By David Wagar, MD – Capital Women’s Care
If your 40s have started to feel strange — physically, emotionally, hormonally — you’re not imagining it. Perimenopause is real. For some, it’s subtle; for others, it’s a full-blown storm. But either way, the more you understand what’s happening, the more empowered you’ll be to face it with strength, humor, and support.
Given the chance, I’m not sure any of us would volunteer to go back and relive the tumult of puberty. Bewildering hormonal surges. Aggravating body changes. Emotions that can’t seem to be controlled. It’s the stuff of legend. Countless books and movies have mined the drama, from the silliness of Big, Freaky Friday, and 13 Going on 30 to the poignancy of Inside Out 2. Most of us have memories of acne, smelly armpits, weird growth spurts, and an internal world we barely understood.
Fortunately, the dust eventually settled. Our frontal lobes matured (well, mostly), and we found some stability in our 20s and 30s. But for women, that’s not the end of the story.
Perimenopause: Puberty in Reverse
While puberty is about your ovaries waking up, perimenopause is about them winding down. And yet, most of us had some version of “the talk” before puberty — an awkward but well-meaning explanation of what was coming. But when it comes to perimenopause? Radio silence. No talk. No roadmap. Just surprises.
During puberty, the hypothalamus and pituitary (two centers in the brain) begin sending signals to the ovaries, which start maturing follicles (eggs) in response to follicle-stimulating hormone (FSH). One dominant follicle produces increasing levels of estradiol (E2), the primary form of estrogen during the reproductive years.
A mid-cycle surge in luteinizing hormone (LH) triggers ovulation. The ruptured follicle becomes the corpus luteum, which produces progesterone in the second half of the cycle. If no pregnancy occurs, progesterone drops, the uterine lining sheds, and a new cycle begins.
Why Your 40s Feel So Unpredictable
By your 40s, you’ve been cycling for decades. But here’s the catch: you were born with all the eggs you’ll ever have — about 6 to 7 million oocytes at 20 weeks of fetal development. That number drops to 1 to 2 million by birth, and by puberty, you’re down to roughly 300,000 to 500,000. Each cycle, 8–12 follicles are recruited, but only one ovulates. The rest die off in a process called atresia.
So in your 40s, the follicles that remain are fewer and often less responsive to hormonal signals. Ovulation becomes less consistent, hormone levels swing more widely, and symptoms start to surface.
What a “Normal” Cycle Looks Like
In your 20s and 30s, assuming you’re not on hormonal contraception, estradiol rises from about 30 pg/mL early in the cycle to a peak around 200–400 pg/mL before ovulation. After ovulation, it dips to 100–250 pg/mL, then drops back to baseline before your period.
Progesterone stays low (<1 ng/mL) until after ovulation, when it rises sharply and typically peaks above 20 ng/mL. If no pregnancy occurs, levels fall, triggering your period.
The truth is, your hormones were never “balanced.” That’s a myth. They were rhythmic, but also dynamic, shifting, and often chaotic. And still, you managed them with grace and consistency.
In Perimenopause, the Pattern Breaks
Now enter perimenopause. Estrogen and progesterone levels still rise and fall — but unpredictably. Some cycles, your estrogen barely reaches 50 pg/mL, and you feel every bit of it: hot flashes, mood swings, poor sleep. Then out of nowhere, your ovaries go into overdrive, and your E2 spikes into the 500s. You might get a strong ovulation, followed by a big surge in progesterone, and then a period that feels like you’re 16 again: heavier, crampier, and more intense than anything you’ve had in years.
And then? Nothing. Maybe no cycle for months. Or two heavy ones back-to-back. It’s unpredictable. It’s not linear. It’s not fair. But it is normal.
That said, if you’re experiencing bleeding that’s very heavy, prolonged, or occurs more frequently than every three weeks, it’s worth checking in. Not all bleeding changes in your 40s are harmless — sometimes they’re a sign that something else needs to be ruled out.
You might also notice weight shifting — especially around your midsection — even if nothing has changed with your eating or activity. That’s not a failure on your part. Hormonal changes, aging, and slower metabolism all contribute. It’s common, and you’re not alone.
Feeling Better Without Hormones: What Really Helps
At this point, you might be thinking, “Okay, that’s enough of the science. I already feel off — can we talk about what might actually help?”
Fortunately, the answer is yes. There’s a lot you can do — and many of these changes are not only good for your hormones, but great for your overall health.
1. Exercise — every day you can
- Exercise is one of the most powerful tools you have.
- Regular physical activity improves hot flashes, sleep, mood, brain function, and more.
Here’s what works best:
- Consistency over intensity: 20–30 minutes most days
- 6–7 days a week is ideal
- Strength training deserves priority:
- If you work out five days a week, aim for three strength-focused sessions
- If you exercise six or seven days, make sure four of those include strength
2. Vitamin D and Calcium
- Critical for bone health, mood, and immune function
- Get them through food and safe sun exposure when possible
- Supplements often needed:
- 1,200 mg of calcium daily
- 800–2,000 IU of vitamin D, depending on needs
3. Prioritize Sleep
- Aim for 7–9 hours each night
- Supports hormone regulation, cognition, and emotional health
4. Mental Health Matters
Perimenopause doesn’t just affect your body — it often impacts how you think, feel, and handle the stress of daily life.
You don’t have to go through it alone. Therapy, counseling, or even just a space to talk things through can make a huge difference. This isn’t about weakness — it’s about support for your whole self. If you think you need help, don’t hesitate to ask.
Hormone Therapy: A Tailored Approach
When lifestyle support isn’t enough — or symptoms are significantly affecting your quality of life — hormone therapy may be a great option. But there’s no one-size-fits-all plan.
1. Combined hormonal contraception
- The pill, patch, or ring can stabilize hormones and provide contraception
- Useful for perimenopausal women who still need birth control or want regular cycles
2. Progesterone IUD + Estrogen
- Offers local endometrial protection and contraception
- Estrogen can be added and dosed flexibly
3. Estrogen delivery methods
- Oral pills
- Transdermal patches or gels
- Vaginal rings (some provide systemic estrogen)
Transdermal options may be preferable — they bypass the liver and are often safer for those with specific risk factors.
4. Progesterone choices
- Can be taken alone or with estrogen
- Available as pills or vaginal inserts
- Cyclical or continuous regimens depending on goals
5. Testosterone
May support libido, energy, and wellbeing in some women — but not a universal fix. Should be carefully dosed and monitored.
If you’re not sure what next step is right for you, talk to one of us at Capital Women’s Care. We’re here to listen, guide, and help you feel like yourself again.
Final Thoughts: You’ve Got This
Perimenopause can feel like a wild and unpredictable ride — physically, emotionally, hormonally. The symptoms may surprise you. The timing may frustrate you. And just when you think you’ve figured it out, your body may change the rules again.
But here’s the truth: you are not alone, and you are not powerless. Whether your symptoms are mild or overwhelming, there are tools, choices, and support available. Some women feel better with lifestyle changes alone. Others benefit from hormone therapy or a combination approach. There’s no right answer except the one that works for you.
So if your 40s have left you wondering what’s going on — take heart. What you’re feeling is real. It’s valid. And with the right guidance, you can navigate this season with strength, humor, and grace.
You’ve made it through puberty. You’ll make it through this too.
At Capital Women’s Care, our experienced providers are here to support you through every stage of your journey — with personalized care, expert guidance, and treatment options that work for your lifestyle. Call us today at (301) 681-9101 to start feeling like yourself again.
