An interview with Sara Szal Gottfried, MD

What is perimenopause, how do you know if you’re perimenopausal, and how do you find the best doctor for perimenopause treatment? 

We couldn’t think of a better person to ask than Dr. Sara Szal Gottfried — a renowned hormone expert, Harvard-educated OB/GYN, and MIT-trained bioengineer who practices evidence-based integrative, precision, and functional medicine. The author of four New York Times bestselling books about hormones, nutrition, and health, she’s our founder (Dara)’s favorite women’s health authority and our go-to expert on all things related to perimenopause.

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Dara: What is perimenopause, and how can you tell if you’re perimenopausal — and when to do something about it? 

SARA SZAL GOTTFRIED, MD:

Perimenopause refers to the years of hormonal upheaval before your final menstrual period. How many years? It can depend — on average, 2-10+ years. It can begin in your mid-thirties or your forties depending on how attuned you are (and your doc) to the 100+ symptoms. Most women don’t realize that perimenopause is much rockier and more difficult than menopause because hormones fluctuate month to month, sometimes mildly and sometimes FIERCELY. It is this fluctuation that can lead women to think they are going "crazy" during the perimenopausal years.

It begins with dropping progesterone levels and ends with dropping estrogen levels. For some women, it is a time when mood becomes unpredictable, weight climbs, and energy wanes—and most commonly, women experience a conflation of all three.

During perimenopause, you need your ovaries, thyroid, and adrenal glands working at their best to feel your best. In perimenopause, your ovaries begin to sputter. They no longer stay on task with monthly ovulation. They start to go intermittently offline, and will ultimately stop producing eggs altogether when a woman enters menopause. Your ovaries are no longer manufacturing the same, predictable, and consistent levels of the sex hormones—estrogen and progesterone—that they used to. Your thyroid becomes sluggish and your metabolism slows. You start to feel depleted, and your mood becomes erratic. At the same time, the adrenal glands get into the act and you just can’t roll with the punches the way you used to.

Some women sail through perimenopause with nary a worry; others believe they are going crazy. Without a doubt, perimenopause is a period of biological rough waters, but it can be navigated optimally with some help.  

Dara: With the understanding that there are 100+ symptoms of perimenopause…what are some of the most common ones to look out for?

SARA SZAL GOTTFRIED, MD:

Women face many symptoms in perimenopause: mood swings, irritability, insomnia, changes in menstruation (irregular, cramping), weight gain, loss of libido, breast soreness, vaginal dryness and discomfort, night sweats, hot flashes, depression, and anxiety.

Here’s a more comprehensive list of the common perimenopausal symptoms:
- Irregular menstrual cycles, or cycles becoming more frequent as you age
- Agitation or premenstrual syndrome (PMS)
- Painful and/or swollen breasts (mastalgia)
- Cyclical headaches (particularly menstrual or hormonal migraines)
- Your blood seems to pool easily, or your skin bruises easily
- Hemorrhoids or varicose veins
- Heavy or painful periods (heavy: going through a super pad or tampon every two hours or less; painful: you can’t function without ibuprofen)
- Bloating, particularly in the ankles and belly, and/or fluid retention (in other words, you gain 3 to 5 pounds or more before your period)
- Ovarian cysts, breast cysts, or endometrial cysts (polyps)
- Easily disrupted sleep, perhaps with night sweats
- Itchy or restless legs, especially at night
- Increased clumsiness or poor coordination
- More cravings for food, alcohol, anything to calm you down
- Miscarriage, usually in the first trimester
- Infertility or subfertility

I recommend women complete the questionnaires in THE HORMONE CURE to help them identify where their imbalances lie and what to work on first.

Dara: Do you suggest doing hormone testing to figure out whether you’re in perimenopause (and what changes to make)?

SARA SZAL GOTTFRIED, MD:

There are several tests you can do to assess your hormone levels, but it can be hard finding a doctor who is willing to collaborate with you. I have heard from thousands of women over the age of 35 who have asked their doctors for a hormone panel to see why they are feeling the way they are, only to be told that hormones fluctuate too much and it’s not worth it.

