Dr. Laurie Alpert, ND
Episode Summary
Can perimenopause cause anxiety, depression and mood swings—and does every woman need hormone replacement therapy or antidepressants to manage them?
In this episode of Girls Gone Wellness, Jeanette Titus and Victoria Gasparini are joined by Dr. Laurie Alpert, ND, a naturopathic doctor with a clinical interest in mental health, sleep and hormonal transitions. Together, they explore how perimenopause and menopause can affect women's mental health, including anxiety, depression, irritability, sleep disturbances, hormonal fluctuations and changes in sexual health.
Dr. Alpert begins by explaining how to recognize the early signs of perimenopause. While hot flashes and night sweats are commonly associated with menopause, changes in menstrual cycle length, worsening premenstrual syndrome (PMS), mood changes and changes in menstrual bleeding may appear earlier. She discusses the clinical criteria used to identify perimenopause, including variations in menstrual cycle length, and explains why some women experience symptoms before meeting these criteria.
A major focus of the conversation is the relationship between estrogen fluctuations, perimenopause and mental health. Dr. Alpert explains how sensitivity to hormonal changes may contribute to worsening PMS, anxiety, irritability, emotional sensitivity and depressive symptoms. However, hormones are only part of the picture. Insomnia, night sweats, fatigue, cognitive changes, relationship difficulties and the stress of caring for children or aging parents can also affect psychological well-being.
The episode distinguishes between temporary mood changes, depressive symptoms and major depressive episodes. Dr. Alpert discusses screening for mental health concerns using the Menopause Rating Scale (MRS), a validated questionnaire that assesses common menopausal symptoms, including psychological and physical concerns. Importantly, she challenges the misconception that depression and anxiety are inevitable during perimenopause.
What are the best treatment options for perimenopause-related mood changes? The conversation examines selective serotonin reuptake inhibitors (SSRIs), antidepressants and other medications sometimes described as neuromodulators. Dr. Alpert explains why these medications may be appropriate for some women, including their potential roles in managing depressive symptoms, hot flashes and sleep disturbances.
Menopausal hormone therapy (MHT), also known as hormone replacement therapy (HRT), is another major topic. Dr. Alpert discusses when hormone therapy may be considered, particularly for moderate to severe vasomotor symptoms such as hot flashes and night sweats. She addresses individualized risk-benefit assessments, breast cancer concerns, the timing of treatment initiation and how long someone may remain on hormone therapy. The conversation also covers local hormone therapy for genitourinary syndrome of menopause (GSM), including vaginal dryness and painful intercourse.
Sexual health, body image and relationships are explored as important but frequently overlooked aspects of perimenopause. Dr. Alpert discusses changes in libido, sexual discomfort, relationship stress, weight changes and the potential re-emergence of disordered eating patterns. She emphasizes the importance of partner support, communication and addressing sexual health concerns rather than accepting discomfort as an unavoidable consequence of aging.
The episode also addresses fertility and contraception during perimenopause. Dr. Alpert explains why pregnancy remains possible before menopause and why menopausal hormone therapy does not provide contraception. Hormonal intrauterine devices (IUDs) and oral contraceptives are discussed as potential options depending on individual needs, including the management of heavy menstrual bleeding.
Finally, the conversation explores practical ways to prepare for and navigate perimenopause, including menstrual cycle tracking, regular exercise, sleep, social connection and nutrition. Dr. Alpert discusses Mediterranean-style eating patterns, dietary fibre, protein, soy consumption and the limitations of exercise as a direct treatment for hot flashes. She also challenges restrictive dietary advice and the misconception that women experiencing menopause should abandon cardiovascular exercise in favour of strength training alone.
Throughout the episode, Dr. Alpert emphasizes individualized, evidence-informed care and shared decision-making. Her central message is that although perimenopause can bring physical and psychological changes, significant suffering should not be treated as an inevitable part of the transition.
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1. What are the early signs and symptoms of perimenopause?
Early signs of perimenopause can include changes in menstrual cycle length, changes in menstrual bleeding, worsening premenstrual syndrome (PMS), mood changes and sleep disturbances. In this Girls Gone Wellness episode, Dr. Laurie Alpert, ND explains that a variation of approximately seven days or more in menstrual cycle length is an important clinical indicator of the menopausal transition. However, some women experience hormonal symptoms, changes in menstrual flow or shorter bleeding periods before meeting this criterion.
2. Can perimenopause cause anxiety, depression and mood swings?
Perimenopause can be associated with increased anxiety, depressive symptoms, irritability, emotional sensitivity and mood swings, although not every woman experiences these changes. Dr. Alpert explains that fluctuations in reproductive hormones may affect women who are particularly sensitive to hormonal changes. Sleep disturbances, hot flashes, cognitive concerns, relationship difficulties and other life stressors may also contribute to changes in mental health.
3. Why can PMS and irritability get worse during perimenopause?
Premenstrual syndrome (PMS) and irritability may worsen during perimenopause because reproductive hormone levels become more variable. Dr. Alpert discusses the theory that some women are particularly sensitive to hormonal fluctuations rather than simply having abnormal hormone levels. Women who previously experienced PMS may notice more intense emotional symptoms as these hormonal fluctuations become less predictable.
4. How do you know if perimenopause is causing mood changes or clinical depression?
Distinguishing perimenopause-related mood changes from clinical depression requires an individualized assessment of symptoms, severity and mental health history. Dr. Alpert describes a spectrum ranging from mild emotional sensitivity, irritability and reduced enjoyment to significant depressive symptoms and major depressive episodes. She discusses using the Menopause Rating Scale (MRS), which includes questions about depression, anxiety, irritability and fatigue, as part of her clinical assessment. Identifying the nature and severity of symptoms helps inform appropriate treatment.
5. Does every woman experience depression or anxiety during menopause?
No. Depression, anxiety and other mental health changes are not inevitable during perimenopause or menopause. Dr. Alpert emphasizes that many women move through the menopausal transition without significant psychological difficulties. She also discusses how expectations and attitudes toward menopause may influence women's experiences, highlighting the importance of increasing awareness without creating unnecessary fear.
6. Do you need antidepressants to manage perimenopause-related mood changes?
No. Antidepressants are one potential treatment for perimenopause-related mental health symptoms, but they are not appropriate or necessary for everyone. Dr. Alpert discusses selective serotonin reuptake inhibitors (SSRIs) and other medications sometimes described as neuromodulators, explaining that certain medications may help manage depressive symptoms, hot flashes or sleep disturbances. Treatment decisions should consider symptom severity, mental health history, individual preferences and other available interventions, including menopausal hormone therapy and lifestyle support.
