. I formulated our Balanced Women's Hormone Support supplement that way. It has myrosinase, which comes from mustard, and sulforaphane from broccoli sprouts, to offer that sulforaphane to support estrogen metabolism.

Now, once you go from phase one to phase two in the liver, you're going to put estrogen into your bile, and that's going to go into your bowels for elimination. It also goes through your kidneys, so you've got to drink plenty of water. But if your gut has dysbiosis, you may be making the wrong amounts of an enzyme called beta-glucuronidase, which can reactivate that estrogen and put it back into circulation. There have been numerous studies showing that not all of our estrogen gets eliminated and estrogen does re-enter the bloodstream, with some researchers starting to point to, okay, when we see endometriosis, ovarian cancer, endometrial cancer, breast cancer, we've got to ask the question: are we not clearing estrogen effectively? So this is, again, where the fiber comes in. There's a whole estrogen ecosystem within your gut called the estrobolome, and by the way, this is a very good thing, okay? Because if you're low on estrogen and it can put some back into circulation, fantastic, we just got some of our estrogen back. But if it's an imbalance in the gut flora that's driving this, then not so fantastic.

Nikkiey: Okay, cool. Good stuff. Love this. This is so informative for everyone listening. I want to switch buckets, because I've got tons more questions to ask you in this short amount of time and I don't want to go over. Let's jump into the mood, energy and libido conversation during hormonal shifts. Mood swings, fatigue and libido changes are common complaints during perimenopause. What's happening behind the scenes that drives these symptoms?

Jolene: Yes. Okay. So actually, in Is This Normal?, the whole first half is about your sexual health and hormones, and the second half is just about hormones. Here is what is going on in perimenopause. It is very multifactorial.

Firstly, cyclically speaking, it is normal for your libido to decline post-ovulation. That's because estrogen drives a lot of our sexual desire, our sexual fantasies, vaginal lubrication, our arousal, all of it. Testosterone also comes into play. It's always the one everyone knows about, but estrogen is important too. Once progesterone comes online, things shift. This is where I joke that you'd rather get into sweatpants than get into his pants, because it's just comfy time. It's just, let's cuddle. And what I always tell women is that you need to tell your partner they need to decrease your stress during this time and up the type of love that you need, whether that is physical touch, praise, or just doing the dishes because it takes a load off your plate. That's going to help you be more receptive to any sexual advances. Otherwise, if your nervous system is dysregulated, you're not going to receive those signals. It's basically like someone cut the phone line. They're trying to talk to you and it's not going anywhere. So that's something really important to know.

Now, in perimenopause, I told you we start with a decline of progesterone. Now we're much more irritable. Our nervous system is much more primed to be sensitive. Maybe we're not getting good sleep. The other thing that happens in perimenopause is that our estrogen starts to go up and down. I like to joke it rocks harder than an AC/DC concert, because it's up and it's down and it's unpredictable. Studies have shown that with the right amount of estrogen, you have sexual fantasies, you're all about your partner. Too much estrogen and you're actually more critical of your partner and much more irritable. Some women have the extra added benefit, and that's a joke, it's not actually a benefit, of histamine issues too. As estrogen goes up, histamine goes up. As histamine goes up, estrogen goes up. We think about histamine for allergies, but histamine in the brain can also make us feel aggravated and more irritable. And if you have period flu, those hormonally driven flu-like symptoms, you're not going to be interested in sex. So there are those two hormonal pieces in early perimenopause.

Once we get into late perimenopause, estrogen is down. Sexual fantasies are down. Pain with sex comes on. We're not able to self-lubricate, which, by the way, in the luteal phase you don't self-lubricate either. That's also normal. So now we need lube. We probably need vaginal estradiol as well, which doesn't go systemic. So we don't worry about that if you have a history of breast cancer. It's going to help keep your vaginal microbiome healthy as well, which is so important so that you don't end up with yeast vaginitis, bacterial vaginosis, and UTIs. Because if you get those, you're also not going to have sex. If every time you have sex you get an infection, you're not interested in that.

So we see that decline, but there's also the effect on the brain. We feel less happy, honestly. We know that in perimenopause and menopause, with the hormone decline that happens, we're seeing 40% of that population with new-onset anxiety and depression. So we're not happy in our brain. Our brain doesn't feel good. Our body doesn't feel good. As estrogen goes down, insulin resistance is rising. Visceral adiposity is accumulating. We're getting belly fat. Our body's changing. Now we have body image issues. Maybe that's not true for you yet, but this can happen. Body image issues and the threat of unintended pregnancy are two big reasons why women get out of the mood, can't get in the mood, or have an inability to orgasm. They have a major impact on our mental health. Now, with that said, for some women, with vaginal estrogen, lube, and no chance of getting pregnant, they are in the mood all the time.