Yet, if a woman wants to get pregnant and is having some problems trying to conceive, there are massive hormone panels that the doctors will run, an entire battery of tests. It’s extremely frustrating. 

I recommend checking hormones at baseline in pre-menopause, when you want to get pregnant, or when you have symptoms that I describe in the questionnaires in THE HORMONE CURE, P24-31. Check them every 3-6 months in perimenopause when feeling dysregulated.

If you need help balancing your hormones but you never did a baseline hormone panel in your 40s, a knowledgeable doctor can make an educated guess. If your doctor is one of those who is unwilling to run a full hormone panel for you, negotiate for a partial list. Alternatively, you can seek a functional medicine doctor here.

The gold standard is blood draw for serum testing, for which you need a doctor. But there are other labs I recommend (watch this video made during lockdown for what labs to use for at-home testing):

ZRT labs

DUTCH test

I’d suggest reading Appendix G in my book THE HORMONE CURE for a list of tests with normal and optimal lab ranges. You can also consider running your first test on your own through one of the direct-to-consumer testing organizations mentioned here in this article: Hormone Testing: What to Check and Why.

Dara: Thank you so much! In going through perimenopause myself, one of the key things I’ve learned is how different everyone’s experience is — so having a great doctor to guide one’s individual journey is important. What should we should keep in mind when looking for a specialist?

SARA SZAL GOTTFRIED, MD: Finding a doctor to work collaboratively with you can be a big challenge. In Appendix D in THE HORMONE CURE, I share suggestions on what to look for as well as scripts to start a discussion with your doctor. Here’s an example script:

“I’ve read a lot about hormones and am trying to make myself an educated consumer. I read in a particular book, by a doctor who specializes in hormones, that it’s important to look beyond some of the standard tests to really understand what’s going on. Because I’m experiencing [insert your symptoms], I wonder if you’d be willing to order a blood test for me.”

Finding a doctor who practices integrative, precision, or functional medicine is the next step if your doctor will not order tests for you. 

Here are some resources:

1. Consider applying to see me one-on-one or in my upcoming mentorship program. Complete the application form here: https://www.saragottfriedmd.com/coaching-app/

2. Also linked above, you can search for members of the Institute for Functional Medicine: https://www.ifm.org/find-a-practitioner/

(Ready for more info? Check out Perimenopause 102, which covers treatments for perimenopause, including bioidentical hormones.)

Note from Ayla:

Perimenopause and menopause can also have a dramatic effect on skin and hair — much of it, unfortunately, unwelcome. We have many years of experience helping our Ayla community through it; you’ll find our favorite recommendations in this Peri/Menopause Toolkit. We also highly recommend booking a complimentary check-in with one of our Guides to help you narrow down the options, especially if you’re noticing changes in your skin and hair.

 But we also know that products can’t do all the heavy lifting on their own; if you’re perimenopausal, your body is going through some significant shifts, and addressing those more systemically will also benefit your skin and hair health. We couldn’t be more thrilled to share Dr. Sara Gottfried’s knowledge to give you a running start. Endless thanks to Sara for being such a gracious guide for us all!

About Dr. Gottfried:

Sara Szal Gottfried, MD is a physician, researcher, author, and educator. She graduated from Harvard Medical School and MIT, and completed residency at UCSF, but is more likely to prescribe a CGM and personalized nutrition plan than the latest pharmaceutical.

Dr. Gottfried is a global keynote speaker and the author of four New York Times bestselling books about hormones, nutrition, and health. Her latest book is called THE AUTOIMMUNE CURE (published in March 2024).

Dr. Gottfried is Clinical Assistant Professor in Dept. of Integrative Medicine and Nutritional Sciences at Thomas Jefferson University, and Director of Precision Medicine at the Marcus Institute of Integrative Health. She takes care of executives and professional athletes. Her focus is at the interface of mental and physical health, N-of-1 trial design, personalized molecular profiling, use of wearables, and how to leverage these tools to improve health outcomes. Learn more at SaraGottfriedMD.com.