In the world of menopause and perimenopause, women have few verified, well-informed allies on our side by name. My story of navigating the world of doctors was quite dramatic; in fact, I still can’t believe I survived it at times.

I saw nine or 10 doctors before I finally landed on the main one who provided most of the help I needed. These included multiple general medicine physicians, two psychiatrists (one of whom agreed the issue may have been perimenopause and encouraged me to pursue that lead), a psychologist (who told me it was probably perimenopause), two OB/GYNs (one told me I was too young for perimenopause and another prescribed me some highly ineffective birth control pills), a neurologist and, finally, my big win: a reproductive endocrinologist who was speaking my language, totally “got it” and did not hold back on prescribing hormone replacement therapy (HRT) for me.

The irony in this is that both OB/GYNs I saw were “Certified Menopause Practitioners” by the North American Menopause Society (NAMS). Physicians who earn this credential are referred to as NCMPs, or NAMS-Certified Menopause Practitioners. In fact, for this reason, I had sought out those particular doctors.

NAMS is akin to a nonprofit professional association of physicians in this specialty, but it is also a clearinghouse for health guidance and information related to menopausal and perimenopausal women, and our adjacent issues, and could also be considered as a semi think tank of sorts. From here stem multiple clinical recommendations and best practices that should inform the work of those who treat women at this stage of life.

Interestingly, the doctor who confirmed what was happening to me and that I was not crazy was not NAMS certified, though she dealt with women’s hormones and reproductive issues every day. Given that my experience with a NAMS-Certified Menopause Specialist was such a bust, I have wondered what it even takes to become one.

Is it a rigorous process? Do you have to prove and demonstrate your expertise in women’s midlife issues? How much do you need to know about prescribing, dosing and tweaking HRT? It is only for OB/GYNs, or can other doctors belong as well? This information is not easily findable, but here is what I have been able to determine.

What kind of doctors are NAMS doctors?
NAMS-certified clinicians are not necessarily of a particular discipline. Naturally, one might presume that NAMS-credentialed doctors are OB/GYNs, fertility specialists or hormone experts. But this is not true. Among those who qualify for the credential are nurses, nurse midwives, nurse practitioners, pharmacists, physicians and physician assistants. Aside from the credential, NAMS also has among its 2,000 members professionals who are pharmacists, nurses, anthropologists, psychologists, complementary / alternative medicine practitioners, OB/GYNs, internal medicine doctors and others.

Why would a doctor become NAMS-certified?
The reasons doctors may pursue NAMS certification is not necessarily about helping women lead better lives. Among the benefits NAMS touts for being certified are “possibility of more patient referrals, job promotion and higher salaries” as well as more industry credibility, legitimate logos for presentations and literature, media relations, permission to use the NCMP acronym professionally and a certificate for framing. Obviously, these perks are about the total value proposition and don’t necessarily mean those who seek NAMS certification don’t fundamentally care about their patients first. NAMS doctors are also featured in a special NAMS provider online directory, a precious resource for women seeking care for their perimenopausal and menopausal symptoms, and basically a pipeline for doctors’ ongoing self-directed patient referrals.

What are NAMS practitioners supposed to know?
The program objectives to be NAMS certified include being well-versed and authoritative on a number of things, including:

• menopause terminology
• endocrine and physical changes associated with reproductive and physiological aging
• risk factors related to lowered ovarian hormones
• performing a physical examination and conducting a health history
• selecting and interpreting appropriate laboratory and diagnostic tests
• describing current research on complementary and pharmacological treatments
• helping patients make informed decisions
• addressing psychosocial issues
• recognizing when referral to other services is appropriate and more

How hard is the test?
The NAMS test features 100 multiple-choice questions, with each question having three presented answer options (e.g. A, B or C). Once earned, NAMS certification is good for three years, but individuals must attain 45 credit hours of continuing medical education (CME) within that time frame. One representative sample question is:
Which of the following is a risk factor for postmenopausal osteoporosis?

1. Genetics
2. Moderate alcohol consumption
3. Regular exercise

What does the test content consist of?
The NAMS Certified Menopause Practitioner exam breaks down the test content as follows: 19% on physiology and pathophysiology of the menopause transition; 20% on symptoms and concerns; 21% on health disorders of midlife; 19% on preventive care and counseling; and 21% on treatment options for common menopausal symptoms. The index of specific topics, concerns and issues covered under these headings appears to be quite comprehensive, which provides the impression that no provider who is NAMS-certified should be minimizing women’s symptoms or writing them off as unrelated to perimenopause.