And we also understand that about 50% of testosterone is made in the ovaries. But you've got your adrenal glands. They make DHEA, and DHEA gets converted into testosterone. So you may still have testosterone going. But if you don't, we need to look at that piece as well, because testosterone plays a very important role in our sexual health.

Now, the thing that doesn't get talked about enough, and I talk about this a lot in Is This Normal?: insulin resistance and inflammation are very bad for your libido and your orgasms. We don't talk about this enough. When we have insulin resistance, damage can be done to the clitoris. When glucose is elevated, the nerves in the clitoris can become damaged. Now we have an inability to orgasm. If sex is painful and not fun and you don't even get an orgasm out of it, you're going to be less inclined to want it.

The last thing I will say on this topic is that women are also going through a significant life change that causes them to reflect on their life and recognize that in most cases they have been a caretaker to their children, their parents, their partner. There's a lot of stress during this period of time. Stress makes some people want more sex, but for most people it makes them want less. Again, it's robbing you of anything that's reproductively driven. The other thing is that relationships can become challenging and strained, because women are tired after 40-something years of showing up for everyone else, and maybe being in a marriage for 20 years where you have constantly let him borrow your brain. You've been his secretary, his house cleaner, his babysitter, all of these roles. As women, we have to pay people to help us do these things. But men get to use women and their unpaid labor, and it is exploitive. It really is. I do want to say there are lots of partnerships where this works absolutely beautifully. But there are ones where it doesn't, and it does feel absolutely exploitive, like I have been used as a means to an end and not valued for the person that I am. And that can create strife in a relationship.

So when it comes to libido, it's never just your hormones. Sometimes hormones lead to a desire not to have sex or to pain with sex, and that leads to relationship issues. And even if we correct the hormone issues, the relationship issues have persisted, so those also have to be addressed. What I want women to hear is that you're not broken and it's not just a you issue. There are so many factors, including societal stressors, inputs and expectations we didn't even talk about, that can be contributing to low sexual desire.

Nikkiey: Wow. Such a great answer. You've also spoken about the importance of the brain-hormone connection. How can women support their mental and emotional wellbeing through this time?

Jolene: Oh gosh. Okay. So I'm going to say I did Lupron. I have endometriosis and adenomyosis. I did an injection of Lupron for two months. Do not recommend. Zero out of 10, worst thing ever. Lupron is a medication that's chemical castration. You essentially go into menopause within a couple of weeks. There's no perimenopause. It's just boom. Here are your hot flashes. Here's your depression. Here's your brain fog. Here's your inability to do anything you used to do to the capacity you would expect of yourself.

Nikkiey: Wait, can I pause you for a second? I'm super interested. I used Lupron when I froze my eggs. Is that the same type of drug? When you go through the process of IVF using Lupron, I had to do it for the whole cycle. Is that the same type of drug you're talking about here?

Jolene: Lupron is given so that you stop making hormones. You stop ovulating, you stop producing estrogen, you stop making all hormones. When you're doing an IVF cycle, they're usually injecting you with FSH and LH, follicle stimulating hormone and luteinizing hormone, to cause lots of eggs to proliferate. Using Lupron long-term in that situation would stop you from producing eggs. So I doubt that's what they used. There are definitely different protocols, but the standard for IVF is follicle stimulating hormone and luteinizing hormone to get you to make lots of eggs, then a trigger shot in some instances. There are actually several medications they can use to free up your eggs, and then they're going to harvest them.

Nikkiey: Gotcha. Okay, makes sense. Got it.

Jolene: You would know if you were on Lupron, because you're going to have hot flashes. You're going to have all the menopausal symptoms. You're going to have vaginal dryness. Everything hits you all at once.

So, to the mental health component, I'm actually developing a supplement that I've named Radiant Mind, because when I went through this, I was like, I have to have something. I was just in a spiral. I leveraged saffron. Most of the companies I found didn't have enough saffron, so I was doubling up on it. Then I was using things like bacopa and citicoline, which is a certain form of choline. You can get choline from eating eggs. We know it's really important for neuronal development in infants, and it's really important for your neuronal health. So I'm coming out with this supplement soon. It's been in lots of research and development. Because I went through that, I'm very much like, when it is my time for menopause, I'm going to have this. This is for me. Several friends have asked, who did you make this with in mind? I'm like, me. Because I don't want to end up on an SSRI with the side effects, which can be low libido, inability to orgasm, having withdrawals when I come off. SSRIs certainly have a time and a place, but if I can do it without needing that... I already have to take a thyroid medication every day, so I'm like, that's enough. And you're talking about IVF. I've been through IVF. I've been through the organized calendar of taking this and taking that, so many things, and I'm like, you need to keep it simple. So anyhow, those are some of the supplements I have utilized.