7. Can hormone replacement therapy (HRT) help with anxiety, depression and mood changes during perimenopause?
Menopausal hormone therapy (MHT), also known as hormone replacement therapy (HRT), may help some women experiencing mood changes during perimenopause, particularly when menopausal symptoms are contributing to psychological distress. Dr. Alpert explains that moderate to severe hot flashes, night sweats and insomnia can negatively affect mood and mental health. When these symptoms are significant contributors, hormone therapy may be considered as part of an individualized treatment plan. However, hormone therapy is not universally appropriate and is not automatically the preferred treatment for a major depressive episode.
8. Is hormone replacement therapy safe, and how long can you take it?
The safety and appropriate duration of menopausal hormone therapy depend on individual health risks, symptoms, treatment timing and ongoing clinical assessment. Dr. Alpert discusses how recommendations have evolved away from applying a universal treatment duration to every woman. She explains the importance of using an effective dose, regularly reassessing treatment and considering the potential risks of long-term use, including breast cancer risk with certain hormone therapy regimens. The episode also discusses how the timing of hormone therapy initiation relative to menopause influences the risk-benefit conversation.
9. Can perimenopause cause low libido, vaginal dryness and painful sex?
Yes. Perimenopause can be associated with reduced sexual desire, vaginal dryness, painful intercourse and changes in sexual satisfaction. Dr. Alpert explains that sexual health during menopause is multifactorial, involving physical symptoms, hormonal changes, psychological well-being and relationship dynamics. Vaginal dryness and painful intercourse may be associated with genitourinary syndrome of menopause (GSM), for which local hormone therapy may be an option. She emphasizes that sexual discomfort should not simply be dismissed as a normal consequence of aging.
10. Can you still get pregnant during perimenopause, and do you need birth control?
Yes. Pregnancy remains possible during perimenopause because ovulation may continue even when menstrual cycles become irregular. Dr. Alpert explains that menopausal hormone therapy does not provide contraception and that women who wish to avoid pregnancy should discuss appropriate contraceptive options with their healthcare provider. The episode explores oral contraceptives and hormonal intrauterine devices (IUDs), including how an IUD may help manage heavy menstrual bleeding while also providing contraception.
11. How can you prepare for perimenopause before symptoms begin?
Preparing for perimenopause involves establishing sustainable health habits and tracking menstrual cycle changes before symptoms become disruptive. Dr. Alpert recommends recording the first day of each menstrual period to help identify changes in cycle length over time. She also emphasizes maintaining regular physical activity, consistent nutrition, adequate sleep and meaningful social connections. These foundational habits may make it easier to manage the unpredictable physical and psychological changes that can accompany perimenopause.
12. What should you eat during perimenopause, and can soy help with hot flashes?
Dr. Alpert discusses Mediterranean-style eating patterns that emphasize fruits, vegetables, dietary fibre, adequate protein and a variety of nutrient-dense foods to support general, cardiovascular and metabolic health during menopause. She also discusses research suggesting that soy consumption may provide some relief from hot flashes, although its effects are not comparable to those of menopausal hormone therapy. Rather than recommending restrictive menopause diets, she encourages practical nutritional changes that women can maintain consistently.
13. Does exercise help with perimenopause symptoms, depression and hot flashes?
Exercise can support physical and mental health during perimenopause, but Dr. Alpert explains that research has not consistently demonstrated that exercise directly reduces hot flashes. She discusses the benefits of physical activity for psychological well-being, including walking as a potential intervention for depression. The episode also challenges the misconception that women should stop cardiovascular exercise during menopause and exclusively perform strength training. Both cardiovascular activity and resistance exercise can have a place in a sustainable exercise routine.
14. Why do body composition changes during perimenopause affect mental health?
Changes in weight, body composition and physical appearance during perimenopause can affect body image, self-esteem and psychological well-being. Dr. Alpert discusses how cultural beauty standards and societal expectations surrounding aging can intensify these concerns. She also highlights that perimenopause may be a particularly vulnerable period for women with a history of eating disorders or disordered eating behaviours, as changes in body composition may reactivate previous difficulties with food and body image.
15. Do mental health symptoms disappear once menopause begins?
Not necessarily. Dr. Alpert explains that whether psychological symptoms improve after the menopausal transition depends on the individual and the factors contributing to those symptoms. Hormonal changes, sleep disturbances, existing mental health conditions and other life circumstances can all influence a woman's experience. The episode emphasizes that mental health concerns should be assessed individually rather than assuming they will automatically disappear after menopause.
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This transcript has been edited for clarity and readability while preserving the substance of the conversation.
Victoria
Welcome to Girls Gone Wellness, Dr. Alpert.
Dr. Laurie Alpert
Thank you so much for having me.
Jeanette
We're so excited to chat with you about perimenopause, the transition, and how it impacts mood and mental health. Vic and I were talking before, and we were saying how, in our education, this is something we don't really get a lot of time on.
We're really excited to talk to you about this because it's such an important topic. Obviously, Vic and I haven't been through this transition ourselves yet, but we know loved ones, we have relatives, and we have patients who are dealing with it. They have all of this information on the internet that they're coming in with, and they just don't really know what to do with it.
We really want to do this topic justice and have an expert like yourself come on, debunk some of these myths, and set the record straight.
Dr. Laurie Alpert
Well, thank you for having me. This truly is one of my favourite things to talk about, so I'm excited.
Victoria
I love it. Tell us a little bit about yourself, why you became a naturopathic doctor, and how you got into the perimenopause and menopause space.
Dr. Laurie Alpert
Well, my parents were in medicine, and I grew up in and around hospitals. I did hospital jobs, so I saw all the amazing things that conventional medicine has to offer, but also where some of the holes were.
When it came time for me to carve my own path, I was looking for something a little bit different, and I found naturopathic medicine. I just fell in love with the idea of treating a whole person, having a little bit more time with someone, and working preventatively to complement where conventional care really excels in emergent, life-saving care.
I went down that path and developed an interest in mental health and mental health in kids. Then I quickly learned that the mental health of our kids is obviously very dependent on the mental health of their caregivers. That includes sleep. I'm a huge advocate of foundational good sleep, and that ties very closely with mental health.
Working with a lot of caregivers included a lot of nurses, a lot of teachers, and a lot of women in their 30s, 40s, and 50s who were very clearly dealing with hormonal changes. It became this confluence of all the factors: mood changes, sleep changes, and hormonal changes, none of which we learn very well through public education for ourselves.