How much does the NAMS certification test cost?
For NAMS members, the test fee is $200, and for non-members, it’s $400.

Why are women’s experiences with NAMS-certified providers so mixed?
I visited two NAMS-certified OB/GYNs. One agreed I was likely perimenopausal, but prescribed birth control pills, which are not recommended first-line treatment for perimenopause or the specific symptoms I was enduring. The other was skeptical that I was in perimenopause, told me I was “too young” and wanted to prescribe an SSRI antidepressant. From what I’ve seen online, mainly in virtual communities, women have very mixed experiences with NAMS providers. Some had very positive encounters and were treated seriously and given effective options, and many have had poor reports of not being taken seriously, being told perimenopause was an impossibility, being told to do more yoga and take deep breaths, and other unbelievable, incredulous things.

I believe there should be some reporting system in place, one wherein women could share with NAMS their experiences with such providers, both good and bad. Without this mechanism in place, and with such discrepancies in reported experiences with NAMS providers, the organization is risking its reputation by extension. There needs to be more quality assurance in place to ensure greater consistency and continuity among providers who hold the NAMS badge.
 

Personal stories are one of the most powerful and relevant ways to know you’re not alone in your perimenopausal journey. All too often, women find themselves on the hunt for information about this midlife change because no one around them is talking about it. Even among friends and family members, women are mum and silent about whether they are menopausal or perimenopausal, of it they worried about what the “change of life” will be like for them . . . let alone actually being candid about their symptoms and what they’re doing about it.

As midlife women’s health advocate, educator and former practicing gynecologist Dr. Barbie “Menopause” Taylor says, “Silence is stupid.”

There is nothing golden about the silence that is so pervasive around menopause and perimenopause. That’s why personal testimonies are so critical. Here, I’ve amassed some stories of striving, persevering and overcoming by women who are willing to be vulnerable and share their own experiences. Every little bit helps in navigating this phase of life.

This list of resources is continually updated.

A Case Study for Menopause Awareness – ZRT Blog, Margaret N. Groves, Sept. 14, 2018 – https://www.zrtlab.com/blog/archive/a-neurotransmitter-hormone-case-study-for-menopause-awareness/

Come Celebrate My 14 Years of HRT Use and Turning 64 Years Old! – Create A Menopause Recovery, Kitty Anderson, July 15, 2021 - https://www.youtube.com/watch?v=GfRhG-un6EA&list=PLURYQrFSaTf9LvHZMZSm0grPmE6e3Xvgb&index=1&t=10s

Davina McCall Opens Up about Her Nightmare Perimenopause Symptoms – Loose Women, Oct. 12, 2020 - https://www.youtube.com/watch?v=up0vjSrcljQ&list=PLURYQrFSaTf9LvHZMZSm0grPmE6e3Xvgb&index=47

Gabrielle Union Says Navigating Perimenopause Symptoms Led to Suicidal Thoughts – Kayla Blanton, Prevention, March 9, 2021 – https://www.prevention.com/health/mental-health/a35773464/gabrielle-union-perimenopause-mental-health/

HRT Patches for Menopause – Taylor Made Beauty by Kris, March 12, 2020 – https://www.youtube.com/watch?v=1KTKiDwFdjc

I Miss What I Used to be Like: Women’s Stories of the Menopause – The UK Guardian, Hilary Osborne, Caroline Bannock, Aug. 25, 2019 - https://www.theguardian.com/society/2019/aug/25/i-miss-what-i-used-to-be-like-womens-stories-of-the-menopause

I’m 43 and I’m Scared to Lose My Best Feature during Perimenopause – Kelly Eden, MamaMia, Jan. 22, 2022 – https://www.mamamia.com.au/perimenopause-story/

I Stopped Taking HRT – Here’s What Happened! – HotandFlashy, June 25, 2019 - https://www.youtube.com/watch?v=4XvAlDgHGjE&list=PLURYQrFSaTf9LvHZMZSm0grPmE6e3Xvgb&index=2

I Wasn’t Me: 10 Women Candidly Share Their Experience of Menopause – MamaMia, Feb. 5, 2022 –
https://www.mamamia.com.au/menopause-stories/
 
Liz Earle’s Personal Menopause Experience – Liz Earle Wellbeing, May 15, 2020 - https://www.youtube.com/watch?v=qbcWx_ffrUM&list=PLURYQrFSaTf9LvHZMZSm0grPmE6e3Xvgb&index=11&t=1641s