Omega-3 fatty acids are another one, super important for brain health. Make sure you're getting one that is third-party tested and distilled in a way that tries to remove some of the environmental pollutants that are inherently in fish and fish oil. In our company, we have ways to remove some of those so that we're not upping our exposure.

Also make sure you're optimizing your blood sugar. If you have insulin dysregulation alone, you don't even have diabetes yet, you don't have prediabetes, but your fasting insulin levels are going up, that can be affecting your brain energy and how your brain is actually able to function. Anything that supports mitochondrial health is going to support your brain health. It will support your ovaries as long as they're working, and your heart as well. So we're looking at CoQ10, a really important one, or ubiquinol, L-carnitine, alpha lipoic acid. And then make sure you're eating a really nutrient-dense diet. Lots of polyphenols.

It's so funny, because I'm writing my next book and I was reading all this research about polyphenols and rosemary, and I have a ton of rosemary growing at my house. Last night I was making tomato soup with onions and garlic, great for liver detoxification, and bell peppers in there, but I was putting rosemary in, and then rosemary garlic bread. I was putting rosemary on everything. My husband's like, whoa, this is rosemary night. I'm like, you don't even know the research I just read today. It's so important. So rosemary, blueberries, pomegranates, green tea: polyphenols. Great for your gut health, great for your brain health, great on the cellular level. Dr. Kara Fitzgerald has done really groundbreaking research showing that a high-polyphenol diet for eight weeks reversed people's biological age by over four years. In just two months of loading up on polyphenols, they aged backwards cellularly. This is why I'm like, your diet matters. And any doctor who tells you it doesn't matter what you eat, just walk away from them, knowing it's not their level of expertise.

Nikkiey: Wow. Okay. I want to shift gears really quickly and talk about birth control.

Jolene: Oh no. All right, let's go.

Nikkiey: Many women in their forties are still using hormonal birth control, sometimes not realizing it could be impacting their symptoms. What should they be aware of here?

Jolene: Ah, okay. So birth control is great if you don't want to have a baby. Fantastic. But if you're cohabitating with a male partner in a monogamous relationship, vasectomy, friend. So much better. Especially when you consider that women have had the burden of birth control for decades of their life, and we have no studies that tell us what happens when you don't have your own progesterone. Because you get zero progesterone in birth control. What happens, when we know progesterone is so important for the brain? We have no idea. I don't say that to scare you. I say it to be like, if you're a researcher, could you get on this study already? Because we've certainly had enough women on birth control.

So here's the thing about birth control. It is very, very poor hormone replacement therapy. Why? Because it is a huge bolus of oral estrogen that is meant to shut down how your brain talks to your ovaries. We would never use that for hormone replacement therapy. In fact, when you're in perimenopause, what you need is that progesterone metabolized to allopregnanolone to help with your GABA on that side. And then we can use topical estrogen, and topical estrogen is not going to have the same clot risk. When we're talking about the pill, this is oral estrogen. That's a high dose of oral estrogen that is going to raise clotting factors and put you at risk for clots.

There's also research that needs to be replicated, and I did talk about this in Beyond the Pill, showing that women who are on birth control within six months of entering menopause have a higher risk of insulin resistance. They have more metabolic issues going on. So we need to be aware of that piece. For some people taking oral estrogen, specifically birth control, because it's ethinyl estradiol, not real estrogen like we make, we see elevations in C-reactive protein, a marker of inflammation. If you have inflammation going on, and birth control can also mess with your cholesterol sometimes because it's passing through your liver, and you've got elevated LDL cholesterol, friend, we are staring down plaques and heart disease, atherosclerosis.

Women die of heart disease at a much higher rate than breast cancer. We don't talk about it. We get a whole damn month of pink ribbons and pinkwashing with the worst endocrine-disrupting products that are going to mess with your hormones. Some of them are known carcinogens, and they're like, but it's pink, it's raising awareness. Could we raise some awareness of the fact that women die of heart attacks at their highest rate when they're postmenopausal, and that we present differently than men?

So when it comes to birth control, you need to be aware of what the risks are. It is not safe across the board for everyone, because no medication on this planet is. And for whatever reason, birth control being part of the feminist movement and women's rights, and the threat of people taking it away, means we're never allowed to question it. And if I have the audacity to say it is lazy medicine to prescribe the pill when a woman has symptoms rather than work her up, I'm called anti-birth control. I'm not anti-birth control. I'm anti-lazy doctors. And the reason you're pissed is because you called yourself out. You are a freaking lazy doctor. Women deserve better.

