---
title: "Feeling Different in Your 40s? What Perimenopause May Be Revealing About Your Health"
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---

Not sleeping like you used to? Feeling exhausted, foggy, anxious, gaining weight, noticing changes in your hair or periods, or simply feeling like your body is changing in your 40s? These can all show up during perimenopause, but changing hormones aren't always the whole story.

Perimenopause can overlap with shifts in thyroid function, blood sugar and insulin regulation, cardiovascular risk, inflammation, iron and nutrient status, and other areas of health, some of which may cause symptoms and others that can develop quietly.

In this article I explain why I created the Perimenopause Insights Foundational Lab Panel, a comprehensive look at approximately 91 biomarkers designed to help women establish a midlife health baseline, investigate what may be contributing to how they feel, and identify important health patterns that may not cause obvious symptoms yet.

Perimenopause is often talked about as a hormone transition.  And yes, hormones are changing.

But your 40s are also an important time to start paying closer attention to your adrenals, cardiovascular health, blood sugar regulation, thyroid function, nutrient status, inflammation, bone health, and other markers that can influence how you feel now, and your health for decades to come.

This is why I believe one of the most valuable things a woman can do as she enters perimenopause is establish a comprehensive preventive health baseline.

Not because something is necessarily wrong.

But because knowing where you are now gives you something incredibly valuable: the ability to see what changes.

Recently, a conversation with a friend reminded me exactly why this matters.

“What Should I Ask My Doctor to Test?”

A friend of mine in her mid-40s reached out to me before an appointment with her primary care provider.  She knew she was entering perimenopause and wanted to be proactive about her health, so she asked me what I would want her to have tested.

Her goal was simple:

- She wanted a baseline.
- She wasn't looking for a diagnosis or assuming something was wrong. She wanted to understand where her health stood now so that she could follow these markers as she moved through perimenopause.
- Nothing major was bugging her but she never woke up energized, hair loss has been a thing and libido could be better. 

I gave her my comprehensive list of 91 biomarkers from the Perimenopause Insight labs to discuss with her primary care provider.  She brought the list to her appointment and asked about having them checked. As I expected, n ot everything on the list was ordered, not one hormone besides TSH was checked.

T ha nkfully, her provider was willing to go beyond a standard cholesterol panel and ordered some advanced cardiovascular markers I had suggested. That decision ended up giving us information we wouldn't have had otherwise.

When we reviewed her results, much of her routine blood work looked good...

- Her Standard Cholesterol Panel Looked Reassuring. 
- Her CBC looked good. 
- Her comprehensive metabolic panel looked good (kidney/liver function). 
- Her ferritin had also improved considerably from the previous year.
- TSH was good but we were missing the rest of thyroid biomarkers
- Vitamin D was not checked
- No hormones were ordered...FSH, LH, estrogen, progesterone, prolactin, Testosterone, DHEA-S
If we had stopped there, there wasn't much that would have immediately jumped out as concerning.

But then we looked at the advanced cardiovascular testing.

Her ApoB was 95, and her LDL particle number was 1,439.

Those results didn't mean that she had cardiovascular disease. But they did make us want to understand her cardiovascular risk picture more completely.

Her provider appropriately recommended additional evaluation with a coronary artery calcium scan...I have my thoughts on this scan because coronary artery calcium (CAC) test specifically looks at hard (calcified) plaque and does not measure soft (non-calcified) plaque (which of course the soft plaque is more directly responsible for acute cardiovascular events, such as sudden heart attacks, because vulnerable soft plaque is much more likely to rupture and block blood flow, but this is a topic for another blog).

And this is where I think her story becomes so important for women entering perimenopause.

The goal wasn't necessarily to find something wrong.

The goal was to establish a baseline and do a check in after years of focusing on caring for her family, and in doing so, we uncovered something worth paying attention to.

And this is the part of her story I keep coming back to:

She couldn't feel those cardiovascular markers.

She hadn't gone to the doctor because she thought something was happening with her heart.

She went because she wanted to understand her health as she entered perimenopause.

That is the value of a baseline.

Some Perimenopause Changes Are Loud. Others Are Silent.

