Learn from Dr. Ty.

Dr. Ty answers, in her own words, the objections she says she hears most from women who think they don’t qualify for a perimenopause conversation: regular periods, being “too young,” a doctor who already said the labs were fine, and the fear that treatment will be generic instead of built around them.

“You’re fine, don’t worry about it.” Sound familiar?

“My name is Zuleikha Tyebjee. I go by Dr. Ty.”

Dr. Ty opens with the line she says patients hear from other doctors: “And the doctor says, well, you’re fine. Don’t worry about it. Just deal with it.”

Her answer to that: “It is not based on labs. It is not based on a certain number. I can’t look at your estrogen and go, ‘You’re in perimenopause.’ If you tell me your series of symptoms, regardless of your labs, that is how that diagnosis comes.”

Is it really affecting more than my body?

“Finding someone who understands that perimenopause and menopause has the vast gamut of symptoms” — she lists what that means: “It is not just your hot and your sweaty. It is that you don’t want to have sex anymore. You’re tired all the time. Your brain doesn’t work. You’re going to work and you are not able to function at the capacity you used to. Your relationship with your husband or your wife or your kids or your partner or anyone around you has changed.”

On brain fog specifically: “So you have the neurocognitive symptoms — so brain fog, very common — not performing the same way at work as they are typically used to. Things like forgetting words, word finding difficulties, going into a room, forgetting why you were there.”

On symptoms women don’t always say out loud: “So certainly vaginal dryness, painful sex comes with that, urinary symptoms. So urinary urgency, hesitancy, frequency, recurrent UTIs.”

Why doesn’t a normal lab result settle it?

“There is still very commonly in the medical field this misconception that the labs have to match up with the symptoms, and that is just really not true.”

“The Menopause Society, which is kind of the leading society on menopause and perimenopause, and then several other major societies, clearly state that for women over 45 presenting with perimenopausal symptoms — which are some of the ones we go over — those routine hormone tests that we all kind of had defaulted to in the past, be that FSH, LH, estradiol, those are not recommended.”

“A big reason for that is that our levels of those fluctuate like roller coasters during the day, but also during perimenopause in general. So you could have normal levels one day and completely off-range the next. You could have high, low, just depending on the day, and they’re impossible to track. It’s not like a fasting lab where I can say, make sure you fast and we’re going to get accurate labs. It’s not like that.”

Can I have perimenopause if my periods are regular?

“Perimenopause can come when your periods are coming just like normal, but you’re having a kind of wide variety of symptoms that we would associate with perimenopause, and those symptoms are primarily driven by wide hormone fluctuations.”

Am I too young for this in my 30s?

“I will say anecdotally, I’m seeing women much earlier showing up in my clinic, in their mid to late 30s. I would say that’s pretty average for my patient population.”

Will treatment be one-size-fits-all?

“I would say I see some of the most diverse responses to HRT in my patients, as opposed to other treatments. So that’s where the importance of having a physician who understands this really comes in. HRT is not one size fits all.”

“And if you have a physician team member who doesn’t understand the different options, you’re going to get stuck. And that can lead to all of its own issues.”

What does Dr. Ty believe her patients need from her?

“I think it’s really, really important to have a physician team member with you on this process, someone who understands that this is very much a global thing, and that there are so many aspects to it: mental, physical, emotional.”

“My patients are my teammates.”

Are there good treatments, and can I still ask for my own labs?

“There are great treatments now for it.”

“You have every right to ask for whatever lab you want to.”

“I take my relationship with my patients very seriously.”

What does Dr. Ty want you to do next?

“I would love to talk to you more about this.”

This is the teaching portion of Dr. Ty’s free, recorded masterclass on perimenopause and menopause — what the symptoms actually look like beyond hot flashes, why she says a normal lab result doesn’t rule perimenopause out, and why she believes the physician you choose matters as much as the treatment itself. It leaves out the sections she and her team flagged for her own further review before they run in new form.

How does a physician actually diagnose menopause?

“I am a family medicine board-certified physician, and I’m going to talk to you a little bit about modern menopause management — talk about the evidence, and how things go a lot beyond the labs.

There are a lot of different stages of reproductive age in women. The ones that are most important for this discussion are going to be perimenopause [and] menopause.

Menopause is pretty easy to diagnose in the sense that it is a year after you have not had a period. So it’s got a nice objective timeline. 12 months after that last period — as long as it wasn’t induced by like a hysterectomy or surgical means, but at naturally occurring 12 months without a period or menstrual cycle — we can officially say you are in menopause, considering all other things are normal, or all other medical conditions are healthy, etc. So yeah — 12 months without a period, we can define that as menopause.”

What is perimenopause, and how is it diagnosed?

“Perimenopause, it’s a little bit, quote unquote, trickier to diagnose, because it is primarily a clinical diagnosis. And I think this is one of the most important kind of shifts in recent data: evidence, studies, research shows us that perimenopause is a diagnosis that a clinician can make regardless of lab work and regardless of period status.”

Can I have perimenopause if my periods are still regular?

“We do often see that those periods are getting irregular, or they’re changing in their duration or flow and those sorts of things — but it’s not always the case. Perimenopause can come when your periods are coming just like normal, but you’re having a kind of wide variety of symptoms that we would associate with perimenopause, and those symptoms are primarily driven by wide hormone fluctuations.”

What age does perimenopause usually start?

“The average age of menopause in the US is 51 to 52; perimenopause typically 4 to 8 years earlier than that. I will say anecdotally, I’m seeing women much earlier showing up in my clinic, in their mid to late 30s. I would say that’s pretty average for my patient population. Again, that’s anecdotal. So data shows that it’s still probably mid-40s [that] is the average. But I would say I’m seeing quite a few patients in the mid to late 30s who are coming in with perimenopausal symptoms, and earlier than that as well.”

