Am I in Perimenopause? A Lab Scientist Explains Why the Best Labs May Be Metabolic | NH and MA
Standing in My Kitchen in My Bra, Wondering What the Hell Just Happened
I'll never forget the day. I was driving down Second Street in downtown Manchester during rush hour, desperate for my exit lane, when I realized my angst was reaching levels much higher than rush hour traffic typically evokes in me.
I was VIBRATING with anxiety. I felt like I was in a skin suit and I wanted to crawl out of it. Uncomfortable, edgy, foreign, like an alien in my own body.
I finally made it home to my tall tower apartment overlooking Elm Street. I poured a glass of wine to calm down and started making dinner. Then something happened I had never experienced before.
A heat wave radiated from within. I felt it rise up my body, quite literally, like mercury rising in a thermometer.
You know when you're baking and forget to step back before opening the oven door, and that blast of heat damn near singes your eyebrows? That is a very close description of the intensity.
And as if in a cartoon, I started peeling my clothes off until I was standing in the kitchen in nothing but my bra and underwear. Then the heat stopped. I looked down at myself, mostly naked. WHAT JUST HAPPENED?
Then it hit me. The insane rage I felt while driving. The anxiety that made me want to crawl out of my skin. And now this hot flash confirmed it.
I was absolutely in perimenopause.
Maybe I Was One of the Lucky Ones
That undeniable hot flash? I knew exactly what it was. We all do.
Women my age (and older) had limited, if not nonexistent, education on perimenopause and menopause. But the one thing we all know is that it comes with hot flashes. So in that way, I was lucky.
But what about all the women who are not having hot flashes? Are they in perimenopause? How would they know?
And had I been in perimenopause for years before that night in my kitchen? Likely. The symptoms were much more subtle, but they were there. (If you want the full rundown of what those early, quieter symptoms can look like, start with my post on perimenopause symptoms at 40, and why they can start in your 30s too.)
Here's the irony of it all. I am a clinical laboratory scientist with a really good grasp on hormone science. And I still found myself dripping wet in the kitchen, panting, what the HELL just happened to me?
"Not Feeling Like Myself" and the Labs That Say You're Fine
If you're past 35 and things start, shall we say, shifting, you may start to wonder: is something going on?
That feeling has a name. Dr. Rachel Rubin calls it NFLM, "not feeling like myself," and it's one of the first recognized yet most powerful symptoms of perimenopause. It's hard to articulate. But any woman who has gone through it knows exactly everything that phrase means.
After a few months of NFLM, you decide you want your labs drawn. You find a doctor (after much pleading, no doubt) who is willing to check your hormones. And to your great disappointment, they come back COMPLETELY NORMAL.
So the doctor suggests managing stress. Sleeping better. Eating better. Perhaps therapy, or an SSRI to even out your moods.
You stand there feeling gaslit. Have I imagined all of this? Is something wrong with me, or am I making this up? Maybe nothing is "wrong" with you. But you still don't feel right and you have no idea what to do next.
So why doesn't perimenopause show up in lab work?
Why Perimenopause Doesn't Show Up in Hormone Labs
There are several reasons, and none of them mean you're imagining it.
1. Fluctuation: the zone of chaos
In perimenopause, ovulation becomes irregular as follicles start to wane. Hormones rise and drop, but you still have detectable hormones. On any given day, your lab assays may show a perfectly normal amount.
The crazy you feel isn't just the highs or the lows. It's that you can be high one day and crash the next. This zone of chaos can go on for years. It makes a woman feel like she's losing her mind, while her labs register as completely normal.
2. Compensation: your body is really good at faking normal
The body is really good at keeping hormones at "normal" levels for a long time. And for a while, it works.
Fat tissue, especially around the midsection, can produce estrogen of its own, which is why some experts call fat another hormone "organ." So the body holds on to more of it. All the women say: yay, thanks.
You've likely read that cholesterol tends to rise through the perimenopause and menopause transition. This confounds otherwise healthy women (and their unknowing providers). But cholesterol is the building block for every sex hormone, and as estrogen shifts, the way your liver handles cholesterol shifts too. Too often, the conversation jumps straight to a statin without anyone mentioning the hormonal change underneath it.
Your pituitary does what it can, too. It sends out more FSH (follicle stimulating hormone) to push the remaining follicles into making estrogen, ovulating, and producing progesterone. But that stimulation is inconsistent, and FSH typically isn't reliably elevated until late perimenopause, close to menopause itself. A woman in early perimenopause can't rely on it.
