The Health Pyramid-Level2-Hormone Balance

HORMONE BALANCE

The Conversation I Wish Someone Had With Me at 35

Hormones are one of those topics that seem to be everywhere right now. Women are talking about perimenopause, menopause, cortisol, thyroid function, insulin, testosterone, estrogen, progesterone and hormone therapy, often because they are trying to make sense of changes happening in their own bodies. I understand that search for answers because I have lived a version of it myself.

My hormone story started long before menopause. Beginning in 2009, I went through seven IVF treatments before I was able to have my middle daughter. After everything it took to become pregnant with her, I became pregnant with my third daughter very quickly afterward. By the time I gave birth in 2014, my body had spent years going through fertility medications, pregnancies, postpartum changes and major hormonal shifts. I do not say that to suggest that IVF caused what happened later. I say it because hormones had already been a huge part of my medical life for years.

Then, at only 35 years old, doctors became concerned that I could have ovarian cancer. That concern ultimately led to surgery and the removal of my ovaries, putting me immediately into surgical menopause. I understood why the surgery needed to happen. What I was not prepared for was how little I understood about what came next.

I was 35. I was not naturally approaching menopause. My body had not spent years gradually moving through the hormonal fluctuations of perimenopause. One day my ovaries were producing hormones and after surgery they were not. I wish someone had sat me down and explained that this was about so much more than periods and hot flashes.

I wish someone had explained what estrogen loss could mean for my bones, muscles, sleep, brain, sexual health, urinary health and cardiovascular health. I wish I had known what questions to ask about hormone therapy, what nutrients I needed to pay closer attention to, what bloodwork or screening might be appropriate for me and what symptoms should not simply be brushed off as 'just hormones.' Instead, I felt like the major medical event was over and I was left trying to understand the aftermath myself.

That is why Hormone Balance belongs in Level 2 of my Health Pyramid. This is not a promise that every symptom can be fixed by 'balancing your hormones.' It is an invitation to understand how interconnected our endocrine system is and to stop accepting the idea that women should simply suffer through major changes without information.

First, What Are Hormones?

Hormones are chemical messengers. They are produced by glands and tissues throughout the body, released into the bloodstream and used to communicate with organs and cells that have receptors for them. The endocrine system includes the hypothalamus and pituitary gland in the brain, the thyroid, parathyroid glands, adrenal glands, pancreas, ovaries and other hormone-producing tissues.

The important part is that these systems do not operate independently. Thyroid hormones affect metabolism. Insulin helps regulate blood glucose. Cortisol is part of our stress-response system. Estrogen, progesterone and testosterone have effects far beyond reproduction. Sleep influences cortisol and glucose regulation. Nutrition and movement affect insulin sensitivity and body composition. This is exactly why the layers of the Health Pyramid keep overlapping.

Perimenopause, Menopause and Surgical Menopause Are Not the Same Experience

Perimenopause is the transition leading up to menopause. During this time, ovarian hormone production becomes more variable and menstrual cycles often change. Hormone levels can fluctuate significantly, which is one reason a woman can feel completely different from one week or month to the next. Menopause itself is reached after 12 consecutive months without a menstrual period when there is no other medical explanation.

Natural menopause happens gradually for most women. Surgical menopause after removal of both ovaries is different because the drop in ovarian hormones can be abrupt. When that happens at a young age, the conversation is not only about symptom relief. Long-term bone and cardiovascular health, sexual and urinary health, and overall quality of life also deserve attention.

One reason this topic feels so confusing is that menopause does not look the same for everyone. Some women have mild symptoms. Others feel as though their entire body changed. Hot flashes and night sweats are among the most commonly reported symptoms, but they are far from the only ones.