There are also some gaps that we'll talk about in our healthcare training along these lines. That's how I ended up here, and I love it.
Jeanette
Amazing. Mental health and talking about mental health are becoming more common now, I would say. Even in family medicine, my family doctor will ask about how I'm doing with my mental health and all of that, which I think is great.
But I'm curious: when you were first starting your career as a naturopathic doctor, was it still a topic that not many people talked about? How have you felt that has transitioned to where we are now with mental health?
Dr. Laurie Alpert
I think it's definitely blown up. It was getting more attention before COVID, and then, of course, COVID really accelerated the conversation around mental health.
I can see how, in your generation, it's something we're very open about. We're much more honest about it, and we make space for it. When I was growing up, it really wasn't a thing. And when my mom was growing up, she told me that her mother's biggest fear was that my mom would have a hysterical incident. So my mom's ability to talk about mental health was really hampered.
I think my generation was able to open it up a little bit more, and then your generation has really embraced it. So we're making progress.
Jeanette
So interesting. I want to jump right into the questions.
First of all, just a general question: how does someone know that they're in perimenopause? I have so many patients who will come in and ask me this, and they just don't really know what's going on with their bodies. I'd love for you to explain that.
Dr. Laurie Alpert
Sure. It's a great question, and it's a really common one too. I've actually developed a tool that's on my website and my Instagram to help people understand this, so they can go check that out.
Basically, we're looking for changes in your menstrual cycle. The clinical criteria are that we're going to see changes in your cycle length. That means the length of time that goes between day one of one period to day one of the next period.
If we say an average of 28 days, we're looking for a variation of up to seven days. So you might have one cycle that's 28 days, one cycle that goes down to 20 days, and one cycle that's 35 days, and it's starting to vary that way.
Now, that's the clinical definition. We have to have that seven-day variation. But in experience, we can see changes or symptoms of fluctuating hormones that can occur before that. If you're susceptible to PMS, it sometimes starts to worsen before we see changes in the menstrual cycle.
I think that clinical definition is going to change with time too, because there are lots of people who are most likely in perimenopause. Their flow is lightening, the length of their bleed is shortening significantly, and they're getting the classic symptoms, but they don't necessarily have that seven-day cycle variation.
So I think there's still some grey zone in there.
Jeanette
Okay, that's good to know. A lot of the time when people come in, or even just on the internet, you'll hear a lot about things like hot flashes or night sweats, and people attribute those to perimenopause and that transition.
But I don't think we're talking enough about the changes in mood or mental health. Like you mentioned, PMS can actually worsen. How can someone's mood, mental health, or the way they adapt to stress change during this transition?
Dr. Laurie Alpert
It's complicated and not complicated at the same time.
For people who are susceptible to PMS, our current theory and understanding is that it has more to do with a sensitivity to changes in hormone levels. There are drops in hormones right before our period that some people are sensitive to, and those can create emotional changes and disturbances.
Through perimenopause, we're getting much more dramatic fluctuations in those hormones, so we're going to see more intense symptoms in our mood. That's one element of it.
Another element is that if you're experiencing significant hot flashes or night sweats, you're starting to lose sleep, you're getting joint pain, you're feeling like you're forgetting your words, and you're tired, all of that is going to feed back into your mood.
It can increase anxiety if you're trying to work and you suddenly feel like you can't present anymore, or you have a big talk in front of your boss and you feel like you're going to blow it. Or maybe you think, "I'm going to get a heavy period at any given moment, and I don't know when that's happening." All of these things can feed back into our mood and mental health.
In addition, it's just a transitional time. There are lots of other things going on that can impact how we're feeling. We may be part of that sandwich generation. We may have teenagers at home and older parents that we're trying to take care of as well.
We may be having challenges in our relationship. It might be the relationship itself, or it might be because our libido has tanked. There are so many levels that are going to impact our mental health.
Victoria
Absolutely. And like Jeanette was saying earlier, I feel like our generation is getting really good at acknowledging mental health and talking about it, but we're not really talking about it for people going through perimenopause. I don't know why, but I feel like it's just the last thing we think about.
It's interesting what you said too, because, yes, there are hormonal fluctuations causing some of these issues, but we're also dealing with symptoms like lack of sleep and intimacy issues, and those are going to impact our mood too.
We're just not talking about it.
Dr. Laurie Alpert
I know. We need to talk so much more about it. It's still taboo. It blows my mind.
Victoria
Why do you think that, in the last several years, the online space has just been completely dominated by information about perimenopause and menopause?
As I always say, it's the Wild West on the internet, and it's hard for people to know: is this misinformation? Is this accurate? Why do you think there's so much about this now?
Dr. Laurie Alpert
I think it's taken some brave women to stand up and be honest, open, and vulnerable about it.
I also think it's a marketing opportunity. This is a huge demographic with significant economic potential. So I think there are a lot of businesses trying to get in there and get their piece of the pie, to be honest. I don't know how else to put it.
It's really like anything else on social media. Everyone is trying to vie for your attention and convince you that their way is the best way. So it's tricky.
Victoria
And it's wild. I think it's great that people are talking about it. That's a positive.
But you're so right. I do feel like these women aren't getting the answers they need, either because they're not bringing it up because it feels taboo, or because that five-minute appointment with their doctor isn't getting them what they need.
It's an opportunity for people to prey on the vulnerabilities of these women by spreading misinformation and then probably selling a product or some kind of strength-training workout online.
Dr. Laurie Alpert
Totally. And I think you called it there. There is a gap in conventional care here.
It's not necessarily urgent care that's required. It has a lot more to do with quality of life and preventative care for certain things that may become urgent down the line. Traditionally, that hasn't received as much attention in the hospital system, in medical schools, and that sort of thing.
But I also think people are starting to demand more. They're saying, "My quality of life matters."
In the past, I think we've normalized a lot of suffering—suffering in women in general and suffering associated with our menstrual cycle—and we haven't talked about it.
I think all of those factors have contributed to this blow-up where people are saying, "Oh, wait. I'm not the only one going through this. There are actually people talking about this. Who can I talk to? Who can I trust?"
There are still a lot of unknowns there.
The research has also really evolved in the last 20 years. We've known a lot for a while, but I think that's another reason it's blowing up: things are changing, and things are changing fast.
Some of the misinformation isn't just marketing or people trying to take advantage. Some of it is totally honest in the sense that we learned one thing five or 10 years ago, and some people just haven't updated that knowledge.
It's changing faster than some people can keep up with because there's a lot.
