When a woman is hit like a deer in headlights by perimenopausal or menopausal symptoms, she often is at her most vulnerable. With almost no warning or often without any foreboding sharing of information from elder women or healthcare providers, women find themselves sweaty and sleepless, anxious and depressed, dried out and all cried out – with virtually no answers or informed, trusted sources to help them.

Women in this position, at least for the few among us who find the strength to advocate for themselves and seek help, are willing to try almost anything. This often means a succession of visits to conventional medicine practitioners – a tour with stops to the internal medicine doctor, an OB/GYN, maybe second opinions of the former . . . and then this is where most women stop. They frequently give up because these doctors have no real solutions or real education on this critical juncture that all midlife women – basically half of the world’s population – will one day face. All too often, physicians tell these women to exercise more, dress in layers, reduce stress or even grin and bear it until it passes.

For the women who give up on mainstream doctors, they may turn to over-the-counter offerings, like various supplements, teas and other untested and unregulated concoctions, seeking relief from evening primrose oil, “menopause vitamins,” black cohosh and other oils, tinctures, herbs and pills.

Still finding little to no relief, said women then may turn to what may be her final frontier: functional medicine doctors and naturopaths.
Sadly, these practitioners often take advantage of perimenopausal and menopausal women by offering hyperbolic hopes, grandiose promises and incredible cures, usually under the umbrella of “natural,” “customized” or “personalized” care. And it doesn’t come cheap, with repeated rounds of testing, reports, office visits and so much more.

So, are naturopaths and functional medicine doctors the equivalent of healthcare quacks? Are they selling snake oil and preying on legions of vulnerable, desperate midlife women?

What are their credentials?

Naturopathic doctors are not necessarily trained or credentialed. Going into the pool of naturopathic medicine providers is like jumping into a hurricane; one may need to survive the harsh, whipping winds before reaching the more tranquil eye of the storm. There is no universal standard for licensing naturopathic practitioners. Some states require that they attend a four-year program, study basic sciences similar to those taught in medical school and pass a state licensing exam. But others have no training at all, being unskilled, unlicensed and with no education whatsoever.

Functional medicine doctors, on the other hand, have usually completed medical school and then earned additional credentials from functional or alternative medicine organizations, such as The Institute for Functional Medicine.

How do they approach perimenopause or menopause?

If menopause and perimenopause communities on Facebook or Reddit are any indication, functional medicine doctors and naturopaths have an interesting approach to managing midlife hormonal symptoms. Their approach often involves repeated, rigorous testing of hormone levels and other metrics, such as vitamin levels, thyroid counts and much more. Women have left untold numbers of remarks about paying $600-$1,000 for a single office visit. They are frequently “prescribed” expensive vitamins and supplements (some of which they later find could have been purchased online for much less), and they may get compounded hormone treatments (available through compounding pharmacies with which these naturopaths have established agreements or relationships). The compounded hormones are not the same as FDA-approved and regulated hormone replacement therapy (HRT) in the form of pharmaceutical grade gels, patches or sprays, and oral micronized progesterone (or Prometrium).

Naturopaths and functional medicine doctors are said to habitually link perimenopause symptoms with other alleged and unproven conditions, like thyroid issues, gut health and adrenal fatigue.

Science-Based Medicine writes: “The problem with ‘functional medicine’ is that at its core it is close to being as nonsensical as the more ‘obvious’ forms of quackery. It just hides it better, given the number of fancy-sounding laboratory tests.”

Is functional or naturopathic medicine evidence-based?

Conventional medicine is based on years of data and research, including clinical trials, empirical case studies, lab experiments and more. That’s how medicine arrives at standards of care for various conditions, and that’s also how prescribed medicines finally reach the level of consumer access, after efficacy and relative safety are vetted. This is not to say there aren’t problems with “Big Pharma” and that all too many physicians reach for the prescription pad and lowest common denominator too readily before actually listening to and looking at the woman before them in the examination room.

But is functional medicine or naturopathic medicine actually based on proven science? Well, both purport to be more “integrative” and “holistic” than their competition. This is described as “addressing the web-like interconnections of internal physiological factors,” and “seeking a dynamic balance among the internal and external factors in a patient’s body, mind and spirit.”

But this is tantamount to a “get out of jail free” card “for basically anything practitioners want to do,” according to Science-Based Medicine.

Insurance usually doesn’t cover naturopathic or functional medicine.

Going to a naturopath or functional medicine doctor is expensive – and generally not covered by health insurance. Most practitioners don’t (or don’t have the authority to) order conventional blood testing, so they use other means, like saliva testing, in an attempt to build out the spider web of imagined conditions their “patients” are suffering from. Plus, lab tests are not necessary to diagnose perimenopause.
“The reason insurance doesn’t cover most of these tests and that conventional physicians won’t order them is because they are unhelpful, useless and / or not based in science and evidence.”

