Podcast Summary: You Are Not Broken – Ep. 324 "Perimenopause is Real"

Host: Dr. Kelly Casperson, MD
Guest: Jackie, Women's Health Nurse Practitioner
Release Date: June 29, 2025

Episode Overview

In this engaging and informative episode, Dr. Kelly Casperson welcomes women's health nurse practitioner Jackie to have a candid, nuanced conversation about perimenopause—what it really is, why it's so misunderstood, and how care and treatment need to evolve. With humor, candor, and personal anecdotes, they smash the myths and dismissals women face during this transition, empower listeners with science-backed insights, and advocate for symptom-driven, preventative, and individualized care.

Key Discussion Points & Insights

1. Defining Perimenopause: Demystifying the Taboo

• What is Perimenopause?
  • Textbook definition: "The time around menopause," but this is vague and insufficient ([04:16]).
  • Median age: 47 (from studies like the SWAN study), but wide individual variation—symptoms and onset can start even in the mid-30s.
  • Menopause = one year without a period; Perimenopause = the lead-up, often 4 years but very variable ([04:16]–[06:31]).

“The perimenopause zeitgeist is brand new. I feel like it's a year old to the three years that menopause has had.”
— Dr. Kelly Casperson ([02:43])

• Traditional medical education covers menopause, but barely touches perimenopause, leading to a lack of awareness even among clinicians.

2. Common Myths & Dismissals

• Myth: It’s Not Real / You’re Too Young
  • Age-based definitions cause unnecessary dismissal of younger symptomatic women ([06:31]–[07:28]).
  • Many clinicians rely solely on age and menstrual status, missing the vast spectrum of experience.

"Age is what you can drive at and vote at and drink at, but it's not what you should make medical decisions upon."
— Dr. Kelly Casperson ([07:33])

• Myth: You Must Stop Having Periods to be Perimenopausal

  • Many people (and providers) wrongly depend on the absence of periods to 'diagnose' menopause, ignoring the multitude of symptoms women experience while still menstruating ([10:42]–[12:24]).

• Myth: Everything That Happens is Perimenopause

  • While not every symptom is due to perimenopause, every woman with ovaries experiences it eventually—though other medical causes should always be ruled out ([12:50]–[14:16]).

3. Symptoms & Lived Experience

• Perimenopause is driven by erratic and declining ovarian function, leading to chaotic hormone fluctuations.
• Symptoms can include: mood swings, night sweats, menstrual irregularities, migraines, breast tenderness, libido changes, fatigue, bone loss, and more.
• The real question women are asking is:
  "Can I get treatment for this?" ([14:16]–[14:42])

"The treatment options are safe, cheap, effective. Like, why not try?... Tolerance of women suffering until menopause is insane to me."
— Dr. Kelly Casperson ([14:42])

4. Medical Understanding & Science Breakdown

• Hormonal Landscape
  • Perimenopause involves “chaotic” communication between brain and ovaries, erratic hormone spikes, and atrophy/fibrosis of the ovaries ([16:25]–[18:24]).
  • It's not simply running out of eggs, but a complex hormonal “shit show” that’s unique to each woman ([20:53]–[21:01]).

“Our bodies being the size they are… Elephant ovaries are bigger.”
— Dr. Kelly Casperson ([16:25])

• Ovaries may still produce some hormones even post-menopause; “zombie ovaries” may explain some ongoing symptoms ([20:53]–[22:21]).
• Testosterone: Declines more linearly from the 20s; the significance is debated ([21:01]–[23:49]).

5. Understanding “Estrogen Dominance”

• Term is often misused online, not a fixed state—high estrogen can fluctuate wildly, leading to migraine storms, breast tenderness, mood changes, etc.
• "Estrogen dominance is oversimplifying...all women in perimenopause are in an estrogen dominant state until they're in an estrogen void state" ([24:36]–[28:10]).
• Cycle irregularity reflects brain/ovary miscommunication—"the wires are totally crossed ... this shit show of a period" ([28:10]–[29:21]).

6. Treatment Approaches: Symptom-Driven, Flexible, Individualized

• Hormone Therapy:
  • Birth control pills: Steady “lazy river” of hormones; can help with certain symptoms, especially if contraception is also needed.
  • Menopausal hormone therapy (bioidentical or “natural”): Targeted, tailored dosing, sometimes only during symptomatic weeks ([30:27]–[33:46]).
  • Progesterone-only therapy can also be effective, especially for sleep/mood ([33:46]–[37:34]).
  • Some clinicians, like Dr. Casperson and Jackie, “grab a surfboard and ride the waves,” adjusting doses as symptoms shift.