Victoria
Absolutely. Something I've also considered is that the generation of women who are going through this transition, for the most part, didn't really have the same kind of open dialogue about their bodies—and specifically their reproductive health—that I feel like we're maybe getting a little bit better at now.
I have patients in clinic who will whisper the word "vagina" when it's just her and me in the room, or they'll prepare me in advance. They'll say, "I have something kind of embarrassing that I want to talk about."
And it ends up being sexual dysfunction, vaginal dryness, or intimacy-related issues.
These are women who, A, aren't talking about it because they feel like they can't—they feel like they can't even say the word vagina—or, B, they're finally opening up to their doctors but are met with, "That's just perimenopause. This is normal. That's just menopause."
I wonder how we normalize talking about these things without normalizing the idea that this is simply to be expected and that's just perimenopause.
Dr. Laurie Alpert
Totally. This is the line that I walk every day and struggle with too. Victoria, you nailed it.
We want to normalize some of the experiences that can happen so people don't feel alone and they know who to talk to and when to seek support, but we also don't want to set the stage for this idea that suffering is inevitable. That's really, really tricky.
I also want to set the stage here and say that there are a lot of people getting really good menopause care through the conventional system from people who know what they're doing and who are updated and informed.
The stories I tell are, of course, from a biased sample. People have come to see me because they're not getting the care they need or because they've had a negative experience.
So the stories I share are from that perspective. I do want to call out that that's not everyone. There are still a lot of great doctors doing great things.
But some of the things people tell me are shocking. Someone might say, "I'm having painful sex," and their doctor's response was, "Do it more with your husband. That'll help it out."
There is something to be said in the sexual space for re-exposing ourselves more often to increase desire, but not repetitive, painful sex. That's not the answer.
Some of this brushing off and dismissive attitude of, "Yes, welcome to aging, welcome to menopause," and then off you go with no support—that's just not good enough.
Jeanette
It's interesting because I find there's more education now for teenagers going through puberty about their periods. There's a lot more literacy there.
I think we've grown in that area for the younger generation, which is great and needed. But then once you get to your 40s and 50s, it's kind of like, "Okay, bye."
Once you get to that certain age, it feels like you're on your own. There's not really that much support.
Dr. Laurie Alpert
I think all that most of us are taught about menopause at any stage—whether it's through the school system or, if you were lucky enough, from a parent who talked about it at home—is that it's when your period stops. That's all people know.
It's the end of your period, the end of your reproductive life cycle.
We don't understand that the experiences can span a decade or longer. Maybe you've heard of hot flashes, but we don't necessarily know that night sweats are hot flashes happening at night. There's still a misunderstanding there.
And then there are all the other parts, like the taboo of bringing up vaginal dryness or sexual discomfort, or even the insecurity that happens around weight gain and body changes.
There's so much that's part of the picture that we don't learn nearly enough about.
Jeanette
I want to switch gears a little bit here. We're taught in school that a lot of women in perimenopause are prescribed antidepressants during this transition.
In your opinion, do we need to take antidepressants to truly handle this transition and all of the mood changes we talked about earlier? Or is there another way to do this?
Dr. Laurie Alpert
Well, my favourite phrase in healthcare is, "It depends."
First of all, I think there's a trend to relabel these medications as neuromodulators because of the taboo around mental health, depression, antidepressants, and anti-anxiety medications.
Calling them neuromodulators makes sense because that's what they're doing: they're impacting the nervous system in some way, whether that's the central nervous system or the peripheral nervous system.
Truly, menopause is a healthy, normal event. It's not a pathology, but it is something that impacts our nervous system. Even hot flashes are a symptom of our thermoregulatory system being off because of the changes in estrogen's effect on our brain.
Using a neuromodulator can sometimes be very helpful.
I think it's important for someone to seek support and for the clinician to get clarity around whether this person is experiencing depressive symptoms or whether they're having a major depressive episode. Those are different.
The differences can be subtle and difficult to distinguish during menopause and perimenopause, but that can help frame the conversation around the need for and potential benefits of medication.
If someone is having a depressive episode or even significant depressive symptoms, they might benefit from a medication or neuromodulator.
Some of these medications have also been shown to help reduce hot flashes independent of their impact on mood, so there might be a role for them separate from mood. Some have also been shown to help with sleep and insomnia.
There are different inroads for using them.
If we think of them as neuromodulators, they're not forever. There's definitely still a bit of taboo and fear among the people I work with.
I'll have some people who finally take that step and take the medication and say, "Oh my God, that was a game changer. Why did I wait so long?"
Then I have other people who try it, or they've tried it in the past, and say, "You know what? It's really not for me. I don't like how I felt on it."
It's a very individual decision. It depends a lot on what you're experiencing, your access to alternatives, perhaps, and your values. I think it's worth having the conversation with your healthcare provider.
Jeanette
It's definitely multifaceted. And I like the name "neuromodulators." I like that a lot better than antidepressant.
I'm curious: in your patient population, will you screen all of your patients who are going through the perimenopause transition for depression? Is this something you do with everyone, or is it on a case-by-case basis?
Dr. Laurie Alpert
I do. I often use the Menopause Rating Scale, which includes 11 questions about common experiences. It's a validated questionnaire in menopause research.
Three or four of the questions have to do with depression, irritability, anxiety, and physical and cognitive fatigue.
So I am often screening people. It's part of my area of interest anyway, and it is so common and, I think, under-recognized.
It doesn't mean we jump to neuromodulators right away, but I think it's another element of women's healthcare and hormonal healthcare that often gets normalized and under-supported.
Victoria
Would you say there's a spectrum here in terms of the mood changes that we expect to see versus a diagnosable mental health concern?
Dr. Laurie Alpert
One hundred percent.
And this is a perfect time to say that there are a ton of people who will go through menopause and perimenopause without any mental health impacts.
I know we talk about these things a lot, but for some people, this isn't even an issue. I want people to keep that in mind. It's not inevitable.
But yes, there is definitely a spectrum.
There's a spectrum of just having a low mood or kind of feeling "meh." That's what I'll call that "meh" feeling. Maybe I'm just not as into things as I was before. Things are fine. I don't feel depressed.
I might be emotionally more sensitive, so I might cry more easily. It's also very common for people to report irritability and rage, like snapping at loved ones more than before, to the point where they realize it's irrational but they just can't help it.
Then, at the more extreme end, yes, there can be a major depressive episode.
And that's just depression. We can see changes in anxiety too—increased anxiety or panic when it wasn't an issue in the past.
So there's 100% a spectrum.
Victoria
Okay, good to know.
