“I don’t feel like myself anymore.”
Many women in their 40s and 50s, and for some, even their late 30s, have likely uttered those words. Maybe it was a passing thought, a conversation with a close friend, or something shared during a doctor’s appointment. But what’s really behind that feeling?
For some women, the answer may be perimenopause.
While hot flashes are widely recognized as a hallmark symptom of menopause, many women don’t realize that anxiety, depression, irritability, brain fog, and sleep disturbances can also be signs of hormonal changes. In fact, Bonafide’s newest State of Menopause survey found that 71 percent of women didn’t recognize their first symptom as menopausal. Anxiety and depression, not hot flashes, were the most impactful symptoms reported, with 60 percent citing mental health effects and 50 percent reporting cognitive effects.
Unfortunately, when women seek help for these concerns, they’re often met with responses such as, “You’re just stressed,” “You’re burned out,” or “You’re depressed.”
That’s not helpful.
And that recognition gap can have significant consequences.
To discuss why so many menopause symptoms go unrecognized, BlackDoctor spoke with Jean Cunningham, PharmD, BCPS, Senior Director of Medical Affairs at Empower Pharmacy. She shared why the first intervention many women need is simply to be believed, and how better patient-provider conversations, symptom tracking, medication literacy, and personalized treatment discussions can help women get the care they deserve.
Menopause Isn’t Just About Hot Flashes
“When people, historically, think about menopause, they think about hot flashes. And that has been one of the key hallmark signs because it is so specific to menopause. You’re not going to have a hot flash in really any other type of disease or condition,” Cunningham explains. “But what we’re noticing is that there are actually a lot of additional symptoms that women will notice. And so that’s going to be sleep disruptions, anxiety, changes in mood, irritability, anxiousness. Those symptoms that women are starting to notice are really disrupting their life in their 40s, or potentially even in their late 30s.”
The challenge is that these symptoms are often dismissed, not only by healthcare providers, but by women themselves.
“Too often women will say, ‘I’m stressed, I have so much going on.’ And what I have seen is women are dismissive of their symptoms for a variety of reasons. It’s just like, ‘Oh, I just need more sleep,’ or ‘It’s just that I’m taking on a lot,’” Cunningham explains.
But there comes a point when symptoms become too significant to ignore.
“When it gets to be so much that it’s really affecting your ability to function or it’s affecting your relationships, that’s really an indicator to have a hard conversation with your provider, ask questions, and don’t just settle,” Cunningham says.
She advises women not to automatically brush symptoms aside with explanations such as needing more sleep or simply being overwhelmed.
“When it’s a chronic pattern, and it’s worsening over time, that is really a chance to learn about what are some options out there that maybe can help you,” Cunningham adds.
Why So Many Women Experience Delayed Treatment
One reality that Cunningham finds particularly frustrating is how many women spend years suffering without realizing their symptoms may be connected to perimenopause or menopause.
“So many people are suffering through without seeking treatment. And then once they try treatment… they’ll have a huge improvement in their symptoms and kind of feel like, ‘I should have started 10 years ago.’ Actually, that’s a quote. I’ve heard from some patients: ‘I wish I would have done this 10 years ago.’”
The longer symptoms go unrecognized, the longer women may struggle with sleep problems, mood changes, anxiety, and cognitive concerns that could potentially be addressed.
Start by Tracking Your Symptoms
One of the most effective ways to begin recognizing patterns is by tracking your symptoms over time. Wearable devices can also be useful for monitoring sleep quality and changes.
“There are a lot of data points, but I think being able to, one, start tracking your symptoms and see how that is lining up with changes in your cycles,” Cunningham notes.
According to Cunningham, menstrual cycle changes can provide especially valuable clues.
“What is happening with your cycles? Are they changing in frequency? Are they worse than they’ve ever been, or are they disappearing? Are you going three weeks out of the month with a cycle? That’s a really good data point too.”
She notes that while providers often rely on objective measures, patients are living with the subjective impact every day.
“It’s always difficult because I think providers are really good at seeing objective measures. But patients are experiencing the subjective effects of it,” she shares.
Ask the People Who Know You Best
Friends and family members may notice changes before you do.
“It’s a good opportunity to reach out and be like, ‘Hey,’ if you have a good relationship with your family and friends, you can ask, ‘Have you noticed? Is it different? Are you walking on eggshells around me?’ That’s an opportunity to get a little bit more of a holistic view,” Cunningham shares.
Sometimes women feel they are managing well enough, but those closest to them may observe meaningful changes in mood, focus, or behavior.
“You might think you are maintaining okay,” Cunningham adds. “But then, are your family or your friends noticing that there’s a change?”
Brain fog is one example.
Many women begin forgetting words, losing their train of thought, or struggling to stay focused. Asking trusted friends or family members whether they have noticed those changes can help provide additional context.
You might ask, “Are you noticing that I’m stumbling over words or having a harder time focusing?”
The more specific information you can gather, the easier it becomes to discuss symptoms with your healthcare provider.
How to Talk to Your Doctor About Perimenopause
Once you’ve identified patterns, the next step is bringing them to your doctor.
Rather than simply saying, “I don’t feel like myself,” Cunningham recommends coming prepared with details.
Start with specific examples:
“Hey, here’s when I’m really anxious.”
Or:
“Here’s when I’m really irritable, and it’s happening not just the week before my cycle, but throughout my cycle or even the week after. It’s kind of like half the month, I’m just annoyed.”