When we think about perimenopause, we tend to focus on the symptoms we can feel:

- Irregular or changing periods
- Hot flashes
- Night sweats
- Difficulty sleeping
- Fatigue
- Brain fog
- Mood changes
- Increased anxiety or irritability
- Changes in weight or body composition
- Hair changes
- Joint discomfort
- Vaginal dryness
- Changes in libido

Those symptoms matter.

Sometimes the symptoms are giving us clues about where we need to look.

And sometimes important changes may be occurring without producing obvious symptoms at all.

That's why I think perimenopause deserves a much broader conversation than simply:

“Should I check my hormones?”  Perimenopause is a whole-body transition.

“Why Am I So Tired?”

Fatigue is one of those symptoms that can have many different contributors.

Hormonal changes can certainly affect sleep and energy during perimenopause.

But when a woman tells me she is exhausted, I'm also thinking about things like:

- Iron and ferritin
- Thyroid function
- Vitamin and nutrient status
- Blood sugar regulation
- Sleep quality
- Stress physiology
- Overall metabolic health

My friend's experience was a perfect example.

Her ferritin had increased from roughly the mid-20s the previous year to the mid-40s, and she reported that her fatigue and hair loss had improved somewhat.

That's useful information.  Instead of simply saying, “You're tired because you're in perimenopause,” we had another clue about something that may have been contributing to how she felt.

This is how I want women to think about symptoms.  A symptom isn't a diagnosis. It's information.

“Why Am I Not Sleeping Like I Used To?”

Sleep can become a major issue during perimenopause.

Some women start waking at 2 or 3 a.m.

Others struggle to fall asleep.

Some sleep through the night but wake feeling like they never truly recovered.

Night sweats can disrupt sleep, but they're not the only possible contributor.

My friend had struggled with sleep for a long time and described herself as naturally being more of a night owl. Even after working on an earlier bedtime and reducing evening screen time, she still wasn't waking with the energy she wanted.

That made me interested in understanding more about her daily stress and cortisol rhythm.

This is where individualized testing becomes important.

Not every woman with poor sleep needs advanced cortisol testing.

But if her history points us in that direction, it may become one of the next layers we investigate.

The symptom helps determine the question. The question helps determine the test.

Not the other way around.

“Why Is My Body Changing When I'm Doing the Same Things?”

This is another frustration I hear frequently from women in their 40s. (I have even said this myself).

They're eating similarly.

They're exercising.

They're doing many of the same things they've always done.

But their body isn't responding the same way.

This is where we want to understand metabolic health.

Instead of waiting until fasting glucose becomes clearly elevated, I may want to look at the relationship between:

- Fasting glucose
- Fasting insulin
- Hemoglobin A1c
- Lipids
- Inflammation
- Hormonal changes

My friend's fasting glucose was 95 mg/dL, which falls within the conventional reference range.

But the A1c result we initially had available was from January 2025, so it wasn't giving us a current picture of her metabolic health.

That made looking at updated A1c and fasting insulin reasonable next steps.

Because sometimes glucose still looks “normal” while the body is beginning to require more insulin to maintain it...by the time your blood sugar is out of the normal range your body is screaming for help, the disease process in 5-7 years in. 

I would rather recognize a changing metabolic pattern early than wait until someone crosses a diagnostic threshold years later.

“Could This Be My Thyroid—or Is It Just Perimenopause?”

This is another place where symptoms can overlap.

Fatigue.

Hair changes.

Changes in weight.

Mood changes.

Brain fog.

Changes in cholesterol.

Many of these can occur during perimenopause, but they can also overlap with thyroid dysfunction.

My friend had a TSH checked, but no additional thyroid markers.

TSH is an important screening test, but given her symptoms and the broader picture we were seeing, I wanted more information about her thyroid.

Depending on the woman and her history, that might include markers such as:

- TSH
- Free T4
- Free T3
- Thyroid peroxidase antibodies
- Thyroglobulin antibodies
That doesn't mean every woman needs every thyroid marker every year.

It means I don't want to assume that a symptom is “just hormones” without considering whether something else deserves attention.

What About Hormone Testing?

Hormones absolutely matter during perimenopause.

But this is where testing requires context.

Estrogen, progesterone, FSH, and other reproductive hormones can fluctuate significantly during the menopause transition.

That means a single hormone level isn't always going to give us a neat answer to the question:

“Am I in perimenopause?”