For women who are experiencing mood changes and maybe don't want to go down the route of antidepressants or neuromodulators, what other treatment options would you consider for someone who's saying, "Absolutely not. I'm not taking that drug"?
And again, that's probably a good reason to call it a neuromodulator, because I think when we hear "antidepressant," people think, "But I'm anxious," or, "I have other things going on with my mood. Why would I take an antidepressant?"
Dr. Laurie Alpert
That's exactly what I hear from patients in my office.
They'll say, "I told my doctor what I was experiencing, and they prescribed me an SSRI. I'm not depressed. Why are they doing this?"
It goes back to the fact that the doctor has seven minutes to make a clinical decision and give you a recommendation. They don't have time to explain, "I'm not doing this because I necessarily think you're depressed. I'm doing this because of X, Y, and Z."
Yes, there are other things.
Depending on how you're presenting and what's going on, we might consider menopausal hormone therapy.
We see that people are more at risk for depression if they're having chronic, untreated, moderate to severe night sweats or hot flashes—vasomotor symptoms—or if they're having insomnia.
If they have a past history of major depression, you might lean more toward the neuromodulators. But if it's the major symptoms of menopause that are contributing to the mood changes, then we might consider hormone therapy as a treatment.
And then, of course, there's all that great foundational work: nutrition, lifestyle, sleep, community, connection, and social supports. We can build a whole strategic plan looking at the different pillars of mental healthcare to support someone.
Jeanette
I know you just touched on this, but I'll have patients come into the clinic—and I'm sure you and Vic do too—who aren't quite in the perimenopause transition yet, but they're approaching it.
They'll say, "What can I do to prepare myself? Is there anything I can do to make this transition as seamless as possible?"
I never really know what to say to that. Is there actually anything you can do to "prepare" someone for this?
You touched on the pillars of health. Would you start there and just try to get those into a good place?
Dr. Laurie Alpert
It's such a good question.
I always like to first say: track your cycle. We need that data. If you're not tracking your cycle, at a minimum, mark day one of each bleed on a calendar. That's information that's going to help your care provider down the road.
Second to that, I think it really is about solidifying those foundations.
It's so common in our 30s and 40s—and it can happen even earlier for some people—that maybe you've started a family, maybe you're really getting going in your career, and things like regular exercise have fallen off.
Maybe you're having trouble eating lunch on a regular basis, or you go out the door without eating breakfast. Maybe you're starting to scroll before bed at night, and your sleep isn't as good as it should be or as you'd like it to be.
Maybe you're getting busy enough in life that you're not connecting with your friends as much. You're not going out. Especially post-COVID, that's a whole other thing.
So I would say really start to solidify those foundations.
One thing that is common once we start going through perimenopause is that we lose the predictability of our menstrual cycle. If we used to struggle, at least we could mark it in our calendar: "Okay, I know the week before my period I'm not going to sleep as well. I'm going to be cranky. I can plan around that."
That starts to disappear as your cycle changes.
If your symptoms are starting to fluctuate or become more significant, those foundations, if they're really well established, are going to carry you a long way.
It's never too late. But often I'll see people when they're already in the throes of it, and now they're trying to establish some kind of foundational order in their life. It always helps.
So hold tightly to those things that we know are so good for us.
Victoria
I also feel like you said it's never too late, but it's also never too early.
First of all, let's track our cycle. I don't care how old you are. Let's start tracking our cycle.
And then let's also practice those foundations.
There's that quote that's more related to body composition: "Don't train for your bikini body; train for your 80-year-old body." It's almost the same idea. Start thinking about your longevity now.
Even if you're not anywhere close to that phase of life, let's start caring about it now so that when we get there, we feel like we have the tools we need.
Dr. Laurie Alpert
Exactly. I think about that when I work out sometimes. I think, "I'm working on my birthday present to myself for when I'm 75," with each workout I get to do.
Victoria
It is so true.
We talked a little bit about changes to relationships and maybe some intimacy issues. I did want to touch on this too, because it's obviously such a big contributor to mood.
Do you see this happening quite often in perimenopause? And how is it something that you address in practice?
Dr. Laurie Alpert
It's very common in the population that I work with.
It's not often the first concern. I screen for it because it's common, and especially because a lot of people won't necessarily volunteer that information. It's almost never someone's chief complaint at the top of their list. It's more like, "Oh yeah, and then there's that."
I think it's because a lot of the time women truly feel that it is at the bottom of the list.
It's like, "I can't sleep. I feel like garbage. I'm not showing up at work the way I want to, and sex is the last thing on my mind. So even if it hurts when it happens, that's another reason not to do it. Let's fix these other things, and then I'll worry about the dryness or the discomfort."
There are some really easy treatments if it's just a question of dryness and discomfort when you have intercourse and the desire is still there. We don't need to wait. We don't need to leave it until last on the list.
But it's very common, and people often just put it aside.
Maybe this is a historical thing with women's sexual pleasure again being last on the list, and it all depends on the relationship. Many of my patients want to treat it more because they care about their partner and they know it's impacting their relationship with their partner.
It's less common for someone to say, "I miss sex, and I want to do it more, and I'm not enjoying this dry period."
It's more common for people to say, "I don't really miss it. I don't really want it. But I feel bad for my partner, and I would like it to improve so that I can connect with my partner in that way."
It's a really fascinating phenomenon, and I think there's a lot to it. We probably don't have time to get into all of it today.
Jeanette
That's so interesting. I'm glad you brought that up because I was going to touch on how it probably is more about their relationship or trying to make their partner happy and connect in that way.
There's such a long history there, and we could probably do a whole episode on that.
It's important to talk about because, like you said, whether they want it to be or not, it's usually at the bottom of their list.
Dr. Laurie Alpert
And there are a lot of people who feel like it's really negatively impacting their relationship.
If you have the kind of relationship where there's compassion, mutual respect, listening, and communication, people are navigating that better. We even see in the research that your mental health—and your whole menopausal experience—is going to be better with partner support.
But then there are people whose partner doesn't understand what they're going through, and they're getting angry and lashing out. It's creating a lot of really unhealthy patterns and negative emotions in the relationship.
It's very complex.
The approach to supporting sexual health and desire is similar to mental health in that it's multifaceted.
We have to look at the physical changes that are impacting it, the relationship changes that might be impacting it, the social cues that we're reading into, the environmental cues—all of the things, all of the pillars.
We'll do another episode.
Jeanette
Definitely. From this conversation, it seems to me like there's a lot of relearning that has to happen during this phase of life.