The Symptoms Women Are Actually Searching For

A woman may enter her forties, or sometimes even her late thirties, and suddenly feel like she does not recognize her own body. The symptoms can overlap with many other medical conditions, which is why it is important not to assume every change is automatically menopause. Still, these are some of the concerns commonly discussed during the menopause transition:

• Hot flashes, night sweats and sudden temperature changes

• Sleep disruption or waking repeatedly during the night

• Fatigue and feeling physically or mentally drained

• Brain fog, forgetfulness and difficulty concentrating

• Mood changes, irritability, anxiety or depressive symptoms

• Changes in menstrual timing, flow or bleeding patterns during perimenopause

• Vaginal dryness, burning, irritation or pain with sex

• Changes in libido or sexual response

• Urinary urgency, discomfort or recurrent urinary symptoms

• Joint aches, stiffness or changes in how the body feels during movement

• Changes in body composition, especially increased abdominal fat

• Loss of muscle mass or strength over time

• Changes in hair or skin

• Headaches or changes in existing migraine patterns

• Heart palpitations or a sensation of a racing heartbeat

The Menopause Society reports that up to 80% of women experience hot flashes or night sweats at some point during the menopause transition, and cognitive complaints such as brain fog are also common at midlife. That does not mean every symptom on a long internet checklist is caused by menopause. It means women deserve a thoughtful evaluation instead of being dismissed.

Estrogen: Much More Than a Reproductive Hormone

Estrogen receptors are found throughout the body. Estrogen participates in bone remodeling, affects tissues of the vagina and urinary tract, interacts with the brain and blood vessels, and influences the way fat and muscle are distributed. When estrogen levels fluctuate during perimenopause or fall after menopause, those changes can be felt in many different ways.

Bones

Estrogen helps protect bone. Bone loss accelerates around the menopause transition, and the years around the final menstrual period are an especially important time to think about bone health. This matters even more when menopause occurs unusually early or is caused by removal of the ovaries.

That is one of the things I wish I had understood at 35. I would have asked much earlier about my individual risk for bone loss, whether I needed a baseline bone-density scan, whether vitamin D should be checked, whether I was getting enough calcium and protein, and what kind of resistance and weight-bearing exercise was appropriate for me.

Brain, Mood and Sleep

Estrogen receptors are present in areas of the brain involved in mood and cognition. During perimenopause, large hormone fluctuations may contribute to mood symptoms in some women, while hot flashes and disrupted sleep can make concentration, memory, anxiety and emotional resilience worse. The relationship is complex, and mental-health symptoms deserve the same serious attention they would at any other stage of life.

Sleep deserves its own mention because it can become a vicious cycle. Night sweats wake you up. Poor sleep worsens fatigue, appetite regulation, stress tolerance and concentration. Then the exhaustion makes everything else feel harder. This is another reason the bottom layer of the Health Pyramid matters so much even when we are talking about hormones.

Vaginal, Sexual and Urinary Health

The drop in estrogen can cause changes in the vulva, vagina, urethra and bladder that are collectively called genitourinary syndrome of menopause, or GSM. Dryness, burning, irritation, pain with penetration, urinary urgency and recurrent urinary symptoms are not things women simply have to accept as the price of aging. There are treatments, including nonhormonal moisturizers and lubricants as well as prescription options such as low-dose vaginal estrogen for appropriate patients.

Muscle, Metabolism and Body Composition

Many women notice that their bodies begin responding differently around midlife. Menopause is not the only reason weight or body composition can change, but aging, declining estrogen, sleep disruption, activity changes and loss of muscle can all interact. The answer is not starving yourself. Preserving muscle becomes increasingly important, which means resistance training, adequate protein, sleep and an overall eating pattern you can actually sustain matter more than another extreme diet.

Progesterone and Testosterone

Progesterone is best known for its role in the menstrual cycle and pregnancy. During perimenopause, ovulation becomes less consistent, which changes progesterone patterns. In women who use systemic estrogen and still have a uterus, a progestogen is generally needed to protect the uterine lining from the effects of estrogen.

Women also produce testosterone, primarily through the ovaries and adrenal-related pathways. Testosterone levels generally decline with age, and surgical removal of the ovaries can affect androgen levels as well. Testosterone therapy for women is not a universal energy, weight-loss or anti-aging treatment. In selected postmenopausal women with appropriately evaluated hypoactive sexual desire disorder, clinicians may discuss testosterone, but this is an area where individualized medical care is important.

Thyroid: When 'Hormonal' Symptoms May Be Something Else

The thyroid gland produces hormones that help regulate metabolism and influence heart rate, temperature regulation, bowel function, energy and many other processes. Thyroid problems can create symptoms that overlap significantly with perimenopause and menopause, including fatigue, weight changes, hair changes, mood changes, temperature intolerance and changes in heart rate.

