It's not always perimenopause
If you're in your forties and something feels off, you've probably already been told it's hormones. Sometimes it is. But often it's hormones and three other things nobody has looked at yet.
The short version
✓ Perimenopause is real and under-diagnosed, but it has also become a catch-all that closes the conversation too early.
✓ Fatigue, fog, low mood and broken sleep are shared by a dozen conditions — iron, thyroid, under-eating and sleep are the ones most often missed.
✓ A useful workup narrows the field. Old results and a clear timeline are often more informative than new tests.
✓ Bring two years of bloods and a symptom timeline to your next appointment, whoever it's with.
Work with me
Ninety minutes, your whole history, and a plan you can actually follow — in clinic at Burnt Pine or by telehealth.
Perimenopause is real, common, and genuinely under-diagnosed. Women spend years being told their cycles are fine while their sleep, mood and memory quietly fall apart. So I want to be careful here, because I am not about to argue that hormones don't matter — they matter enormously, and the transition deserves far more clinical attention than it gets.
But something else has happened alongside that overdue recognition. Perimenopause has become the answer to almost every symptom a woman over thirty-five reports. And that's a problem, because it closes the conversation at exactly the point it should be opening.
Why everything looks like perimenopause
Fatigue. Brain fog. Low mood. Broken sleep. Weight changes. Irregular cycles. Read that list back and notice how unspecific it is. Those six symptoms are the shared vocabulary of a dozen different conditions, and hormonal change is only one dialect.
Iron deficiency speaks it fluently. So does subclinical thyroid dysfunction, chronic under-eating, sleep apnoea, coeliac disease, long-term stress, and a nervous system that hasn't properly stood down since about 2019. Several of them can be present at once — and frequently are, in the exact demographic most likely to be handed a perimenopause label and sent home.
Hormone-shaped symptoms deserve a wider look before we settle on a story.
The reason this matters is practical rather than philosophical. The treatment for iron deficiency is not the treatment for burnout, and neither is the treatment for perimenopause. Get the story wrong and you can spend two years doing something reasonable that was never going to work.
The four things I find most often missed
In clinic, the same handful of things come up again and again in women who have already been told it's hormones:
Iron studies read as “normal” when ferritin is sitting at 15 or 18. Within the lab range, yes. Nowhere near where most women feel well, and worth investigating rather than shrugging at.
Thyroid function assessed on TSH alone. It's a reasonable first screen and a poor complete picture, particularly where there's a family history or an autoimmune pattern elsewhere.
Energy intake well below what a body that size and activity level actually needs — usually after years of well-intentioned dieting. The body responds by turning things down, including cycles, mood and thyroid output.
Sleep that has been broken for so long it now reads as personality. Broken by a child, a bladder, a partner's snoring, or genuine sleep-disordered breathing that nobody has screened for.
None of those are exotic. They're just rarely all considered in the same fifteen-minute appointment, and that's a structural problem with how long appointments are, not a failure of any individual GP.
What a proper workup looks like
A good workup should narrow the field, not confirm what someone already decided. In practice, for this presentation, that usually means going back over the last two years of results rather than immediately ordering new ones — trends tell you more than a single snapshot — and then filling the gaps deliberately.
It also means a timeline. When did this start? What else was happening that year? Did it change after a pregnancy, an infection, a bereavement, a house move, a new medication? Symptoms that arrived together usually have something in common, and the answer is very often sitting in the part of the history nobody has had time to hear.
Where testing genuinely will change what we do next, I'll order it or refer for it. Where it won't, I'd rather you spent the money on food. I say that to nearly every new client and I mean it — testing is a tool, not a personality.
Where to start this week
If you're waiting on an appointment with anyone, three things are worth doing in the meantime. Ask your GP for a copy of every blood test you've had in the last two years, including the ones you were told were fine. Write a plain timeline of when each symptom started. And eat a proper breakfast with real protein in it for a fortnight, because a surprising number of afternoon crashes are a nine-a.m. problem.
None of that will diagnose you. All of it will make your next appointment — with me or with anyone — considerably more useful than the last one.
If this sounds like the last two years of your life,
that's what the initial consultation is for.
This article is general wellbeing information, not individual clinical advice. It isn't a substitute for care from your GP or specialist, and nothing here should be used to start, stop or change a medication. If a symptom is new, severe or worsening, please see a doctor.