You're relearning how your body works. You're relearning changes in your mental health. You're relearning how to navigate your relationship and all of this.
I feel like this is why this conversation needs to happen, because if you have no support system, it's going to be really hard to understand and know what to expect.
Dr. Laurie Alpert
Absolutely.
I think of it as a realigning with oneself because a lot of people may see themselves one way in their 20s, and then their 30s can bring a change—whether you start a family, you're in a longer, more serious relationship, or you've made changes in your career.
We kind of put our heads down and go with it.
Then we wake up one day, and for many people it happens in their 40s, and it's like, "Oh, wait. Who am I? I don't recognize myself anymore. I don't necessarily have the same joy and excitement for things."
There is a relearning, and it's like a reawakening when you reconnect with yourself and what you need.
You start to pay attention to the things that really make you feel well and the things that really make you feel unwell, and you make conscious decisions around which way you want to go.
Jeanette
I think that can be empowering too—to work with someone, relearn all of that, and reconnect with yourself.
If you frame it that way, I think it can be an exciting part of life as well.
Dr. Laurie Alpert
Yeah. That's why I love to talk about perimenopause as an opportunity.
I don't want people to feel like, "Oh God, this is coming up. What am I going to do?"
It's like you said earlier, Victoria: it's that fine line of, "Okay, this is what might happen. This is what you can expect. This is what to pay attention to. And this is how we can make it awesome."
We don't want to normalize suffering.
Jeanette
Exactly.
I know we talked about body composition and body image a little bit earlier, but I'd love to touch on this more. When it comes to perimenopause, how do changes to body composition impact a woman's mental health?
Dr. Laurie Alpert
Everyone is different, but there is definitely a trend toward more disordered eating. It's a very susceptible demographic and time of life for that.
If someone has a history of an eating disorder, it's likely to resurface because of these body composition changes.
In my office, I work with people all the time on weight management and weight loss. Sometimes it's about people coming into their own as far as recognizing what's really valuable to them.
Again, this is a whole other episode, but it is one of the elements that can play with your mental health through that time, for sure.
That's a result of our culture. It has to do with beauty ideals, beauty standards, this fascination with youth, valuing youth, and the idea that as we get older—or if our body looks a certain way—we have less value or we're less desirable.
And then there's the idea that we need to be desirable to have value. Don't get me started. That's a whole other thing.
It's very difficult for a lot of people.
I think for people who don't find it as difficult, they've often battled it more effectively their whole life in the sense that they've pushed against those standards and come to a place of confidence on their own.
So yes, it's challenging.
Victoria
Definitely. I always think of it as the Special K generation, where we grew up with this idea that "thin is in" and the smaller your body is, the better.
I feel like we're kind of getting back to that now, unfortunately, but that's a conversation for another time.
For the generation of women going through perimenopause, that was a really big thing growing up.
I see this with my own patients too. Even women who never struggled with their body size, who were always in that kind of smaller body, don't know how to deal with this change.
They've followed this low-calorie, cardio-all-the-time approach to weight loss their whole life. Then they get here and they're like, "Oh my gosh, I've never had to deal with weight around my middle," for example.
I feel like that's a shock to the system. And a lot of these people probably don't even know that they had disordered eating in the past.
Dr. Laurie Alpert
You're absolutely right. You nailed it.
I have the same experience where people who naturally fit, without much effort, into the beauty ideal and then things start to change have a much harder time than someone who maybe has struggled with it for longer.
It's challenging.
Victoria
Absolutely. Now, we talked a little bit about hormone replacement therapy.
I did want to have that conversation because, especially now that that newer follow-up on the HRT research from years ago came out, the message was essentially, "Yep, our fears have been overblown."
Of course, we talked to Dr. Ashley Chauvin about some of those fears, and there absolutely are risks associated with it, just like there are with any kind of pharmaceutical treatment.
However, I think it's a really interesting area to talk about and an awesome option.
How do you have a conversation with your patients about HRT? Is it always the answer?
Dr. Laurie Alpert
Good question.
It's not always the answer. I don't think it's always the answer.
I'm not pro-hormone therapy; I'm anti-suffering.
That doesn't mean I think everyone absolutely, 100% needs hormones. I can understand the argument some people make for it, but I think we have a lot more to learn.
As far as how I approach that conversation, like I said, I'll often do the Menopause Rating Scale.
I look for the indications for hormone therapy, which include moderate to severe hot flashes or vasomotor symptoms. If you've gone through menopause or have low ovarian function at a younger age, it might be indicated.
Or if you have what's called genitourinary syndrome of menopause, which includes some of those vaginal dryness symptoms we talked about or changes to the tissues there, in that case we can use local hormone therapy.
If someone qualifies based on the indications, then we'll start the conversation about risk versus benefit. I go through a detailed risk-benefit conversation.
For the majority of people, the benefits far outweigh the risks. That's what we have come to understand. But there are people where maybe—
I like to say I'm not the one to tell you whether the benefits outweigh the risks for you. Let's talk about what the risks are for you, and let's talk about what the benefits are for you. Then you make the decision about what you're comfortable with in terms of those risks and benefits.
Some people may say, "You know what? I'm not comfortable with that." Another person in the exact same situation will say, "Yes, sign me up."
It's very individualized.
That's where we'll start.
Then I'll have a lot of people who are curious about hormone therapy but may not fit the indications. Maybe they have mild hot flashes, or they might not have hot flashes at all, but they're having a bunch of other classic menopause symptoms and they're curious about what hormones can do for them.
Those conversations are a little bit longer.
I'm really about shared decision-making and informed consent. I do believe that a lot of very useful therapies have been withheld from women specifically for a very long time.
A lot of the patients who come to see me are interested in having some autonomy over their healthcare and playing an active role in their care.
I like to have those discussions and come to an agreement around what we can expect, what risks we might be taking on, and what benefits we can expect, and then go from there.
It's an individualized conversation.
Victoria
Absolutely. I also wonder about the safety of how long a patient can be on hormone replacement therapy.
Once they reach that phase, is it something they can continue? How long until we start talking about changing the treatment options?
Dr. Laurie Alpert
That's a very common question.
It used to be that there was a time limit put on it because we do see, with longer use—like decades of use—an increased risk of breast cancer.
But now the current recommendation from The Menopause Society, in its 2022 statement on hormone therapy in menopause, is to use the lowest effective dose for as long as needed.
So there's no more time cap. It's basically an ongoing risk-benefit discussion.
I will usually get to about the five-year mark and say, "Okay, it's been five years. Let's take another look and reconsider. Do we still need it? What are the potential benefits of continuing? What are the potential risks of continuing?"