This is why I do not love the idea of blaming every symptom on menopause without looking at the rest of the picture. If symptoms suggest a thyroid problem, thyroid testing may be appropriate. We can have more than one thing happening in our bodies at the same time.

Cortisol, the Adrenals and the Stress Response

Cortisol is produced by the adrenal glands as part of the hypothalamic-pituitary-adrenal, or HPA, axis. Cortisol is not a bad hormone. We need it. It helps regulate the stress response, blood pressure, glucose availability, immune activity and our daily sleep-wake rhythm.

There is a lot of online conversation about 'adrenal fatigue.' Feeling completely exhausted is real, but adrenal fatigue is not a recognized medical diagnosis. True adrenal disorders, including adrenal insufficiency and cortisol excess, are real medical conditions and require proper evaluation. For most of us, the more useful question is whether chronic stress, poor sleep, illness, under-fueling, overtraining or another medical condition may be affecting how we feel.

Insulin and Blood Sugar Are Hormone Conversations Too

Insulin is a hormone produced by the pancreas that helps glucose move from the bloodstream into cells where it can be used or stored. During midlife, changes in body composition, sleep, activity and aging can affect insulin sensitivity. That is one reason blood sugar, cholesterol, blood pressure and waist circumference deserve attention as part of overall midlife health.

You do not need to fear every carbohydrate or wear a glucose monitor just because you are in perimenopause. The basics still matter: eating enough protein and fiber, choosing minimally processed foods most of the time, moving after meals when practical, building muscle, sleeping consistently and getting appropriate screening for diabetes or prediabetes based on your risk.

Hormone Therapy: It Deserves a Real Conversation, Not a Blanket Yes or No

Hormone therapy is one of the most confusing parts of menopause because many women have heard completely contradictory information about it. Current expert guidance is much more individualized than the old idea that hormone therapy is either good for everyone or dangerous for everyone.

Systemic menopausal hormone therapy is the most effective treatment for bothersome hot flashes and night sweats and also helps prevent bone loss. For many healthy women who begin treatment when they are younger than 60 or within about 10 years of menopause onset, the benefit-risk profile may be favorable when they have bothersome symptoms and no contraindications. The decision depends on the person's age, medical history, whether she has a uterus, the type and dose of hormone, route of administration and her own priorities.

There are different forms of therapy. Estrogen can be delivered through pills, patches, gels, sprays or other formulations. Women with a uterus generally need endometrial protection with a progestogen when using systemic estrogen. Women without a uterus may be able to use estrogen alone depending on their medical history. Low-dose vaginal estrogen is a different type of treatment used primarily for vaginal and urinary symptoms and has much lower systemic absorption than standard systemic therapy.

Hormone therapy is not appropriate for every woman, and risks can include blood clots, stroke and, depending on the regimen and duration, breast cancer risk. Personal and family history matter. If hormone therapy is not appropriate or not desired, there are also evidence-based nonhormonal treatments for vasomotor symptoms and other menopause concerns.

I think the most important message is this: do not let a social-media post decide for you, but do not let fear keep you from having the conversation either. Ask about your individual risks, benefits and alternatives.

What About Vitamins and Nutrients?

This was a huge missing piece for me. I did not need someone to hand me a giant supplement list after surgery. I needed someone to explain what areas of nutrition deserved more attention because of the change in my hormones and my age.

There is no universal 'menopause supplement stack.' Nutrient needs depend on diet, health conditions, medications, bloodwork and individual risk. Still, there are several areas worth discussing with a healthcare professional, especially when menopause occurs early:

• Calcium: Bone health depends on adequate calcium intake, preferably from food when possible. Supplementation should be individualized because more is not automatically better.

• Vitamin D: Vitamin D helps the body absorb calcium and supports bone and muscle health. A blood level may be checked when deficiency risk is present, and replacement should be tailored to the individual.

• Protein: Preserving muscle becomes increasingly important with age. Spreading adequate protein across meals can support muscle maintenance, especially when combined with resistance training.

• Magnesium: Magnesium participates in hundreds of biochemical reactions and is present in nuts, seeds, legumes, whole grains and leafy greens. Deficiency should be addressed, but magnesium is not a cure-all for menopause.

