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The average age of menopause in the U.S. is 51 to 52, perimenopause typically four to eight 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 is the average. But I would say I'm seeing quite a few patients in the mid to late 30s who were coming in with perimenopausal symptoms, and earlier than that as well.

And 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.

So we do often see that those periods are getting irregular or they're changing in the 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.

And then several other major societies clearly state that for women over 45 presenting with perimenopausal symptoms, which are some of the ones we went 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.

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. And 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.

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. Anxiety and mood changes is another one.

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, you know, your face flushes, but hot flashes are so much more than that. They can sometimes come as panic. They can sometimes, sorry, 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.

The GSM is another really common set of symptoms. It's the genitourinary syndrome of menopause. 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.

And then, excuse me, we also have the musculoskeletal and metabolic changes. Achy joint pain. It can be diffuse, so you've got all of a sudden 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.