Some of the tests often recommended or ordered include those for heavy metals, micronutrients, methylation, inflammation, gut permeability, adrenal stress and metabolism. These tests are sometimes followed by the caveat that they are not intended to diagnose or treat a disease or to substitute for a physician’s expertise.

Why don’t they just prescribe regular hormone replacement therapy?

Many women are still afraid to take standard HRT, largely based on the continued reputational damage done from the now-misguided 2002 WHI study, which caused millions of women to abandon hormonal treatment almost overnight. Oncologists like Avrum Bluming are now going ultra-public about the safety and benefits of HRT for the symptoms of perimenopause and menopause, including longer-term brain, heart and bone health, as are many gynecologists, women’s health specialists and even psychiatrists. In fact, HRT is now known as the “gold standard” for addressing perimenopause and menopause difficulties, many of which can be life-altering and debilitating.

But naturopaths and functional medicine doctors continue to corral mistruths about HRT’s safety and effectiveness, preying on women’s fears and desire to be “as natural as possible.” Dr. Jen Gunter blows up the confusion they add about “body identical” vs. “bioidentical” hormones in “Stop Using ‘Body Identical’ and ‘Bioidentical’ to Refer to Menopausal Hormone Therapy” in this piece.

One such practice in Metro Atlanta proclaims: “We offer complete counseling and diagnostic testing to help you determine which treatments are right for you. We always prefer to treat patients with the most natural, least invasive therapy possible. Dietary supplements such as Estrovera are effective at relieving the symptoms of menopause. Other therapies such as acupuncture, biofeedback and dietary changes can also have a profound impact on patients’ symptoms.”

This same practice requires a log-in to view the prices of the dozens of supplements they “prescribe.” But a quick online search of Estrovera reveals it costs about $123.00 for 90 pills – about the same or more than what a typical HRT prescription of bioidentical estradiol and progesterone cost without insurance. This product does seem to have mostly positive reviews, but many of the reviews are tainted by women’s expressed fears of going on HRT, trying to stay away from HRT as long as possible, or seeking relief of hot flashes only (when there are 100+ known symptoms of perimenopause that HRT mostly can address, including vasomotor symptoms).

So is a naturopath or functional medicine doctor right for you?

Only you can decide if seeing a naturopath or functional medicine doctor is right for you. In this case, as with all things that are potentially expensive in both time, energy, emotional labor and monetary cost, buyer beware.

Given the increasing amount of evidence about the tried-and-true solutions for perimenopausal symptoms, those with the greatest amount of efficacy remain FDA-approved HRT and low-dose antidepressants (for those who can’t or won’t use HRT, or for those who still have breakthrough anxiety, depression or insomnia).

Supplements, vitamins, exercise and nutrition have their place in the total continuum of well-being, whether you’re perimenopausal or not. These can be adjuncts to HRT, or in the case of exercise and nutrition as the foundation of health, serve as building blocks.

But there is little defensible grounds for paying hundreds or thousands of dollars on minimally proven – or even outright disproven – homeopathic “prescriptions” to treat menopause and perimenopause.

​This may not be a popular or widely accepted idea – in fact, in some circles, it may even be considered controversial. But here it is: I don’t believe that CBT helps eradicate perimenopausal symptoms.

CBT stands for Cognitive Behavioral Therapy. The American Psychological Association (APA) defines CBT as “a form of psychological treatment that has been demonstrated to be effective for a range of problems, including depression, anxiety disorders, alcohol and drug use problems, marital problems, eating disorders and severe mental illness.”

According to the APA, CBT helps people change their thinking patterns. The premise is that psychological problems are rooted in untrue or unhelpful thinking styles and behaviors. Additionally, the notion is that if people learn different ways of coping, they are achieve relief from symptoms and lead better lives.

It doesn’t elude me that the APA and other professional organizations whose members offer services like CBT have a vested interest in promoting it as a solution. Doing so keeps their appointments booked and a steady flow of clients who are hopeful that the remedies for what ails them is CBT.

So when I hear about women being recommended counseling or CBT for perimenopausal symptoms, I want to scream. Why?!

Perimenopause Is Not All In the Mind

Well, for starters, perimenopause is increasingly being considered as a complex, dynamic “neurological transition state.” Some go a bit further and classify it as a neuro-endocrine process that affects multiple body systems all at once – the brain, the reproductive organs, the adrenal system and all sorts of involved hormones and neurotransmitters.

What this means, exactly, is pretty involved. At a minimum perimenopause is not relegated to the reproductive tract. It affects more than the ovaries and includes the involvement of the brain, its structures and its chemicals, and every place and function in a woman’s body that estrogen touches. Estrogen-related systems include those responsible for temperature control, sleep and circadian rhythms, cognitive function, mood, bone health and more.

