AskNat The column where you ask and I answer like the doctor-friend you wish was in the room with you. Real questions from real women, straight from my inbox. General education, never a substitute for your own doctor.
This week most of the questions are about hormones beyond fertility. As always, these are real questions from your submissions, cleaned up so no one is identifiable, and answered the way I would if you were sitting across from me. I will tell you what the science says, where the science is thin, and what I would want my own sister to know. None of this is personal medical advice, because I am not your doctor and I have not seen your chart. But you deserve to understand your body, and that is what we are here to do.
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Questions answered this week:
“I’m 46. My hot flashes are getting worse and my cycles are shorter, and my weight and blood sugar are creeping up even though nothing about how I eat has changed. Is this perimenopause, and are these connected?”
“A wellness clinic ran a hormone panel, told me I have ‘estrogen dominance,’ and put me on compounded progesterone and testosterone creams. Is that a real diagnosis?”
“I’ve been exhausted for a year, my hair is thinning, I’ve gained weight, and my periods are heavier. Everyone says it’s stress. How do I know if it’s my thyroid, and what should I ask them to test?”
“How long should we actually try before getting help? I keep hearing ‘a year,’ but I’m 37 and don’t want to waste time.”
Yes, this sounds like perimenopause, and yes, those things are connected, more than you have probably been told.
Perimenopause is the stretch of menstrual changes as your egg count winds down, and it has a classic evolution: cycles first get a little shorter with earlier ovulation, then longer with later ovulation, then irregular and skipping, and eventually they stop. It can last anywhere from two to ten years, and here is the part most women are never told: the hormone shifts and symptoms begin while you are still getting periods (and specifically while your periods are still regular). So you do not have to have stopped cycling to be in it. Shorter, less predictable cycles plus worsening hot flashes at 46 yo this squarely.
Estrogen is not only a reproductive hormone, it is a metabolic one. It helps your cells respond to insulin, helps your muscle pull sugar out of your blood, and keeps fat from settling around your organs. As estrogen declines through perimenopause, insulin resistance tends to rise, and the long-term data show it rises independent of aging and independent of your habits. That is why your weight and blood sugar can drift even when nothing about your eating changed. It is not a willpower failure. It is a hormone shift. And there is striking new research suggesting your metabolism and your hot flashes are part of the same story: higher insulin around this age has been linked to earlier and longer hot flashes, even independent of body weight.
So here is what I would do. Track your cycles now, because it flags the subtle changes early and buys you time. Ask for the metabolic labs (a fasting insulin and glucose, lipids, and A1c), plus a thyroid panel (including thyroid antibodies), since thyroid can mimic all of this. Pull the levers that actually move insulin: protein and fiber at meals, strength training, and real sleep. And treat hormone therapy as a genuine, evidence-based conversation, for your symptoms and, as a bonus, your metabolism. You are not falling apart, and it is not in your head.
This one frustrates me because “estrogen dominance” is not a real, defined medical diagnosis (and often patients are mistreated because of this!). This is a marketing phrase, not a condition with agreed-upon criteria, and it is very often used to sell you compounded creams from the exact clinic that just diagnosed you.
Here is why the panel misled you: your hormones swing dramatically across a single cycle, by design. A one-time blood draw is a snapshot of a moving target, so an estrogen or progesterone number means almost nothing unless we know precisely where you were in your cycle when it was drawn. “High estrogen, low progesterone” is literally the normal state in your follicular phase and is perfectly normal. Labeling that “dominance” is like taking a photo of a wave and diagnosing the ocean.
And the treatment is not the harmless “balancing” it is sold as. Compounded progesterone and testosterone can suppress ovulation. I have seen a woman put on progesterone and testosterone cream for “estrogen dominance” who was, in effect, handed a form of birth control by the very clinic promising to help her hormones, and whose partner was started on testosterone “for fatigue,” which can shut down his own sperm production. The treatment can quietly cause the problems it claims to fix. That story is in my book for a reason.
None of this means hormones do not matter or that real conditions do not exist.
Thyroid disease, PMOS, perimenopause, hypothalamic dysfunction, and a true luteal phase progesterone issue are real, and we diagnose them with properly timed testing interpreted against your symptoms, not a single scary panel with a cream attached. My rule of thumb for you: be very skeptical of any place that diagnoses you and sells you the treatment in the same visit.
“It’s just stress” is what a lot of women hear right before a real, treatable diagnosis gets missed. Your cluster of symptoms is a classic thyroid picture.
Your thyroid sets your metabolic thermostat. In hypothyroidism, an underactive thyroid, your whole metabolism slows down, and that produces almost exactly your list: fatigue, weight gain, hair thinning, and heavier or more irregular periods. The most common cause is an autoimmune condition called Hashimoto’s, where the immune system gradually dials down the gland.
For your thyroid, the most sensitive early sign is an elevated TSH, sometimes even when your actual thyroid hormones (T3 and T4) still read in the normal range. TSH is essentially your brain shouting louder to squeeze more hormone out of a struggling gland, so it rises first. That means a “normal T4” by itself does not rule this out, and you want the TSH specifically.
So what to ask for: a TSH], a free and total T4, T3, and thyroid antibodies (TPO and TG) to check for Hashimoto’s.
You should also ask for a ferritin, because iron deficiency causes its own fatigue and hair loss, and a vitamin D, since deficiency is common and adds to fatigue. If it is your thyroid, the good news is that it is very treatable, usually with a single daily thyroid hormone, and treatment often reverses the symptoms you have been told to just live with.
I have been pushing back on the trying to conceive for a year narrative before getting testing for a while. I understand that recommendations have to come from some place, but this delay in testing doesn’t help most people.
Infertility is technically defined as not conceiving after twelve months of regular, unprotected sex. But that number was built around younger couples, and it is a starting point, not a universal law. In fact, this is the longest you should try before getting an evaluation: under 35, twelve months of trying before an evaluation is reasonable. From 35 to 39, get evaluated after six months. At 40 or older, do not wait, seek help right away or after just a cycle or two. At 37, that puts you at about six months, and there is genuinely no harm in a preconception check-in now.
My personal recommendation (and preference), would be for everyone to get testing before they conceive. Why should you have to try and fail before you find out your tubes are blocked? or your partner has no sperm? or that your egg count is low? I have sat across from too many women who wish they could get this time back and make difference decisions.
And do not wait the full window, at any age, if there are red flags: irregular or absent periods, known PMOS or endometriosis, prior pelvic surgery or infection, a history of miscarriage, or any known concern on the sperm side.
Two things to hold onto. Most couples who will conceive do so within the first six months of trying, so seeking care is not panic, it is just refusing to lose months you cannot get back. And an evaluation is not a fast track to IVF. It is confirming that you ovulate, that your tubes are open, and a semen analysis, because it takes two. Simple testing that either reassures you or finds something fixable. You should not have to fail for a year before someone is willing to look.
Before you go
If one of these gave you language for your next appointment, that is the whole point. So much of what scares us about our bodies is really just information no one ever sat down and explained. None of us should have to fail before we understand our own bodies, and none of us should have to figure it out alone at midnight with a search bar.
XO, Nat
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