Menopause: An Honest Chat – – Dawn’s Life, Over 40, April 9, 2021 – https://www.youtube.com/watch?v=GVOyYg_7o84

Menopause, MHT and Me – The Spinoff, Anna Sophia, July 27, 2021 - https://thespinoff.co.nz/society/27-07-2021/menopause-mht-and-me/

Menopause Update: Finding the Right Balance! – Hot and Flashy, Jan. 7, 2020 – https://www.youtube.com/watch?v=akQpg6K5Wr0&list=WL&index=1

Mission Menopause: “My Hormones Went Off a Cliff – And I’m Not Going to be Ashamed” – The UK Guardian, Kate Muir, May 9, 2021 - https://www.theguardian.com/society/2021/may/09/mission-menopause-my-hormones-went-off-a-cliff-and-im-not-going-to-be-ashamed

My Bosses Were Happy to Destroy Me – The Women Forced Out of Work by Menopause – Sirin Kale,The UK Guardian, Aug. 17, 2021 – https://www.theguardian.com/society/2021/aug/17/my-bosses-were-happy-to-destroy-me-the-women-forced-out-of-work-by-menopause

My Hormone Replacement Therapy Journey So Far – Elle is For Living, Jan. 23, 2014 – https://www.youtube.com/watch?v=fauPe6ChxMQ (Also see “An Update on My Hormone Replacement Journey” – https://www.youtube.com/watch?v=sw9Iry6yx1I

My Menopause Journey – Dawn’s Life, Over 40, Jan. 15, 2018 – https://www.youtube.com/watch?v=ki8CMD-qbiI

We Need to Talk about Perimenopause – Alyssa Schwartz, Elle, Nov. 2, 2021 – https://www.elle.com/beauty/health-fitness/a37922110/we-need-to-talk-about-perimenopause-november-2021/
  

In the online perimenopausal community, there appear to be some battle lines drawn. If you thought these virtual watering holes were full of women supporting one another with no judgement or disagreement, then you would be mistaken. Just as in real life, factions are present, and strong opinions drive polarities that sometimes erupt in typed jabs and laughing, angry and crying emojis.

One of the more obvious and ever-present ones is the pharmaceutical vs. natural camp.

Simply put, one group of women is more open and receptive to prescribed medications that have been battle-tested in clinical trials, and this includes FDA-approved hormone therapy (estradiol and progesterone) that is produced by major pharmaceutical companies and available in generic and name brand formulations (vs. hormones made by compounding pharmacies). This group of women may include those who tried natural remedies that proved inadequate, harmful or ineffective as well as those who trust conventional medicine because it has been trialed, tested, in many cases with proven efficacy, and is produced according to regulations, with known and documented side effects.

The other group of women trends toward the “natural at all costs” philosophy. This is the group that may discourage going to conventional doctors and favors naturopathic and functional medicine practitioners instead. They are also the ones likely to caution against using prescribed medications, such as antidepressants (including but not limited to other drugs prescribed off label to help with perimenopausal hot flashes, night sweats, anxiety and more), as well as pharma-grade HRT. Their rationale may be that Big Pharma drugs have harmed them personally or those they know, that there is an unsavory profit motive involved in the practice of medicine that doesn’t put people first and that natural alternatives can’t harm you.

Naturally (pun not intended), there is a deep affinity among women thrust into perimenopause to try what’s close at hand, readily available and perceived as harmless. So many of us had no warning and little or no education about what would happen to our bodies and minds in midlife. We just knew that when we hit our late 30s to mid 40s, we started feeling different, off-kilter and a bit abnormal. Thus, we are fending for ourselves – at least those of us with the grit and resilience to even try to address the panoply of hormonal change symptoms. And that self-advocacy often starts with over-the-counter supplements and various concoctions, potions and pills recommended by word of mouth and easily obtained.

The problem is that just because something is natural, doesn’t mean it’s good for you, beneficial to your individual biochemistry or without side effects. Here are some commonly suggested natural remedies, bandied about through the grapevine among communities of women, or offered to us by supplement companies and holistic non-MD providers whose biggest competitors are, in fact, the commercial pharmaceutical industry and the very few mainstream physicians skilled in caring for midlife women (oh, those precious few!).

5-HTP:

• A nervous system and brain neurochemical used to boost serotonin, a mood regulator, in the body with the goal of reducing depression.
• Sometimes used to help treat insomnia and anxiety.
• Possible risks include heartburn, nausea, diarrhea, stomach pain, drowsiness, muscle spasms. Avoid use if taking antidepressants.
• May be safe if taken for up to one year.

