 Hormonal shifts are an inevitable part of every woman’s life, but the transition into and through menopause is often misunderstood or oversimplified. Understanding the stages--perimenopause, menopause, and postmenopause—can help women feel more informed, empowered, and proactive about their health. This article breaks down each phase in detail, outlining the key signs, symptoms, and physiological changes so you can better recognize and respond to what your body may be experiencing. Perimenopause: The Transitional PhasePerimenopause marks the beginning of reproductive decline. It’s the transitional phase that can start as early as a woman’s late 30s or early 40s and typically lasts 4–10 years. What’s happening hormonally?
Common Symptoms:
Perimenopause is largely a progesterone-deficient state with fluctuating estrogen. It’s often the most symptomatically turbulent phase. Menopause: The Milestone MomentMenopause is defined as the point in time when a woman has gone 12 consecutive months without a menstrual period. The average age is 51 in the United States. What’s happening hormonally?
Common Symptoms:
Menopause is not just about the absence of periods—it’s a significant hormonal shift with systemic effects on metabolism, bone health, cardiovascular function, and emotional well-being. Postmenopause: The New NormalPostmenopause refers to the rest of a woman’s life after the 12-month mark without a period. Some symptoms subside, but the effects of long-term low hormones become more pronounced. What’s happening hormonally?
Common Symptoms:
While many uncomfortable symptoms may lessen, postmenopause introduces new health considerations—bone density, heart health, and muscle preservation become top priorities. Rethinking Estrogen Decline in Menopause: A Closer Look at Tissue vs. Serum LevelsFor decades, conventional medicine has framed menopause and postmenopause as a state of estrogen deficiency, largely based on blood serum levels. This reductionist view has shaped the widespread use of estrogen replacement therapies (ERT) under the assumption that low circulating estrogens are the root cause of common menopausal symptoms. However, emerging research challenges this narrative, offering a more nuanced understanding of hormonal dynamics in the postmenopausal body. A recent study measured steroid hormone concentrations not just in serum, but also in adipose tissue—where hormones are stored and act locally. This dual approach reveals a critical insight: serum hormone levels may significantly underrepresent actual tissue concentrations. The study found that estradiol (E2), estrone (E1), and estrone sulfate (E1S) levels in adipose tissue of postmenopausal women were not only detectable but remained within or even above the expected physiological range. In some cases, estrone and estrone sulfate in tissue were orders of magnitude higher than what serum testing alone would suggest. Additionally, while serum progesterone appeared low and borderline deficient, tissue levels were still present—though not proportionally balanced with estrogens. This leads to a key takeaway: it's not just the absolute hormone levels that matter, but their ratios—especially the progesterone to estrogen (Pg/E2) ratio, which serves as a vital indicator of endocrine balance. Optimal ratios are generally considered to be in the 200–500 range. Alarmingly, in the study’s menopausal control group (those not receiving HRT), the Pg/E2 ratio hovered between 16 and 38 across serum and tissue samples—well below the optimal range, signifying a state of relative estrogen dominance. In cases of estrogen dominance, a woman may have low circulating estrogen yet still have excessive estrogenic stimulation in tissues due to:
This estrogen dominance—despite no "deficiency" in absolute estrogen levels—has been observed in nearly all cases of ER+ breast cancer, and yet it remains overlooked in many menopausal women labeled as “healthy.” Had these hormone profiles been seen in younger women, they likely would have prompted clinical concern and intervention. Instead, the misperception of “low estrogen” leads many into estrogen replacement without addressing the underlying imbalance. In light of these findings, a one-size-fits-all approach to hormone therapy, particularly estrogen-centric models, may be not only misguided but potentially harmful. Greater emphasis must be placed on tissue-level hormone dynamics and hormonal ratios, as well as the potential need to support progesterone rather than indiscriminately boosting estrogen. The myth of estrogen deficiencyThe claim that estrogen is protective and that its loss drives menopausal symptoms and age-related disease doesn't hold up under scrutiny. Rates of estrogen-sensitive cancers actually