3. Low hormones are a menopause thing, not a perimenopause thing
Consistently low or nonexistent hormone levels show up in menopause. In perimenopause, you still make hormones, just erratically. That's why hormone assays in a perimenopausal woman have very limited value for answering the question, am I in perimenopause?
The Best Labs for Perimenopause May Be Metabolic Markers
I'm going to propose something that may seem radical. But five years of reading labs and working alongside women in perimenopause (and beyond) has taught me this:
The best lab tests to show a woman is in perimenopause are not hormone assays at all. They are metabolic markers.
Why? Women in early perimenopause are living in the hormone zone of chaos. It feels awful, and it's hard to prove in lab work.
But what else is going on? She's sleeping poorly. She's slowly gaining weight. Her skin is dulling. She feels aches and inflammation she never felt before. Her PMS and moods are getting worse. She is, generally, miserable.
The biggest problem of perimenopause is the inflammatory shit storm that ensues, driven by those hormonal swings. And that, we can measure in lab work.
The metabolic labs I tell women to ask their provider about:
Fasting insulin
Hemoglobin A1C
Ferritin
A lipid panel (cholesterol)
TSH, with Free T4 and Free T3
Lipoprotein A (good to understand your genetic risk factor for cardiac outcomes)
hsCRP
Apolipoprotein B
Suddenly, the picture changes, and it's showing inflammation. She's inching toward insulin resistance. Her A1C has crept up to 5.4, and her sugar cravings are at an all-time high. Her once perfect TSH of 1.0 is now 3.0 and climbing. Her poor sleep is further driving poor blood sugar control during her waking hours. Her low ferritin tells me she is not absorbing iron well, and her gut is likely dealing with inflammation. Her cholesterol starts to tick up, telling me her body is in compensation mode.
THIS is the metabolic picture of perimenopause. And this, you can measure.
Normal Isn't the Same as Unchanged
Here's the nuance. None of these labs may come back flagged as abnormal. But there is certainly a trend, a shift toward less optimal.
This won't be caught by a provider who only looks for red flags on a single draw. A clinician who understands the entire picture will see it. They'll compare this year's numbers to last year's. They'll connect the TSH creeping up, the A1C inching higher, and the cholesterol climbing to what you've been telling them about your sleep, your moods, and your waistline.
And they'll know the changes you're going through are not the result of poor lifestyle or a lack of willpower.
It's biology.
How to Get the Most Out of Your Labs
If you're in New Hampshire or Massachusetts and wondering whether perimenopause is behind how you feel, a few things make your lab work far more useful:
Ask for copies of every result. Trends only show up when you can compare year over year.
Get metabolic labs fasting, so fasting insulin and glucose are meaningful.
Track your symptoms and cycle for a few months before your appointment. A written record gives your provider a pattern, not just a snapshot.
Ask "is this trending?" instead of only "is this normal?"
Look for a clinician who knows the transition. Menopause informed care can be hard to find, which is exactly why Ember offers concierge telehealth for women across New Hampshire and Massachusetts.
For more on what the transition can feel like, read my posts on perimenopause brain fog, night sweats treatment options, and mood changes in perimenopause.
Still Asking "Am I in Perimenopause?" Take the Quiz
No single lab can answer that question. But your symptoms, your patterns, and your story can point the way.
Take the Ember perimenopause quiz to see where you may be in the transition, and bring your results to your next appointment. It's a starting point for the conversation, not a diagnosis.
You're not imagining it. And you're not alone.
Frequently Asked Questions
Can a blood test tell me if I'm in perimenopause? Not on its own. Hormones fluctuate day to day in perimenopause, so a single hormone draw often comes back normal even when symptoms are real.
Why are my hormone labs normal if I feel terrible? In perimenopause you still make hormones, just erratically. Your body also compensates for a long time, which keeps levels looking normal on paper.
Is FSH a reliable test for perimenopause? FSH swings too much in early perimenopause to be reliable. It typically isn't consistently elevated until late perimenopause, close to menopause.
What labs should I ask about if I think I'm in perimenopause? Many women benefit from asking their provider about fasting insulin, A1C, ferritin, a lipid panel, and a full thyroid panel (TSH, Free T4, Free T3). Watching how these trend over time can reveal the metabolic shift of perimenopause.
Can perimenopause cause higher cholesterol and blood sugar? Yes. Cholesterol and markers of insulin resistance often rise through the transition, even in women who haven't changed their habits.
Where can I find perimenopause care in New Hampshire or Massachusetts? Ember offers concierge telehealth for women navigating perimenopause and menopause across New Hampshire and Massachusetts. Learn more at myember.com.
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