We kind of start over.
We see that it's quite safe in many ways when initiated in the window around menopause. We talk about the 10-year window.
The risks of hormone therapy have more to do with reintroducing our systems to hormones after a long period of no hormone exposure. That's where we see that bigger risk and why we have that sort of 10-year window.
When it's started earlier on, then it's a different risk-benefit conversation even 10 or 15 years down the road.
So again, it depends, and it's individualized.
Jeanette
I'm glad we talked about this because I'm sure you see a lot of misinformation and disinformation about MHT on social media.
I think this can be an area where that becomes dangerous. People can get information and run with it, and it can be harmful.
So I'm glad we touched on that.
Dr. Laurie Alpert
Me too. Thanks for bringing it up because I agree.
It can be harmful in terms of people not getting access to it when it could benefit them, and it can also be harmful when people jump on the bandwagon too fast without really understanding.
The pendulum swings.
Jeanette
I wanted to touch on something quickly because, when I was watching a menopause summit, one of the naturopathic doctors brought up birth control during perimenopause.
It was something I hadn't really thought about: you can still get pregnant during the perimenopause transition.
I remember thinking, "Oh my goodness, this is definitely a conversation that needs to happen."
When someone is in that transition, do you talk to your patients about contraception, oral contraceptives, and all of that?
Dr. Laurie Alpert
Absolutely. Part of it is on our intake form anyway, so we do have that in there.
But with hormone therapy prescribing, there's always the clarification that this does not provide contraception. You need to consider that.
Until you've officially reached menopause, you could potentially conceive.
Before, when we had more fears around hormone therapy and weren't using it as much, the go-to treatment would often be birth control because there was some hormonal impact and some stabilizing, if you will, of those hormonal changes. So it did give some people symptom relief.
It's an option.
Many people like the IUD. It's very common for your period to actually get heavier and more frequent before it starts to spread out and slow down.
For a lot of people, their introduction to this whole journey is a scare with heavy bleeding, going to their doctor, having an ultrasound, and making sure everything is okay.
Sometimes we'll land on the IUD to help slow the heavy bleeding and also provide contraception.
What's nice is that, should you need it, you can safely layer in transdermal estrogen as hormone therapy down the line with an IUD.
Otherwise, you'll look at oral contraceptives as an option.
Classic menopausal hormone therapy might be the start of the conversation, but everyone's needs are different. If they don't want to do it that way, if they have different risks, or if they need contraception, all of those things are on the menu when we're talking about care through this stage.
It's a good point. We have to make sure everybody remembers it.
When I remind people of this, they're like, "Oh God, no." If they're 45 and already have three kids who are maybe in their teens or 20s, they're like, "Nope."
The idea of an unplanned pregnancy is not attractive to many people.
Victoria
I think there's also a myth that you can't get pregnant in perimenopause. I don't know why people think that.
I think they think, "Oh, now I'm in perimenopause, so I don't have to worry about that anymore."
And it's like, no, that's not true.
Dr. Laurie Alpert
Really? I didn't know people were thinking that.
Maybe it's like the myth that when you're breastfeeding, you can't get pregnant. We need to clarify some of those things.
Victoria
We recently talked about preconception, conception, and postpartum with Dr. Annalisa Caputi. She was saying she also sees patients who think, "Okay, that time's done. I've had my kids. I'm done."
They don't know that you can absolutely still have children at this stage.
So I'm glad we highlighted that again.
I think this whole conversation around HRT, IUDs, birth control, SSRIs, or neuromodulators really goes to show the importance of integrative medicine and how we have so many tools.
We don't have to do it just one way, which I think is super empowering for people.
I was also thinking as we were chatting that using an SSRI might feel a little bit scary for someone, but imagine if we can target these mood changes and how everything else in our life can shift—the sleep aspect, for example.
Then maybe they'll have more energy to want to work out more or to want to be intimate with their partner.
I don't want to say everything falls into place, because that's not necessarily always true, but when we have a bigger tool belt, I feel like we can really support patients best.
It just shows the beauty of integrative care.
Dr. Laurie Alpert
I love that.
It also highlights the importance of having someone who's going to look at your whole picture and understand what's at the root of it—what's the key, and where should we start?
What's driving these mood changes?
Is it really because you're having night sweats that are keeping you up at night, and now you're exhausted, grumpy, and angry? Then we really want to target those night sweats.
Or are you waking up every night to pee, and so you're snapping at people? Then we want to target why you're peeing so often in the night because it's going to have those trickle-down effects.
Victoria
Absolutely. Which is another reason why it's so special that we get to have so much more time with patients in our career, because we can really get to the bottom of that.
Aside from pharmaceutical interventions and even some of the more natural-medicine interventions we have, are there lifestyle or dietary measures that can help?
Dr. Laurie Alpert
I think there are always lifestyle and dietary measures that can help. For sure in mental health, we know this.
I think the issue is accessing them for a lot of people.
If you're not feeling great, the idea of doing a workout is really unappealing. If you're not feeling great, the idea of making yourself a salad is just not going to happen for many people.
Specific to menopause, it's interesting. Obviously, in the line of work I do and based on everything I just said, of course I think exercise has so many benefits.
In the research, it hasn't been shown to help with hot flashes. So it's been dismissed as a potential "treatment for menopause," quote-unquote, in some of the guidelines.
But no one's going to tell you not to exercise. Exercise has so many benefits.
We even see that the guidelines for major depressive disorder were updated to include supervised walking three times a week for half an hour as a treatment for major depression. So we do see benefits from exercise.
When it comes to nutrition, that's another whole episode.
At least in guidelines such as those from The Menopause Society, they don't support anything dramatic. It's more the standard advice: eat your fruits and vegetables, have more fibre, make sure you get enough protein, and follow something like a Mediterranean-style diet for heart health, metabolic health, and all of those things.
There is some research to show that a serving of soy per day can help with hot flashes.
Soy is also a great plant-based protein. It has a lot of nutrients, so it's a great addition if you like it.
It's on the menu, but it's not going to have the same impact as hormone therapy, for example, which is first-line therapy for hot flashes.
I find that nutrition recommendations are pretty consistent for most conditions.
Don't eat a lot of ultra-processed foods. Make sure you're getting your nutrients and variety, and increase your greens.
When I talk about nutrition, I get more prescriptive with people because we all know what we're supposed to do—or a lot of us do. Actually making it happen is the challenge, so we'll strategize around that.
I don't know if you were looking for more specifics, but we can dive deeper if you want.