increase with age in both women and men, and anti-estrogenic medications remain a primary intervention in treating such cancers. Furthermore, large-scale studies like the Women’s Health Initiative (WHI) have shown that estrogen supplementation—particularly when unopposed by progesterone—actually increases the risk of cardiovascular disease (CVD), strokes, and heart attacks in women of all ages. Perhaps even more revealing, research has shown that aging men can produce more estrogen on a daily basis than young, ovulating women. If estrogen were truly the protective, life-sustaining hormone it’s often made out to be, why then would rates of chronic disease increase alongside estrogenic load with age? In contrast, recent observational and interventional studies suggest that declining levels of progesterone and androgens—not estrogen—are the true hormonal changes correlated with many hallmark symptoms and diseases of aging. One study found that low testosterone and DHEA levels (not low estrogen) were strongly linked to increased risk of CVD in aging women. This pattern mirrors a consistent decline in androgens with age, even as estrogen levels remain within or above reference range, particularly in perimenopausal women. Even the classic symptoms of menopause—such as night sweats, insomnia, and mood fluctuations—appear more closely tied to low progesterone, not low estrogen. A placebo-controlled interventional trial using bioidentical progesterone showed significant improvements in sleep and night sweats—two of the most commonly reported and disruptive perimenopausal symptoms. The authors noted that previous attempts to alleviate these symptoms with estrogen (either alone or in low-dose contraceptives) were largely ineffective, further challenging the estrogen-deficiency dogma. As Dr. Michelle Fung, endocrinologist and co-author of the study, observed: “Although menopausal women have low hormone levels, perimenopausal women may experience heavy flow, sore breasts, and migraine headaches related to higher estrogen levels.” Dr. Jerilynn Prior, another leading voice in the field, concluded that progesterone’s efficacy in improving sleep, reducing the severity of night sweats, and even moderating daytime vasomotor symptoms (VMS) should make it a first-line therapeutic consideration--not estrogen. It is time we question the mainstream hormone replacement paradigm. Rather than viewing menopause as a deficiency disease of estrogen, we must recognize it as a time when the balance between hormones shifts—often toward relative estrogen dominance due to precipitous drops in progesterone and androgens. In light of these findings, restoring bioidentical progesterone and supporting androgenic tone—not flooding the system with synthetic or unopposed estrogens—may be the more physiologically sound path to supporting women through this transition and beyond. Summary of key differences
A Functional Approach
Menopause isn’t a disease—it’s a natural biological transition. However, the symptoms and health risks it brings are real. With proper education and personalized care, women can not only survive but thrive through every phase. If you're in the midst of these changes, you don’t have to navigate them alone. Working with a practitioner who understands both conventional and functional approaches can make a world of difference. referencesHetemäki N, Robciuc A, Vihma V, Haanpää M, Hämäläinen E, Tikkanen MJ, Mikkola TS, Savolainen-Peltonen H. Adipose Tissue Sex Steroids in Postmenopausal Women With and Without Menopausal Hormone Therapy. J Clin Endocrinol Metab. 2025 Jan 21;110(2):511-522. doi: 10.1210/clinem/dgae458. PMID: 38986008; PMCID: PMC11747684.
Prior, J.C., Cameron, A., Fung, M. et al. Oral micronized progesterone for perimenopausal night sweats and hot flushes a Phase III Canada-wide randomized placebo-controlled 4 month trial. Sci Rep 13, 9082 (2023). https://doi.org/10.1038/s41598-023-35826-w Islam, Rakibul M et al. Safety and efficacy of testosterone for women: a systematic review and meta-analysis of randomised controlled trial data. The Lancet Diabetes & Endocrinology, Volume 7, Issue 10, 754 - 766 Islam, Rakibul M et al. Associations between blood sex steroid concentrations and risk of major adverse cardiovascular events in healthy older women in Australia: a prospective cohort substudy of the ASPREE trial. The Lancet Healthy Longevity, Volume 3, Issue 2, e109 - e118 https://www.monash.edu/medicine/news/latest/2019-articles/large-study-shows-beneficial-role-of-testosterone-for-postmenopausal-women https://www.monash.edu/medicine/news/latest/2022-articles/low-testosterone-levels-in-women-associated-with-double-the-risk-of-cardiac-events
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