If you’re over 40(ish) and you’ve ever walked out of a gynecology appointment feeling like you got a perfunctory once-over followed by a quick dismissal, you’ve got plenty of company. We hosted a Menopause & Wellness Panel here at Ayla this past fall, and Dr. Jila Senemar, a Miami-based board-certified OB-GYN with over 22 years of clinical experience, described what has, for many, long been a source of quiet frustration:

"You go in, you do your mammogram, you do your breast exam, you do your Pap smear," she said. "And then: ‘Any other questions? No? Okay, bye.’ That's pretty much what we get at this point. And it's really a disservice to women, because there's so much more to it all."

Dr. Senemar sees over 100 patients a week through JilaMD, a concierge practice focused on perimenopause, menopause, hormone therapy, and metabolic optimization. She’s on a mission to change how women experience this stage of life, and the minute we met this super-smart, pint-sized powerhouse, we adored her.

So, what do we need to know about perimenopause, post-menopause, and everything in between? Dara asked Dr. Senemar (also known as Dr. Jila) to break it all down. After reading this, you’ll adore her, too.

Dara: Walk us through the hormonal arc of a woman's life. Where do you think everything goes sideways in terms of the way we think about it?

DR. JILA: Puberty is celebrated. Pregnancy is celebrated. There are baby showers! And then after we're done having babies, it's kind of like, “Yeah, you're on your own.”

We spend about 40% of our adult lives in post-menopause. Women are living longer: the average life expectancy is up into the 80s. So we need to rethink this completely.

Perimenopause can happen in your late 30s, early 40s; it can last up to 10 years. And yet a lot of women—even today, after the menopause movement has gotten so much momentum—still don't know what it is. It's not just hot flashes. There are huge mental changes happening, social changes: relationships shifting, children growing older, empty-nesting. All of this is happening while your hormones are fluctuating daily.

And then menopause itself is literally one day. It's a definition word. It means you haven't had a period for 12 full months. That day is “menopause." The next day you're post-menopause, and you'll spend the rest of your life there. So, really, it's perimenopause and post-menopause that we should be focused on.

Dara: So what's actually happening hormonally in perimenopause?

DR. JILA: In perimenopause, progesterone is the hormone that tends to become deficient first, then estrogen, and finally testosterone. 

The way progesterone deficiency shows up is: you're not sleeping. You're short-tempered. You have this unrelenting anxiety that you've never had before—fear of flying, fear of something happening—and you can't understand where it's coming from. Gut dysbiosis starts happening. You used to love kale salads, and now you can't touch kale; you bloat and you look like you're five months pregnant. These are all signals your body is giving you.

I think if you're in early perimenopause—a little brain fog, but sleep is mostly okay, energy is pretty good—that's where we start with lifestyle modifications and supplementation. But late perimenopause is where things are snowballing. Symptoms are worsening. You're almost ready to leave your job. You feel as though you may be headed to divorce court because you're fighting with your husband or yelling at your kids. That's where we talk about adding hormone therapy.

Dara: What's the most important myth to bust about hormone therapy, aka HRT?

DR. JILA: The WHI study—when it came out, there was, overnight, an 85% drop in the number of HRT prescriptions. Women were told that if they went on hormone therapy, they'd get breast cancer, have a stroke, and die. That generation of women was done a terrible disservice. Many have passed from heart disease; many have dementia. That is not going to happen to this generation.

What is the number one cause of mortality in women after 50? Everyone thinks it’s cancer, but it’s actually heart disease. Number two is osteoporotic fractures. Number three is dementia. Number four is cancer. So I'm not just treating your symptoms with hormones; my goal is to protect your heart, your bones, and your brain so that in 20 years, you don't have any of those diseases.

The other myth I want to address is that if you didn't start HRT before 60, it's too late. Absolutely not. I have women come to me at 65 who are devastated, thinking they missed it. We look at their medical history, we do a cardiac workup, and if everything checks out, we can start. That's where the conversation should be.

Dara: Before we get to hormones, what are the lifestyle fundamentals you always start with?

DR. JILA: Nutrition, diet, stress, sleep—those four things have to be tuned in first, and it's not a race. It's a marathon. One little daily change in one of these lifestyle aspects is where it's at, and we just build upon that and add as we go. 

It's not “I need to sleep perfectly, or else!” Some nights you'll sleep better than others. We see what works and what doesn't. I love wearable devices, because you think you got eight hours of sleep last night, but was it quality sleep? That's why I use continuous glucose monitors, Oura rings, all of these tools with my patients. I like data points. They give women the information they need to actually take care of themselves.

Certain herbs and magnesium come into play for sleep optimization, too. And breathwork, like what Annee de Mamiel has walked us all through, can lower cortisol almost instantaneously. These things genuinely matter. We are busy, go-go-go people. We say “yes” to everyone else. This is the time to optimize yourself, because you cannot pour from an empty cup.

Dara: And when does supplementation give way to hormone therapy? How do women know when it's time?

DR. JILA: It really comes down to symptoms and quality of life. Early perimenopause—a little brain fog, sleep mostly okay, energy pretty stable—that's where we start with lifestyle and supplementation. Supplements can cover you for a year or two; I recommend MPOWDER in my clinic. And then when things start to bubble up again, that's when you get into your doctor's office and get checked.