Depending on a woman's age, symptoms, cycle pattern, gut issues, and clinical history, I may look at markers such as:

- Estradiol
- FSH
- LH
- Progesterone
- Testosterone
- SHBG
- DHEA-S
- Microbiome Gut Testing 
But I'm not trying to chase one perfect hormone number.

I'm looking for patterns.

And more importantly, I'm not looking at those hormones in isolation from the rest of her physiology.

The Things You Can't Feel Matter Too

This may be the most important part of this conversation.

You can feel a hot flash.

You can feel exhaustion.

You know when you're waking up at 3 a.m.

You notice when your period suddenly comes 10 days early.

But you can't necessarily feel your:

- ApoB
- Lipoprotein(a)
- Insulin
- Hemoglobin A1c
- Homocysteine
- hs-CRP
- Vitamin D
- Ferritin
- Thyroid antibodies
And you may feel perfectly well while some of these markers begin to change.

That doesn't mean every woman needs every test.

And it certainly doesn't mean we should become afraid of every laboratory value that falls outside an “optimal” range.

It means preventive healthcare gives us the opportunity to identify meaningful patterns before they necessarily become symptoms or disease.

Why Cardiovascular Health Matters During Perimenopause

One of the reasons I was particularly interested in my friend's advanced cardiovascular markers is that midlife is an important time to begin thinking about a woman's long-term cardiovascular health.  A woman's risk of a heart attack and cardiovascular disease effectively doubles within 10 years after going through menopause. [1] (https://ubiehealth.com/doctors-note/menopause-heart-risk-disease-cv-rise-postperiod2762q2). Our estrogen drops which in turn causes vessels to stiffen. Women have cholesterol changes: Low-density lipoprotein (LDL or "bad") cholesterol tends to rise, while high-density lipoprotein (HDL or "good") cholesterol can fall and blood pressure and blood sugar levels often climb after menopause.  A woman's risk for a heart attack rises significantly after menopause, and by about age 70, women's rates of having heart attacks catch up to and even surpass men's rates. 

So depending on personal history, family history, and other risk factors, I may also want to understand the story behind the advanced cardiovascular markers:

- ApoB
- Lipoprotein(a), or Lp(a)
- LDL particle measurements
- hs-CRP
- Homocysteine

My friend's standard cholesterol panel alone wouldn't have prompted the same conversation.

Her advanced markers didn't tell us that she had disease.

They told us:

There's another question worth asking. To me, that's what good preventive testing should do.

- Testing is about asking:
- What is happening in your physiology now?
- Are there patterns beginning to emerge?
- Are there areas we could support now that may influence how you feel—and potentially your long-term health?
And:

- What looks great and doesn't need support?
That last question matters too.  I don't want to find problems where there aren't any.

I want to understand the patterns and the whole picture.

Why I Created the Perimenopause Insights Foundational Lab Panel

I keep meeting women in their 40s who want exactly what my friend wanted.

They want a baseline, the check in because something feels off.

They want to know:

- Why am I so tired?
- Why can't I sleep anymore?
- Why does my body feel different?
- Are my hormones changing?
- Is my thyroid contributing?
- Is my blood sugar beginning to shift?
- What does my cardiovascular health look like?
- Are my nutrient reserves where they should be?
And sometimes: I actually feel pretty good.

- What should I be paying attention to now so I can protect my health later?
Those questions are exactly why I created the Perimenopause Insights Foundational Lab Panel.

The panel evaluates approximately 91 biomarkers across areas including:

- Cardiovascular health
- Metabolic health
- Thyroid function
- Hormonal health
- Inflammation
- Nutrient status
- Iron storage
- Blood cell health
- Liver and kidney function

It isn't 91 biomarkers because I believe every number needs to be optimized or treated.

It's because I wanted a comprehensive foundational picture of the systems that become increasingly important during midlife.

From there, we can determine:

- What looks great?
- What might help explain how you're feeling?
- What deserves attention even though you can't feel it?
- And is there anything that tells us we need to look one layer deeper?

When Do We Look One Layer Deeper?

Foundational testing is exactly that an insight to the foundation.

Not every woman needs comprehensive functional testing.

The initial results, symptoms, and health history should guide what happens next.

For one woman, persistent poor sleep and lack of morning energy might make a multi-point cortisol assessment worth considering.