Victoria
I think with nutrition, it's just so much simpler than we make it out to be.
The same goes for lifestyle and exercise.
I actually had this conversation with my mom a little while back where she said, "But I heard that I'm not supposed to do high-intensity exercise or cardio. I'm supposed to only lift weights."
When we tell women, "Well, you can only lift weights," if you've never lifted a weight in your life, good luck getting women to do that.
I personally don't want to do it. I know I have to, but it's hard when we've grown up with "cardio, cardio, cardio," and now we're telling women to completely switch it up.
I tried to tell her that there's still room for cardio and walking, and all of those things are great too.
The same goes for nutrition. You hear about things like the carnivore diet or myths about soy causing breast cancer.
We've already debunked that, thankfully, with Dr. Ashley, but there are so many things coming at women. Of course we're overwhelmed.
Dr. Laurie Alpert
You nailed it. We overcomplicate things all the time.
I'll go through an intake with someone, and we'll go through an average day of what they eat.
I had a patient who was talking about her morning coffee. She wasn't sure whether having a splash of maple syrup in her coffee or using oat milk was worse for her or better for her, and she wanted to circle back to that.
Then we went through her day, and basically she was skipping lunch and then overeating when she came home on lots of convenient, snacky food.
We got through the whole day, and I said, "You know what? At the end of the day, whether you have maple syrup or oat milk in your coffee is much less significant to your overall health and how you're feeling than whether you could just eat lunch."
We totally overcomplicate things.
It goes back to what you said earlier about all the stuff on social media, the myths, and the marketing.
Sometimes we need to just zoom out and get some perspective.
Jeanette
I completely agree.
Okay, it's time for rapid fire.
We do this every episode. We're going to give you about four or five statements, and you can tell us: myth, truth, or it depends.
Most of them are probably going to be "it depends," but we'll get to that.
First one: antidepressants or neuromodulators are the only way to manage the mental health changes that come with perimenopause.
Dr. Laurie Alpert
Myth. We debunked that, I hope.
Jeanette
Yes. Some of these we definitely want to drive home. We might have mentioned them earlier in the episode.
Second one: every woman is pretty much guaranteed to deal with mental health changes during the transition.
Dr. Laurie Alpert
Myth.
I actually want to elaborate on that for a second.
There was a great paper that came out in The Lancet just last month about supporting mental health through menopause.
It called out that, while it's great that we're talking much more about mental health and there's hopefully more awareness around what can happen or what people can experience through perimenopause, that also has the potential to set an expectation and worsen someone's experience if we're scared of or anticipating a negative experience.
We do know that our attitudes around aging and menopause are going to impact our experience of aging and menopause.
So if we have an attitude that says, "Oh my God, I'm at increased risk for depression. I'm going to feel awful. This is going to suck," it's almost like a self-fulfilling prophecy.
We need to be very careful about how we talk about mental health and perimenopause. It's not guaranteed to suck. It's not an issue for everyone.
But for the people who do struggle, we want them to be able to step up and say, "I need help."
Jeanette
I also think that highlights the mind-body connection and how powerful your mind is. Your perception of things can influence how you set yourself up as well.
Dr. Laurie Alpert
Absolutely.
Jeanette
Okay, the next one: mental health challenges go away once menopause begins.
Dr. Laurie Alpert
It depends.
Jeanette
HRT is an effective way to manage mental health changes in menopause.
Dr. Laurie Alpert
It depends.
Jeanette
Last one: the symptoms you deal with in perimenopause are inevitable.
Dr. Laurie Alpert
Symptoms might be inevitable for many people, but suffering is not.
Jeanette
I like that.
Victoria
That was actually really good. "Suffering is not." I feel like this is our Instagram post.
Dr. Laurie Alpert
Love it.
Victoria
At the end of every episode, we ask our guests the same question.
What is one myth—it can be something we've already talked about that you really want to drive home, or something we didn't touch on—in the perimenopause and mental health space that you want to bust once and for all?
Dr. Laurie Alpert
I think it's what we just said: the myth that it's inevitably going to suck.
We need to change that.
Victoria
I love it.
Jeanette
And I think it goes back to what we mentioned before. If we change our thought process and see this transition as something that can be more empowering, where we can take charge of our health, I think that can change things as well.
Dr. Laurie Alpert
Yes. And it means the people who are struggling can go and ask for support too, so they know they don't have to just suck it up in silence.
Jeanette
Exactly.
Thank you so, so much, Dr. Alpert, for coming on the episode today. We really appreciate it.
Where can our listeners find you? Where can they book with you? All of that information.
Dr. Laurie Alpert
Thank you so much for having me. This has been a lot of fun.
They can find me at my website, www.drlauriealpertnd.com.
I'm also on Instagram at @drlauriealpertnd.
Like I said, I have some little tools there. If you're struggling with mental health and you just want to do a little survey, most of those are available through my Instagram link.
I have something for sleep, something for mental health, and something to assess whether you might be in perimenopause.
Those are the best ways to get in touch with me.
Jeanette
Amazing. You have some great resources on your Instagram, so we'll link those in the description below so everyone can find you there.
Thank you so much again for coming on. We really appreciate it.
Dr. Laurie Alpert
Great. Thank you. Thanks, I look forward to it.
Victoria
Thank you!
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Dr. Laurie Alpert is a Naturopathic Doctor and Menopause Society Certified Practitioner who helps menstruators in their 40s and 50s navigate perimenopause with more comfort, clarity, and choice so they can feel like themselves again. She is on a mission to challenge the normalization of suffering associated with menstruation and the menopause transition and helps you take full advantage of the opportunities of this life stage to positively impact both your current and long term health and quality of life. As a long standing member of the evidence based continuing education platform for integrative medicine, The Confident Clinician, she participated in the inaugural Menopause Fellowship, and contributed to the Carry On Health Menopause Summit outlining the research on several topics including menopause at work, long-covid in menopause, and changes to sleep in perimenopause. She has educated her colleagues on advanced hormone therapy prescribing and other menopause related topics and offers consultations to naturopathic students and colleagues to discuss challenging cases. She has guest lectured at MacMaster University Health Sciences Department on nutrition and mental health and takes advantage of every opportunity to support and destigmatize menstruation, menopause, and mental health in anyone born with ovaries. Drawing from years of practice as a naturopathic doctor and educator, and combining extensive research into hormones, menopause, mental health, and sleep, she works with individuals across Ontario who are frustrated by the lack of conventional support available towards more confidence, strength, and connection during midlife andthe decades that follow.