Black Cohosh:

• An herb original to North America commonly deployed as an estrogen booster, even casually called “herbal estrogen.”
• Often sought to help with hot flashes and commonly included in so-called menopause supplements.
• Potential side effects are upset stomach, rashes, headaches, weight gain, bloating and liver damage.

Chasteberry / Vitex:

• Also known as Vitex agnus-castus, chasteberry and monk’s pepper, an herb used to help with infertility, PMS (migraines, depressed mood and breast pain in particular), menopause (specifically mood and sleep improvement), acne, breastfeeding, inflammation, bone repair, headaches and epileptic seizures.
• Potential risks: nausea and upset stomach, skin rashes, acne, headaches, heavy menstruation and should not be taken with antipsychotic medications, birth control pills and HRT.

Evening Primrose Oil:

• Comes from a plant and used historically to treats skin problems, wounds and hemorrhoids; also contained omega-6 fatty acids.
• Often used for breasts pain, PMS, arthritis, asthma and eczema.
• Possible side effects: upset stomach, dizziness, nausea, headaches, rashes and not recommended for those taking anticoagulant, antiplatelet, blood pressure, antidepressant and phenothiazine medications.

Inositol:

• Also known as myo-inositol, a type of sugar involved in bodily insulin response and hormones linked to mood and cognition, also called vitamin B8.
• Has antioxidant features that may counteract free radicals in the brain and circulatory system and naturally occurring in fiber-dense foods, such as beans, brown rice and wheat bran.
• Used to treat high cholesterol, insulin regulation, anxiety and panic, depression and polycystic ovarian syndrome (PCOS).
• Potential side effects: stomach pain, headaches, nausea and dizziness.

Kava Kava:

• Sourced from the pipe methysticum plant, often purported to help with anxiety, drug withdrawal, insomnia and stress due to impact on the brain and central nervous system.
• May be safe to use for up to six months, but is linked to liver damage and should be avoided by breastfeeding women, those with Parkinson’s disease and at least two weeks prior to surgery.

Maca:

• A root vegetable known to be used for at least 3,000 years, sourced from the Andes Mountains.
• Used to help male infertility, decrease depression, aid hair growth, stimulate libido and address menopausal symptoms (hot flashes).
• Side effects could include unpredictable impact on hormone levels and should not be taken by those with fibroids, thyroid issues, breast cancer, uterine cancer, ovarian cancer or endometriosis.

Red Clover:

• A plant used in traditional medicine to treat osteoporosis, heart disease, arthritis, cancer, menstrual symptoms and menopausal issues.
• Contains isoflavones, a variety of phytoestrogen, that weakly mimics estrogen in the body, with most research inferring benefits for menopause produced by supplement manufacturers. 
• Also claimed to help with anxiety, depression and even vaginal dryness.
• Possible side effects: vaginal bleeding, skin irritation, headaches, nausea and potential contraindications with various medications.

Tryptophan:

• Also known as L-Tryptophan, an amino acid needed for protein production, naturally occurring in protein-rich foods such as poultry, eggs and red meat.
• A precursor to 5-HTP, which converts to serotonin, a mood-balancing brain neurotransmitter that is also responsible for a host of other bodily functions, and used to help with PMS, depression and insomnia.
• Possible side effects: drowsiness, stomach pain, vomiting, blurry vision, diarrhea and, potentially, a neurological disorder called eosinophilia-myalgia syndrome (EMS) [possibly connected to contaminated products].

Valerian Root:

• Commonly used for insomnia, believed to affect GABA receptors in the brain responsible for controlling fear and anxiety.
• Also used to address headaches, anxiety, digestive problems, menopause symptoms (hot flashes), pain and fatigue.
• Possible side effects: headache, dizziness, itchiness, upset stomach, dry mouth, vivid dreams, daytime drowsiness and liver damage.
• Probably should not be combined with over-the-counter cold and flu medicines, antidepressants, sleeping pills or alcohol.

As you can see, there are side effects and risks associated with “natural” agents as well as pharmaceutical prescriptions – the most commonly cited and warned against in perimenopause being antidepressants and HRT. Coincidentally, many of the side effects of these supplements mirror some of the side effects associated with certain medications.

Many supplements have not been thoroughly tested through randomized, double-blind clinical trials, and many reports of potential benefit for the symptoms they are said to address are limited at best. In perimenopause and menopause, women ultimately must decide which options work best for them. For some, it will mean medications of any type are off limits. For others, they will embrace FDA-approved medicines. And many, many more will adopt an integrative approach, blending options from both worlds.