What do hot flashes and night sweats actually feel like?

“So in terms of those symptoms, there’s a broad landscape. We see the majority of women who are in perimenopause or menopause do experience what we call vasomotor symptoms. Those vasomotor symptoms are going to be your kind of typical symptoms of hot flashes and night sweats.

Night sweats are drenching, soaking sweats that occur at night or when you sleep, and kind of regardless of temperature — although the heat doesn’t make it any better.

And hot flashes are a systemic, overwhelming hot flash. So you certainly get hot, you certainly sweat, you get red — your face flushes — but hot flashes are so much more than that. They can sometimes come as panic; they can sometimes feel like panic attacks almost. Your whole body is engaged: your heart, your blood pressure, your vasculature. So it’s all kind of in overdrive. So hot flashes are more than just feeling hot, and they are extremely disruptive.”

What does perimenopause brain fog and insomnia feel like?

“We also see a large range of symptoms. So you have the neurocognitive symptoms — so brain fog, very common — not performing the same way at work as they are typically used to. Things like forgetting words, word finding difficulties, going into a room, forgetting why you were there.

Just general brain fog. Insomnia, huge one: difficulty with sleep, not being able to fall asleep, stay asleep, or have good quality of sleep.”

Can perimenopause cause painful sex and urinary symptoms?

“Vasomotor symptoms, we talked about that. The GSM is another really common set of symptoms — it’s the genital urinary symptom complex.

So certainly vaginal dryness, painful sex comes with that, urinary symptoms. So urinary urgency, hesitancy, frequency, recurrent UTIs. Those are all potentially caused by that lack of estrogen in the vaginal environment.”

Can perimenopause cause joint pain?

“We also have the musculoskeletal and metabolic changes. You see joint pain. It can be diffuse, so you’ve got all this in multiple joints that you’ve never had issues with. You’re having like arthritis type pain. Frozen shoulder is a pretty common one. Tendons, ligaments, things like that, not working the way they used to.”

Does perimenopause affect sex drive?

“Another one — which I don’t have up here because I’m going to talk about it later — is a change in our sex drive, our sex life, libido, those sorts of things. Very important, not talked enough about, and I’ll touch on that in a bit.”

Why doesn’t a normal lab result rule out perimenopause?

“There is still very commonly in the medical field this misconception that the labs have to match up with the symptoms, and that is just really not true. The evidence recently, in the most recent years — really solid, legitimate evidence — shows that that is not how we should be diagnosing these patients.

The Menopause Society, which is kind of the leading society on menopause and perimenopause, and then several other major societies, clearly state that for women over 45 presenting with perimenopausal symptoms — which are some of the ones we go over — those routine hormone tests that we all kind of had defaulted to in the past, be that FSH, LH, estradiol, those are not recommended.”

Can I still ask my doctor to check my hormone levels?

“And certainly we can do them if a patient wants — you have every right to ask for whatever lab you want to. But the fact is they just don’t provide any diagnostic credibility or criteria for us.”

Why do hormone levels swing so much during the day?

“A big reason for that is that our levels of those fluctuate like roller coasters during the day, but also during perimenopause in general. So you could have normal levels one day and completely off-range the next. You could have high, low, just depending on the day, and they’re impossible to track. It’s not like a fasting lab where I can say, make sure you fast and we’re going to get accurate labs. It’s not like that.”

Why did my doctor tell me my labs were normal and to just deal with it?

“So often what we see is women coming to their primary care doctor or even to their OB-GYN saying, I’m having this series of symptoms. Can we check my labs? If the labs are checked, they’re perfectly normal. And the doctor says, well, you’re fine. Don’t worry about it. Just deal with it. And that’s where a lot of the issues from that comes.”

So what actually decides the diagnosis?

“So kind of in summary — menopause and perimenopause, it’s a clinical diagnosis. Menopause, easier. It’s got some objective data. We can give you that: twelve months, no period. But perimenopause is a clinical diagnosis. It is not based on labs. It is not based on a certain number. I can’t look at your estrogen and go, ‘You’re in perimenopause.’ If you tell me your series of symptoms, regardless of your labs, that is how that diagnosis comes.

There are great treatments now for it.”

Will my treatment look the same as everyone else’s?

“I would say I see some of the most diverse responses to HRT in my patients, as opposed to other treatments. So that’s where the importance of having a physician who understands this really comes in. HRT is not one size fits all.”

What happens if my physician doesn’t know the different options?

“It is very different per person, and there’s often no predicting why or what’s going to work or what’s not going to work. And so that’s where having someone who really understands these things is so, so important, because it really can become very frustrating. Some people will not respond well to one thing, and if you have a physician team member who doesn’t understand the different options, you’re going to get stuck. And that can lead to all of its own issues.”

What does Dr. Ty want you to know before you book?

“My name is Zuleikha Tyebjee. I go by Dr. Ty. I would love to talk to you more about this.

I take my relationship with my patients very seriously. As I said, I think having someone to guide you through this process — someone who understands evidence, the science, etc., but also understands that your body is different than everyone else’s — is really, really important, and it’s not easy to find.

Finding someone who understands that perimenopause and menopause has the vast gamut of symptoms. It is not just your hot and your sweaty. It is that you don’t want to have sex anymore. You’re tired all the time. Your brain doesn’t work. You’re going to work and you are not able to function at the capacity you used to. Your relationship with your husband or your wife or your kids or your partner or anyone around you has changed.

I think it’s really, really important to have a physician team member with you on this process that understands that this is a very much a global thing, and that there are so many aspects to it: mental, physical, emotional. And I think that’s really important.

I certainly am that for my patients. My patients are my teammates.”