So if you're going to be on birth control, please know the risks and the side effects. It doesn't mean you have to be off of it. It doesn't mean you have to stop it. For example, we know birth control leads to nutrient depletions in some women: vitamins like folate and B12, minerals like magnesium and selenium, really important nutrients, antioxidants, vitamin C, vitamin E. We know that. So let's make sure your diet is the best it can be, and let's get you an insurance policy called a multivitamin so that you're making sure you're bringing these in. With any medication that depletes nutrients, a provider will recommend you replenish it. You're on metformin and it's causing a B12 deficiency? Let's get you some sublingual B12. But you're on birth control? You're going to be fine, just eat a standard diet. The standard American diet, the one associated with the absolute worst outcomes, the standard to be measured against as the worst of the worst. We know the majority of people in the United States aren't meeting their nutrient requirements. They're not getting enough fiber. They are lacking. So to give them a medication that also depletes nutrients and then act like, oh, you don't need to worry about it, multivitamins are just expensive urine... I mean, some of them are, but there are quality ones out there. I think that is a huge disservice.

If you know you have a higher risk of mental health conditions running in your family, or you've experienced postpartum depression, then maybe birth control isn't the best thing for you as you enter menopause, because it isn't going to help your mood. In fact, most women will report that birth control has a negative impact, but bioidentical estrogen might help. Why? Because estrogen is needed to run the energetic processes in our brain that allow it to work right.

And I will say, for people who are interested in this, I go through all of it in my book, Beyond the Pill. I go through what your alternatives to the pill are. You don't have to take the pill just because you have a heavy period. Let's figure that out. I also tell you, if you're going to stay on the pill, this is what you should be looking for, these are the labs you should be testing, and this is what you should do to take care of your health while you're on it. We do need to support our body while we're on it. And if you're ready to transition off the pill, I also give you a protocol for that. Because doctors tell us when we're 14, you'll just come off, you'll get pregnant right away, everything will be fine. But then you get on it at 14 and you come off at 44 and you're like, why do I have cystic acne now? Why am I bleeding like there's no tomorrow? Why am I having all of these problems?

Because while the research will say, hey, we took this cherry-picked population and showed an outcome in just them, that doesn't mean it's true for you, and it may not apply to you. That's the mistake clinicians make: they take a study and think it must be true for everyone. But the real pharmaceutical research begins when medications enter the general public and people start reporting their outcomes. Somewhere along the way, we forgot that people are experts in living in their own bodies. When they come to you saying, this is true for me, it is, whether or not you have a research study to validate their experience.

Nikkiey: What? I'm just mind blown right now. There's been so much information packed into this short episode, and maybe if you're up for it, we could do a round two in the future, because there are definitely questions I didn't get to ask you. I'm just grateful for the work you're doing. Throughout this entire episode, listening to your words and the education you're providing to so many women, there needs to be more of your voice out there. People will just take at face value what clinicians and doctors have to say, when there's so much more that needs to be assessed than just, here's birth control at 14, here's XYZ prescription. Like we talked about at the beginning, I'm just so grateful for your work and for how you showed up in this episode with your education. Again, so many questions I didn't get to ask you, but where can people find you? What does it look like to work with you?

Jolene: Sure. You can find me at drbrighten.com, D-R-B-R-I-G-H-T-E-N dot com. I have tons of free resources there. If you're looking for a meal plan on all the things I talked about today, go to drbrighten.com/plan, which is a bunch of anti-inflammatory recipes geared towards perimenopausal women. But if you get a jump on that before perimenopause, it's going to be so much easier for you. And of course you can find me all over social media at @drjolenebrighten. The last thing I'd like to say to everybody is: be a troublemaker. Question your doctor, question me, question everything and everyone, and always ask, is this true for me?

Nikkiey: Amazing. Dr. Brighten, thank you for sharing your expertise and for helping so many women feel seen, heard, and most importantly, empowered in their health journeys. You guys, if you want to check out any of her work, as she just shared, there are also going to be links in the description below for her books, her social media, and we'll put that plan there too. So thank you, Dr. Brighten, for your time today and for sharing your expertise. Appreciate you.

Jolene: Thank you so much.

Nikkiey: Real quick: if this episode resonated with you or gave you the push you needed, I'd love for you to pay it forward. Drop a quick rating and review, share the podcast with someone who might need it, and help me keep spreading the word. Your feedback not only helps the show grow, but it might just be the nudge someone else needs to kickstart their transformation. Thank you so, so, so much for your support.