Late perimenopause is where symptoms are snowballing. You're almost ready to leave your job, you're fighting with your partner, you're yelling at your kids, and you keep chalking it up to stress. It *is* the same stress. But now it's affecting you differently, because your hormonal foundation has shifted underneath it. That's where we add hormone therapy.

And it doesn't have to be all the hormones at once. In perimenopause, progesterone goes first, then estrogen, then testosterone. So we can be gradual with it. Someone who is really struggling across the board gets everything right away, and we monitor her closely—every six to eight weeks at first. Someone with more specific symptoms, we add one piece at a time and let her body respond.

Dara: What about blood work? So many women have been told their labs are "normal" and sent home.

DR. JILA: This is one of the most validating things I can tell you. In perimenopause, blood work is often not going to show you much. That's because your hormone levels fluctuate so dramatically day to day; what we catch on the day of your test may look completely fine. And so the doctor calls you back and says, “Your labs are great, you're not there yet, come back when it's worse.” I know. I'm sorry. That should not be happening.

Symptoms are the data. If you're not sleeping, if you're anxious, if your gut is off, if your hair is falling out, those are the data points. A good provider will listen to all of them together and not wait for a lab value to validate what you're already living.

Dara: You also touched on the importance of integrating Eastern and Western medicine. How do you think about that in your practice?

DR. JILA: I've literally shifted my whole career around this. I'm not a conventional gynecologist anymore, because I know the value of bringing in the other side; you need both. And this is the first time in a very long time that the two have crossed paths in a real way. We're getting back to root-cause healing—treating the base of what's happening, not just putting a band-aid on the problem.

I love that patients are doing acupuncture, herbal medicine, all of that. But what I can tell you is those things, as valuable as they are, are not going to prevent you from getting osteoporosis. They're not going to prevent heart disease. There is a place for both. The goal is to take the best of all of them, put them together, and marry the two. Lifestyle modifications and herbals will help with symptoms, but they won't get to the silent components of what's happening internally.

Dara: GLP-1 medications—Ozempic, Wegovy—come up constantly in midlife conversations now. What's your take?

DR. JILA: There genuinely is a place for them, especially in midlife women. And here's why: the fat we gain in the midsection during perimenopause isn't the same fat we gain when we go on vacation and overindulge. That vacation fat is subcutaneous fat: you can lose it relatively easily, and it's not particularly dangerous. 

What happens in midlife, due to estrogen shifts, is visceral fat. That's the fat inside, around your organs. It leads from prediabetes to diabetes to heart disease. It's dangerous.

GLP-1s work to reverse that ratio, bringing skeletal muscle mass up and visceral fat down, so the body composition becomes healthier. There's actually a recent study on menopausal women where one group was on HRT and another was on HRT plus GLP-1s. The second group lost 30% more fat and had better overall health markers. So there is a role for both, together.

That said, this is not "I just want to get skinnier." That is not the conversation. It's really about body composition, root cause, and individualized care. GLP-1s have been around for over 10 years; we've been using them in the diabetes community for decades. It's just that we're now applying them more broadly. If it's done with a provider certified in obesity medicine, and if it's the right fit for you specifically, it can be a meaningful part of a midlife health protocol.

Dara: We all desperately wish we could see you for care, but we can’t. So, what should women look for in a provider, and what are the red flags we should look out for?

DR. JILA: If they give you only one option, that's a red flag. If they make you feel foolish or silly for asking questions, that's a red flag. And if they tell you that you're going to get breast cancer just because you go on hormones—and they're not explaining the nuance of what kind of hormones and why—that's a red flag. You deserve precision care. Your chemistry is different from the woman next to you, and your protocol should reflect that.

My goal is for my patient to walk out of the room with all of the information. Then she can stew on it, read the books I recommend*, come back, and say, "I think I'm ready to try this." It's not my way or the highway; it’s “let's have a conversation.”

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There's a lot to sort through in the menopause world, and there's a lot of noise, too. What we love about Dr. Jila’s approach is how clearly she connects the science to the everyday experience and how emphatically she insists that women deserve better than what most of us have been getting. (Dr. Jila for President?)

For those navigating the supplement side of perimenopause, we carry MPOWDER, Dr. Jila-approved, botanically synergistic formulations created specifically for perimenopause and post-menopause. Every purchase comes with access to a naturopath consultation and monthly masterclasses, so you're never just getting a product: you’re getting wrap-around support, too.

If you don’t live in or near Miami but you’re interested in working with Dr. Jila, we have some good news…she is not self-promotional in the least and didn’t mention this while at Ayla, but we did some hunting around on her site and found this tidbit: “We require an in-person visit first to establish care. After that, virtual visits are totally on the table! The best way to make an appointment is to join the waitlist. Once you're a patient, we’ll handle everything via text or email—easy, breezy.”

*Books DR. JILA recommends: 
The New Menopause by Dr. Mary Claire Haver
Generation M by Dr. Jessica Shepherd  
Estrogen Matters by Drs. Avron Bluming and Carol Tavris 
The XX Brain by Dr. Lisa Mosconi
The Menopause Brain by Dr. Lisa Mosconi