When Something Shifts — and No One Has an Answer

There were stretches, last year, where my executive functioning was simply not what it used to be. I'm a physician — I've built a career on precision, on language, on holding complex clinical pictures in my head. And there were moments where a word I'd used a thousand times simply wasn't there.

I was eating an anti-inflammatory diet. Strength training, daily aerobic workouts, yoga, breathwork — all of it, consistently. I was doing work aligned with my purpose. And still — that blankness didn't fit any category I had for myself.

I was not burned out. I was not depressed. For a brief stretch, I genuinely wondered if I was looking at early dementia.

And then it clicked — I was in perimenopause.

That experience, combined with something my friend and colleague Dr. Rachel Rubin says often — that any physician who sees women as patients needs to know how to treat perimenopause and menopause, not just OB-GYNs — is what pushed me to go deeper into this work. This post is what I wish someone had handed me.

Perimenopause is the hormonal transition that precedes menopause — typically lasting four to ten years — during which estrogen fluctuates significantly before it eventually declines. It is distinct from menopause itself, defined clinically as twelve consecutive months without a period.

Because estrogen receptors are distributed throughout the brain, gut, cardiovascular system, and skin, the effects of those fluctuations are wide-ranging.

This is not your body malfunctioning. It is a transition it was designed to make — one that is considerably more manageable with the right clinical support.

Melinda French Gates recently wrote in The New York Times about a scene that plays out constantly: a woman walks into her doctor's office with sleep destroyed, joints aching, heart racing, memory slipping — and walks out with no diagnosis, no treatment, and no plan. It's not because physicians don't care. It's because most of medicine still isn't trained to look for this.

Much of this traces back to 2002, when the Women's Health Initiative trial's hormone therapy findings were widely misinterpreted. Hormone therapy was abruptly abandoned across the board, research into menopause care slowed, and an entire generation of physicians went through training with little to no education on how to recognize or treat this transition. We are still living with that gap today.

These women are not imagining their symptoms. They have not been helped.

I've written before about burnout as a metabolic phenomenon — the body losing its ability to convert input into energy. Sometimes that's exactly what's happening, and the fix is restoring the stress system.

But sometimes the depletion is not burnout. It's perimenopause. The two look identical on the surface — exhaustion, fog, mood instability — but one is a stress-system failure and the other is a hormonal transition. Treating one as the other means the right treatment never gets a chance to work.

The cost is not abstract. The Society for Women's Health Research found two in five women have considered leaving — or have left — a job due to perimenopause or menopause symptoms, and one in four passed on a leadership opportunity as a result.

Perimenopause brain fog is the most frequently reported symptom. Between 44–62% of perimenopausal women report subjective cognitive decline — difficulty concentrating, word retrieval failures (El Khoudary et al., 2019; SWAN).

What women actually say sounds like this:

Each traces back to specific physiology: brain fog to estrogen's role in neural connectivity, early waking to declining progesterone, weight gain to estrogen's loss of influence over insulin sensitivity, palpitations to estrogen's effect on autonomic tone. These are not separate problems — they are one transition expressing itself across multiple systems.

Hormone therapy, when appropriate, is a significant part of good perimenopause care — not a footnote.

But it's one piece, not the whole picture. To get a woman to real, durable balance, I build around a framework — true whether or not hormones are part of the plan:

• Diet

  An anti-inflammatory eating pattern that supports hormonal and metabolic stability.

• Movement

  Strength training and regular aerobic movement to support insulin sensitivity and mood.

• Mind–body

  Practices like yoga and breathwork to regulate the nervous system alongside hormonal shifts.

• Sleep rhythm

  A real, protected sleep routine — often the first thing perimenopause disrupts.

This is where my practice stands apart from "here's your prescription, see you in a year." For women who cannot or choose not to take hormones — a choice I respect completely — evidence-informed options like acupuncture, botanicals, and clinical hypnosis deserve just as much clinical rigor as the hormonal path.