Some of the most common symptoms of perimenopause are not just those hot flashes and night sweats so many people hear about. Instead, some of the most disruptive consequences of the hormonal changes are the emergence of anxiety or depression, trouble with sleep, the onset of headaches, the occurrence of new aches and pains and even dryness of the skin, tissues and eyes.

When women present to their doctors with these symptoms, many are often told one of two main things:

1. “You’re too young to be in menopause.” This is frequently said by doctors who are pretty unfamiliar with the difference between perimenopause and menopause, and who have limited knowledge of the fact that hormone changes begin in the 30s. They tend to think of menopause as the end of menstrual cycles – and only that – discounting the many associated symptoms that can offer beforehand.
2. “Let’s get you an antidepressant.” This is usually offered by gynecologists and general medicine doctors who are afraid to prescribe hormone replacement therapy, who know almost nothing about perimenopause or who are going for the lowest common denominator in terms of menopause management.

Sadly, when some women hear this, they walk out of the doctor’s office feeling dejected and unheard. And, moreover, they begin to think that maybe all these symptoms really are in their minds – that they need some emotional help – aid that comes in the form of therapy.

Perimenopause Is a Time Ripe for Spending Money Unnecessarily

Also, even more sadly, there are many social workers, counselors and therapists ready and willing to take women’s money and time, claiming that therapy sessions will help resolve their physical perimenopause symptoms. Some promote the concept that 1:1 counseling will temper the night sweats, the racing heartbeats and the sudden feeling of doom. The problem with this is that these perimenopause symptoms are physiological in nature – that means they stem from the way we, as human organisms, and our actual internal bodily systems, are working (or not working). Most of the time, these disruptions boil down to the same thing: the consequences of erratic and shifting hormones.

Fortunately, more is coming out about the ineffectiveness of CBT. For example, “After analyzing 70 studies conducted between 1977 and 2014, researchers Tom Johnsen and Oddgeir Friborg concluded that CBT is roughly half as effective in treating depression than it used to be.” The paper, titled The Effects of Cognitive Behavioral Therapy as an Anti-Depressive Treatment Is Failing: A Meta-Analysis, is long and extensive and available online.

There’s even information about CBT for menopausal insomnia, known as CBTMI. Between 30-60% of perimenopausal and menopausal women experience insomnia, sometimes related to night sweats and often not related to any vasomotor symptoms. CBT for insomnia features strategies like sleep restriction (limiting time in bed), stimulus control (going to bed or the bedroom only when time for bed – no other activities) and sleep hygiene.

Every perimenopausal woman I’ve heard of who suffered from insomnia has tried these tactics on her own, often with no success. Why? Because the issue, at its core, is hormonal!

What CBT Might Help

While I don’t believe CBT does anything for the actual physical manifestations of hormonal changes endemic to perimenopause, it may help for specific issues women are apt to have during this time of life. For example, if a woman is having trouble accepting the fact that she’s aging, therapy could help her reframe her thinking to see maturing, instead, as a welcome life stage. It may help her see this time as a period for renewal and novelty rather than one of irrelevance and burdens.

Similarly, CBT may help those struggling with empty-nest syndrome, changing marital dynamics, finding a sense of purpose and modifying their lifestyle.

What Works (often, anyway)
Perimenopause is a time of vulnerability and fragility for many women. It is a time of mystery and inconvenience, as some are completely caught by surprise by the alien experience they now have in the bodies they occupy and cannot predict how they may feel from one day to the next. CBT and other forms of counseling may help women feel better about this transition and help them start to view the situation more objectively. But it cannot treat the actual physical, physiological symptoms of perimenopause.

For those symptoms, I suggest doing this instead (if medically possible):

• Get on hormone replacement therapy (HRT). HRT for perimenopause usually consists of estradiol and progesterone – the former in the form of a transdermal patch or gel, and sometimes a pill, and the latter as an oral capsule. Research increasingly supports that the sooner, the better with the initiation of HRT before the age of 60. The old WHI study linking HRT with catastrophic health outcomes for healthy women has long been decried as faulty and harmful, even by the North American Menopause Society (NAMS).
• Get on an antidepressant, too, if you need it. For some women, who either 1) are not candidates for HRT, 2) don’t want HRT or 3) are already on HRT but need more support, antidepressants can provide added relief. Antidepressants can help reduce hot flashes and night sweats. They can also help with mood (anxiety or depression) and sleep. In these cases, they are usually prescribed at much lower doses than used for treating standard anxiety or depression. Some are even used off label to help with headaches. I know of two perimenopausal women in their 40s who had never been on antidepressants in their lives until now. One is on an antidepressant for hormonal headaches, which have now abated. The other was put on one for hot flashes, and says she hardly has any now, plus she realizes she had a low level of depression that has lifted.