Specific examples help paint a much clearer picture of what’s actually happening.
Don’t Be Afraid to Ask About Hormones
Cunningham says one of the most impactful questions women can ask is whether hormones may be contributing to their symptoms.
“That is probably one of the most impactful questions you can bring up in an appointment because if you show up with sleep or mood changes or anxiety, the first-line therapy for a lot of that is going to be an antidepressant or an anti-anxiety medication, or an anti-insomnia medication,” she says.
She stresses that those treatments can absolutely be appropriate and helpful.
“But if the root cause of what is causing these changes in your sleep or in your mood is a change in your hormones, or the fluctuation in your hormones, then treating that first can be really helpful,” she adds.
A simple way to start the conversation is:
“Hey, I’m in my 40s.”
Or:
“I’m in my late 30s. Could my hormones be a part of this?”
And if you feel dismissed?
“If they say, ‘Absolutely not, you’re way too young, your cycles are normal,’ but you feel like there’s something else going on, I would really encourage you to then say, ‘You know what? I know myself,’ and maybe seek out another provider. Get another opinion,” Cunningham advises.
Cunningham also recommends looking for providers with additional women’s health training through organizations such as the International Society for the Study of Women’s Sexual Health (ISSWSH) or The Menopause Society, both of which offer provider referral resources.
Understanding Menopause Hormone Therapy
Menopause hormone therapy (MHT), also known as hormone replacement therapy (HRT), can help address certain symptoms of perimenopause and menopause by supporting hormone levels that naturally fluctuate and decline during this transition.
The primary hormones used are estrogen and progesterone, while testosterone remains an emerging area of research.
Estrogen: Helping Women Feel Like Themselves Again
As estrogen levels fluctuate and decline, many women experience symptoms that affect mood, cognition, sleep, and overall quality of life.
Hormone therapy can help provide more consistent estrogen levels to reduce these symptoms.
Describing estrogen’s effects, Cunningham shared an analogy she once heard from a compounding pharmacist.
“It’s like pouring 10 cups of coffee into your brain.”
While the comparison is obviously simplified, it illustrates the widespread role estrogen plays throughout the body.
“I would say estrogen helps women feel more like themselves,” Cunningham notes.
Estrogen therapy is available in multiple forms, including:
- Patches
- Creams
- Pills
- Vaginal preparations
Cunningham notes that current clinical guidance generally favors transdermal estrogen, which is absorbed through the skin, because risks can differ depending on the formulation.
“We want to be very careful as you get older because we know that the breast cancer risk or blood clot risk is different with oral, so taken by mouth, versus applying it through the skin,” she says.
Progesterone: The Hormone That May Improve Sleep
While estrogen often gets most of the attention, progesterone plays an important role as well.
“Progesterone actually is more than a calming hormone, and it can help women with their sleep over time,” Cunningham shares.
For women struggling with sleep during perimenopause and menopause, the effects can be substantial.
“I do notice that some women, if you’re having a hard time sleeping, progesterone is one of the few game changers, I would say, for women at this age and stage,” she adds.
Progesterone also serves another important purpose. For women with a uterus who are using systemic estrogen therapy, progesterone helps protect the uterine lining from the effects of estrogen alone.
Testosterone: An Area Researchers Continue to Explore
Testosterone is another hormone gaining attention in menopause care.
Current evidence-based guidance primarily supports testosterone therapy for hypoactive sexual desire disorder (HSDD), a condition characterized by persistent low sexual desire that causes distress.
Researchers are also studying whether testosterone may help with:
- Mood
- Cognition
- Muscle preservation
- Body composition changes
“We are starting to see newer evidence showing a benefit with testosterone for mood, cognition, and muscle preservation,” Cunningham notes.
However, more research is still needed, and testosterone is not currently recommended as a routine treatment for general menopause symptoms.
Menopause Care Isn’t One-Size-Fits-All
Ultimately, hormone therapy is highly individualized.
Women should work with a qualified healthcare provider to weigh the benefits and risks of different hormones, formulations, and doses based on their symptoms, health history, and treatment goals.
The Most Important Message: Advocate for Yourself
For Cunningham, the biggest takeaway is simple: women need to advocate for themselves.
“One of the best things women can do for themselves right now is advocate for themselves,” she shares.
If you’re worried you’ll forget symptoms or concerns during an appointment, she recommends coming prepared.
“Go to your appointment with notes. Go to your appointment with questions written out. That really helps get a doctor’s attention and shows, ‘Hey, I wrote these things down and I want to talk about them,’” she adds.
If needed, bring support.
“If you have a trusted relationship, you can have a conversation ahead of time and say, ‘I really want to make sure I talk about this.’ Having somebody else hear the conversation with you is helpful,” Cunningham explains.
She also recommends using your doctor’s patient portal whenever possible.
“If you can message through the patient portal or message your provider, that’s another really great tip for patients who want to make sure they’re advocating for themselves because it’s a written format,” she says.
Having documentation can make follow-up conversations easier and ensure important concerns don’t get overlooked.
“You can document, ‘Hey, we talked about this. I have a question about this.’ It’s documented, it’s sent, and that can really foster additional conversations,” Cunningham notes.
For women who feel dismissed, unheard, or uncertain about what they’re experiencing, Cunningham believes the message is clear: trust yourself, track your symptoms, ask questions, and keep advocating until you find answers. Sometimes the first step toward feeling like yourself again is simply realizing that what you’re experiencing may not be “just stress” after all.