For another, significant digestive symptoms might lead us to investigate gut health and look at her microbiome.

Someone with significant fatigue or hair loss may have nutritional concerns may benefit from more comprehensive nutrient or metabolic testing.

And another woman may need nothing beyond her foundational evaluation and a thoughtful plan for nutrition, exercise, sleep, and preventive care.

The goal is to know what question we're trying to answer.

Maria's Clinical Insight

One of the biggest shifts I want women to make in their 40s is to stop thinking about perimenopause as simply something they have to survive until their periods stop.

This is an incredibly important health transition.

And I think it's also an opportunity.

You don't have to wait until your cholesterol is high.

You don't have to wait until your blood sugar crosses into prediabetes.

You don't have to wait until you're so exhausted that you can't function.

And you don't have to assume every symptom is simply something you're supposed to tolerate because you're getting older.

Instead, we can get curious.  Establish your baseline.

Understand your cardiovascular health.

Look at your metabolic health.

Know your thyroid status.

Evaluate your nutrient reserves.

Put your hormones into context.

Then follow those patterns over time.

My friend's original reason for reaching out to me was beautifully simple:

She wanted to know where she was now so she could see what changed.

That's exactly the conversation I want more women to be having in their 40s.

Because some changes in perimenopause are loud.  Others are completely silent.  I want us paying attention to both.

Frequently Asked Questions

- What are the most common signs of perimenopause?
Perimenopause can look different for every woman. Common changes include irregular or changing periods, hot flashes, night sweats, difficulty sleeping, mood changes, brain fog, fatigue, vaginal dryness, changes in libido, and changes in weight or body composition.

Not every new symptom in your 40s is necessarily caused by perimenopause, which is why looking at the broader health picture can be important.

- Why am I so tired during perimenopause?
Hormonal fluctuations can affect sleep and energy, but fatigue can have many contributors. Depending on your individual history, it may be appropriate to consider iron status, thyroid function, blood sugar regulation, nutrient status, sleep quality, and other factors rather than automatically attributing fatigue to hormones.

- Why am I waking up in the middle of the night in my 40s?
Sleep disruption is common during the menopause transition. Hormonal fluctuations, night sweats, stress, mood changes, sleep habits, and other health factors may all contribute.

Persistent sleep problems deserve an individualized evaluation rather than being dismissed as simply part of aging.

- Can my labs be “normal” and I still be in perimenopause?
Yes.  Perimenopause is a clinical transition, and reproductive hormones can fluctuate considerably during this time. A single normal hormone result doesn't necessarily rule out perimenopause.

Symptoms, menstrual-cycle changes, age, health history, and laboratory findings all provide pieces of the picture.

- What labs should I consider during perimenopause?
There is no single laboratory panel that's appropriate for every woman.  Depending on symptoms, medical history, family history, medications, and individual risk factors, testing may include metabolic, cardiovascular, thyroid, inflammatory, nutrient, iron, and reproductive hormone markers.

The goal should be to answer meaningful clinical questions, not simply order as many tests as possible.

- Why should I get tested if I feel fine?
This is where establishing a baseline can be especially valuable.  Some changes that matter to long-term health may not cause obvious symptoms. Understanding cardiovascular, metabolic, thyroid, nutrient, and other foundational markers during midlife can provide information to discuss with your healthcare provider and follow over time.

The Bottom Line

Maybe you're waking up exhausted.

Maybe your periods have changed.

Maybe you're suddenly dealing with brain fog, poor sleep, hair changes, anxiety, weight changes, or a body that simply doesn't feel like it used to.

Or maybe you feel great and simply want to know what is happening beneath the surface.

Either way, your 40s are an important opportunity to understand your health.

How you feel gives us clues.

Your labs can help us investigate those clues.

And preventive testing may identify important patterns before you feel anything at all.

That's what I want perimenopause care to look like.

Ready to Understand What Your Body Is Telling You?

The Perimenopause Insights Foundational Lab Panel evaluates approximately 91 biomarkers across cardiovascular, metabolic, thyroid, hormonal, inflammatory, nutrient, and foundational health.

It was designed for women who want to understand both sides of the perimenopause story:  the changes you can feel, and the ones you can't.

[→ Explore the Perimenopause Insights…