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If you want to seek therapy, by all means, go ahead and do so. It may help you better contextualize perimenopause and cope with the changes it entails more fluidly. But it will not help with the actual physical symptoms of this change of life. As with all things, one’s mileage may vary, and buyer beware.

In the United States, most adult men are married. As of the year 2019, 53 percent of adults ages 30-34 were married, followed by 62.5 percent between ages 35-39, 66.1 percent aged 40-44, and 65.6 percent between 45-49 years old. This means that many men are married to women who are likely perimenopausal, as female hormones can start their decline from the mid-30s onward.

We are seeing an increase in coverage about menopause and perimenopause. From across the pond, the UK government is going to lower the cost of HRT, Davina McCall is launching a call for more workplace protections for women going through menopause, and a widower is now calling upon all men to be mindful of the mental health implications “the change” can introduce, after losing his wife to suicide. 

And even singer and ‘80s chart-topper Rod Stewart is speaking out, saying that if men learned more about menopause, their marriages would survive.

Here, in the States, we’re seeing slightly more traction about perimenopause and menopause, with celebrities like actress Tracee Ellis Ross going public about perimenopause and former supermodel Paulina Porizkova almost baring it all in recounting her menopausal journey. Such coverage should help amplify the voices about perimenopause and menopause that are growing louder, larger and looming over conversations and dialogues about women’s health. And, it is.

Countless online groups and communities are each brimming with tens of thousands of women in search of answers, explanations and solutions for unmanaged and mismanaged symptoms. They are seeking recommendations for doctors and providers. They are leaning on each other for emotional and moral support. They are sharing lifestyle regimens and supplements taken.

But what is missing from this percolating brew of a perimenopausal uprising? The voices of men.

For months, I’ve mentioned to my husband that the treatment of women entering perimenopause and in the throes of menopause would be an absolute game-changer, only if more men got up to speed and spoke out about how it affected – or could affect – the women in their lives. So much would change: Industry would have to adjust. The workplace would re-think what health and wellness really includes. Science would commit to new understandings. Big pharma would develop sustainable solutions that fine-tune hormone replacement therapy beyond its current incarnations – perhaps even one that couples the best of HRT and the best of antidepressants into one seamless pill for the women who need both. There would be fewer suicides of midlife women, fewer midlife divorces and less misunderstanding in general.

If one considers that the average man has not only a wife, but also a mother, aunts, nieces, female cousins, daughters, and friends, co-workers, supervisors, neighbors and acquaintances of the opposite sex, the web of potential influence expands dramatically. So why aren’t men using their gender capital to support women in this phase of life? How can they heighten awareness that will lead to change in policy, medicine, science and daily living?

Let me count the ways.

Create online support groups. There is a major void in the virtual perimenopause landscape – a watering hole for men who need the insight, resources and camaraderie to support not only themselves, but also their wives and girlfriends through this period of change. As they rally together, their voices will coalesce and magnify awareness and the need for more options, both socially and medically.

Propose policy changes. Men are overrepresented in government and business at all levels; as such, they have the numbers and representation to drive serious conversations about policies in the workplace, government (and related programs) and the educational system about perimenopause and menopause. Women are not necessarily seeking special accommodations, but they are interested in wellness programs and workplace-sponsored resources that provide education and advocacy, as well as insurance plans that cover treatments like HRT.

Speak with their primary care physicians about aging. Men go to the doctors, too, albeit usually less frequently. After all, they are human beings who get physicals and other routine checkups. Even though it might not be on the agenda of a typical office visit, men can ask their primary care, internal medicine and family medicine physicians what kind of menopausal medicine options they offer to patients. You know, asking for a friend? Or, if that’s too direct for comfort, they can ask about getting their own testosterone levels checked as a gateway for more conversation. Such inquiries could heighten the awareness and pique the curiosity of doctors, one by one, perhaps eventually creating a groundswell of expanded understanding to serve their women patients.

Talk to their guy friends. Most married men are friends with fellow married men, who have wives of a certain age. Though men are comfortable talking shop about sports, current events, music and celebrities, they tend to tread lightly when it comes to more personal matters. It will take some brave souls to bring up the topic of perimenopause among a crew of cronies, but whomever does will likely be surprised by the shared observations and experiences they’re having with their wives, fiancées or girlfriends.
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Start a campaign. Most of the awareness about perimenopause and menopause is being done by women, predictably so. The few male voices in this space tend to be anti-aging, reproductive and naturopathic doctors who have some monetary skin in the game. If men launched a campaign to raise awareness, it would certainly stand out if for no reason other than the gender of those behind it. 

What are you ideas for how men can become part of the change? Are the men in your lives supporting you during this time? If so, how?