• Vitamin B12 and iron: These are not automatically low because of menopause. Testing may be appropriate based on diet, symptoms, medications, bleeding history or other medical conditions.

• Omega-3 fats: Fatty fish and other sources of unsaturated fats can be part of a heart-healthy eating pattern. Supplements are not automatically necessary for every woman.

The point is not to buy everything on the supplement shelf. The point is to know what your body needs, use food as a major part of the foundation, test when testing is clinically useful and supplement intentionally rather than blindly.

Things You Can Do to Support Yourself Through Perimenopause and Menopause

There is no way to control every hormonal fluctuation, but there is a lot we can do to support the systems those hormones interact with. These are the practical pieces I would want every woman to have in front of her:

• Track what is changing. Keep notes on periods, hot flashes, sleep, mood, headaches, urinary symptoms, vaginal symptoms, libido, energy and anything else that feels different. Patterns are much easier to discuss when you can actually see them.

• Protect your sleep. Keep a consistent sleep-wake schedule when possible, address snoring or possible sleep apnea, make the bedroom cool and dark, and talk with a clinician if night sweats or insomnia are repeatedly disrupting sleep.

• Build and preserve muscle. Strength or resistance training is one of the most valuable things women can do for muscle, bone, function and metabolic health as they age. Start at your own level and modify for injuries or medical conditions.

• Include weight-bearing movement. Walking, stair climbing and other weight-bearing activities can support bone health. The right type and intensity depend on your body and fracture risk.

• Eat enough protein. Protein needs vary, but making protein a consistent part of meals can help preserve muscle. If you have kidney disease or another condition affecting protein needs, ask your clinician or dietitian.

• Get enough calcium and vitamin D. Focus on dietary calcium and discuss supplementation or vitamin D testing with your healthcare professional if your intake or levels may be low.

• Eat for blood-sugar stability, not perfection. Pair carbohydrates with protein, fiber or healthy fats, choose minimally processed foods most of the time, and avoid turning menopause into another reason to fear food.

• Use fiber to support more than digestion. Fiber supports bowel regularity, the gut microbiome, cholesterol management and metabolic health. Increase it gradually if your current intake is low.

• Limit smoking and excessive alcohol. Both can work against bone, cardiovascular and overall health, and alcohol can worsen sleep and hot flashes for some women.

• Pay attention to stress. Stress does not cause every symptom, but chronic stress can worsen sleep, mood, eating patterns and how intense symptoms feel. Build in realistic recovery rather than waiting until you are completely depleted.

• Take vaginal and urinary symptoms seriously. Dryness, painful sex, burning, urgency and recurrent urinary symptoms have treatments. You do not have to quietly tolerate them.

• Know your cardiovascular numbers. Blood pressure, cholesterol, blood glucose or A1c, weight trends and family history become increasingly important in midlife.

• Ask about bone density when appropriate. Earlier menopause, surgical menopause and other risk factors can change when bone-density screening should be considered.

• Review medications and supplements. Bring everything you take to appointments. Some products interact with medications, and some symptoms blamed on hormones may actually be medication-related.

• Find someone who actually treats menopause. If you feel dismissed, look for a clinician with experience in menopause care. A Menopause Society Certified Practitioner is one option.

What Testing Can and Cannot Tell You

This is another area where women can spend a lot of money unnecessarily. In many women over 45 with typical symptoms, perimenopause and menopause can often be identified clinically without repeatedly measuring estrogen, progesterone or FSH. Hormones can fluctuate substantially during perimenopause, so one 'normal' level does not necessarily explain how you have felt for the previous six months.

Testing can still be important when the situation is unusual, when symptoms occur at a younger age, when periods change for other possible reasons, or when another condition such as thyroid disease, anemia or diabetes needs to be considered. The right tests depend on the person.

Depending on your age, symptoms and history, questions for your clinician may include:

• Do my symptoms fit perimenopause or menopause, or should we investigate other causes?

• Do I need thyroid testing?

• Should my blood count, iron, B12 or other nutrient levels be checked based on my symptoms and history?

• Should my vitamin D level be checked?

• When should I have a bone-density scan given my age and risk factors?

• Are my blood pressure, cholesterol and blood glucose or A1c up to date?