“Treating perimenopause with menopausal hormone therapy [is] like grabbing a surfboard and ... getting ready to ride the waves.”
— Jackie ([32:08])

• When to Use Birth Control Pills

  • For cycle control, symptom suppression, and contraception (especially with sperm exposure).
  • Particularly helpful in severe PMDD (linked to drospirenone-containing pills) ([39:00]–[41:50]).
  • Risks: Higher blood clot risk than natural hormone therapy—should be off by age 55 ([41:50]).

• Myth-busting:

  • It is absolutely possible to have hot flashes and periods simultaneously.
  • Migraines may be due more to hormone fluctuation than the hormone level itself ([42:01]).

7. Why Perimenopause Matters: More Than Just Symptoms

• Accelerated health risks during perimenopause:
  • Increased risk of cardiometabolic syndrome, bone density loss, arterial stiffness, lipid changes, and viscosity fat gain.
  • Majority of bone loss happens in the two years prior to the final period ([44:26]–[46:43]).
  • “Not feeling like myself” is a hugely common—but difficult to quantify—marker ([43:38]).

“These are not sex hormones, these are brain hormones.”
— Dr. Kelly Casperson ([46:43])

8. Practical Takeaways & Modern Paradigms

• Individualized assessment: Track symptoms, use data, empower women to direct their own plans.
• Start with low-hanging fruit: Address hot flashes, vaginal dryness, sleep, mood, with safe, proven interventions first ([51:12]–[51:52]).
• Prevention: Early intervention may decrease future risk of osteoporosis, heart disease, diabetes ([49:19]–[51:52]).

Notable Quotes & Memorable Moments

• On Medical Gaslighting:
  “Gaslighting them and telling them to suck it up. Hope that helps. Thanks for your copay.”
  — Dr. Kelly Casperson ([16:25])

• “Estrogen Dominance” Reality Check:
  "Calling someone estrogen-dominant oversimplifies the issue…it's just Tuesday, next month your estrogen could be in the bucket again."
  — Dr. Kelly Casperson ([23:53])

• On Baseline Dismissal:
  “Every woman in her 30s is completely dismissed.”
  — Dr. Kelly Casperson ([56:11])

• On Tracking and the Millennial Generation:
  “We've been tracking shit on our phones since 2002...we know how to track stuff. We've got rings and earrings and watches and phones and everything to get data.”
  — Jackie ([35:15])

Timestamps for Key Segments

• Intro & Importance of Perimenopause: [00:48]–[02:43]
• Defining Perimenopause; Medical History & Studies: [04:16]–[06:31]
• Myths About Age & Symptoms: [06:31]–[08:57]
• Symptoms, Treatment, and Suffering: [08:57]–[15:17]
• Science of Hormones & Ovarian Aging: [16:25]–[22:21]
• Estrogen Fluctuations & "Estrogen Dominance": [23:53]–[29:41]
• Treatment Philosophy — "Surfing the Waves": [30:27]–[33:46]
• Stages of Perimenopause & Tracking: [35:15]–[37:34]
• Birth Control — When & Why: [37:34]–[41:50]
• Migraines in Perimenopause: [42:01]–[43:38]
• Accelerated Health Risks (“the gas pedal”): [44:26]–[46:43]
• Lab Testing & Preventative Care: [49:19]–[51:52]
• Bone Loss & Osteoporosis: [51:52]–[54:06]
• Healthcare System Strain & Solutions: [54:06]–[55:32]
• Dismissal of Young Women: [56:11]–[57:27]
• At-Home Hormone Testing & Consumer Trends: [58:15]–[60:00]
• Expert’s Role: Patient Navigator, Not Gatekeeper: [60:00]–[60:53]

Final Takeaways

• Perimenopause is real, complex, and worth treating. Every woman’s journey will be different—care must be individualized and proactive.
• Symptoms are valid. Whether you’re 35 or 55, being dismissed on the basis of age or menstrual patterns is unacceptable.
• Both hormone therapy and birth control have their place—tools, not dogma.
• Prevention, education, and self-tracking will be increasingly vital, especially as a new, empowered generation hits midlife.
• The conversation is evolving rapidly. Nuance, openness, and patient-centered care are the future.

“If we all agreed on everything all the time, the earth would still be flat.”
— Dr. Kelly Casperson ([61:31])

Resources & Further Learning

• Monday Night HER Medicine — Dr. Lisa Larkin hosts weekly clinician education on menopause and perimenopause ([62:41]).
• Dr. Kelly Casperson—Adult Sex Education Masterclass & Membership:
  www.kellycaspersonmd.com

This episode is a must-listen for anyone approaching midlife, those experiencing mysterious symptoms in their 30s or 40s, or partners looking to support loved ones. Dr. Casperson and Jackie offer a validating, actionable, science-based conversation about what perimenopause is—and why it’s time for cultural and clinical change.