• Am I a candidate for hormone therapy? What are my personal risks and benefits?

• Would a patch, pill, gel, vaginal treatment or nonhormonal medication make more sense for my symptoms?

• If I still have a uterus, what do I need for endometrial protection if I use systemic estrogen?

• What symptoms or bleeding patterns would require additional evaluation?

Hormonal Symptoms Are Not Always Hormones

This may be one of the most important sections in this entire article. Fatigue, weight changes, brain fog, hair loss, palpitations, mood changes and poor sleep can happen during the menopause transition, but they can also occur with thyroid disease, anemia, sleep disorders, medication effects, depression or anxiety, nutritional deficiencies, diabetes, heart rhythm problems and many other conditions.

We should not dismiss women by telling them everything is menopause. We also should not assume every symptom is a dangerous disease. The goal is thoughtful evaluation. Sometimes the answer is menopause. Sometimes it is something else. Sometimes it is both.

When to Seek Medical Care Instead of Assuming It Is Menopause

• Very heavy bleeding, bleeding between periods that is new or concerning, or any bleeding after menopause

• Chest pain, fainting, severe shortness of breath or a new sustained abnormal heartbeat sensation

• New neurologic symptoms such as weakness, facial drooping, difficulty speaking or a sudden severe headache

• Severe depression, thoughts of self-harm or a major change in mental health

• Unexplained weight loss, persistent fever or symptoms that are progressively worsening

• New breast changes or other symptoms that concern you

What I Wish Someone Had Told Me

If I could go back to 35-year-old me, I would tell her that losing ovarian function was not simply the end of her periods. I would tell her that hormones communicate with tissues throughout the body and that she deserved a plan for the years ahead.

I would tell her to ask about her bones. Ask about her vitamin D. Ask about muscle. Ask about cardiovascular risk. Ask what hormone therapy could and could not do for her. Ask what changes might happen vaginally and sexually, because nobody should have to discover that information only after symptoms become painful. Ask how often things should be monitored. Ask whether a symptom is truly expected or whether it deserves its own workup.

Most of all, I would tell her that there is a huge difference between being handed a prescription and being educated about your own body. I needed education. I needed context. I needed someone to explain how all of these systems fit together.

That is what I hope women take from this part of the Health Pyramid. You do not have to become an endocrinologist to advocate for yourself. You do not have to chase every new hormone trend online. But you deserve to understand enough to ask questions, recognize changes and participate in decisions about your own care.

A Simple Menopause and Hormone Check-In

Take a few minutes and ask yourself:

• What has changed in my body over the last year?

• How is my sleep?

• How is my mood and stress level?

• Have my periods changed?

• Am I having hot flashes or night sweats?

• Have I noticed changes in vaginal comfort, urinary symptoms or sexual health?

• Am I strength training or doing anything to intentionally preserve muscle?

• Am I getting enough protein, calcium-rich foods and vitamin D?

• Do I know my blood pressure, cholesterol and blood sugar numbers?

• Do I have risk factors for osteoporosis or early bone loss?

• Have I been dismissing symptoms because I assume they are 'just age'?

• Do I feel heard by the healthcare professional helping me navigate this stage?

You do not need to fix everything this week. Pick one or two areas that stand out and start there. That is how I want the Health Pyramid to work: not as another impossible wellness checklist, but as a way to understand what your body needs and build from the ground up.

A Note on Medical Information

This article is for education and is not a substitute for individualized medical care. Menopause treatment, hormone therapy, supplementation and testing should be personalized based on symptoms, age, medical history, medications, family history and individual risk factors.

Sources & Further Reading

• The Menopause Society. Perimenopause: patient education on symptoms, vasomotor symptoms, cognitive changes and treatment options.

• The Menopause Society. Symptoms: common menopause symptoms, genitourinary syndrome of menopause, mood and cognitive changes.

• The Menopause Society. Hormone Therapy: benefits, risks, routes of administration and individualized decision-making.

• The Menopause Society. 2022 Hormone Therapy Position Statement.

• National Institute on Aging. What Is Menopause?

• Endocrine Society. Menopause and Menopause Treatment.

• Endocrine Society. Menopause and Bone Loss.

• Endocrine Society Clinical Practice Guideline. Androgen Therapy in Women: A Reappraisal.