The Modern Midlife Collective

Brain fog? Hair shedding? Restless legs? Before you automatically blame menopause, it may be time to take another look at your iron.

New 2026 guidelines are changing how iron deficiency is diagnosed, and yes, you can have iron deficiency even when you're not anemic.

In Episode 42 of The Modern Midlife Collective, Dr. Jillian Woodruff and Dr. Ade Akindipe unpack the newly released American Society of Hematology guidelines on diagnosing iron deficiency.

We're going beyond the symptom everyone already knows, fatigue, and talking about the signs midlife women may not associate with iron:

• Brain fog and difficulty concentrating
• Hair and nail changes
• Restless legs
• Poor exercise tolerance
• Mood changes
• Pica and ice chewing
• Heavy menstrual bleeding during perimenopause

You'll also learn why a “normal” CBC doesn't automatically rule out iron deficiency, what ferritin tells us, why laboratory reference ranges aren't always the same as clinical decision thresholds, and why finding low iron should prompt another important question:

Why is the iron low in the first place?

In this episode:

• Iron deficiency vs. iron-deficiency anemia
• The new 2026 ferritin diagnostic thresholds
• Why brain fog isn't automatically menopause
• The complicated connection between iron and hair loss
• Heavy periods and iron depletion during perimenopause
• Why postmenopausal iron-deficiency anemia needs further evaluation
• Ferritin, CBC and transferrin saturation
• Why you shouldn't automatically start iron supplements
• Three questions to take to your next medical appointment

Your three questions:

1. What was my actual ferritin?
2. Could I have iron deficiency even though I'm not anemic?
3. If my iron is low, why is it low?
   
   

Resources

American Society of Hematology: 2026 Guidelines on Diagnosis of Iron Deficiency
CMAJ: Diagnosis and Management of Iron Deficiency in Females
JAMA: Iron Deficiency in Adults: A Review
American Gastroenterological Association: GI Evaluation of Iron Deficiency Anemia
American Academy of Sleep Medicine: Treatment of Restless Legs Syndrome Guideline

The Modern Midlife Collective
Because thriving at 40 and beyond isn't just possible. It's your birthright.

Back in Episode 20, Dr. Jill and Dr. Ade covered the FDA's decision to walk back twenty years of black box warnings on hormone therapy. Since then, hormone therapy has become a genuine moment on social media, and not always an accurate one. In this quick-turnaround update, they separate what the newest research actually shows from what the internet is claiming, including a new Stanford study linking estrogen-only therapy to lower Alzheimer's markers, why that finding does not extend to combined therapy, and what the twenty-year-old dementia data really pins the risk on.

Segment Guide

• Cold open: What changed since Episode 20, and why this update exists
• The quick WHI recap, done right: relative risk versus absolute risk, and the age-stratified "timing hypothesis"
• What the FDA actually changed, and when: the November 2025 label update, and what stayed in place
• What's actually prescribed now versus what WHI tested: bioidentical estradiol and micronized progesterone versus the oral synthetic combination used in the original trial, including how the two progestogens differ at the receptor level
• The hype swing of 2026: what hormone therapy is well-supported for, and what it is not
• The new Stanford Alzheimer's study: what its three parts can and cannot tell us, and why the dementia-risk signal from 2003 traces to one specific drug, not to progesterone as a category
• What we'd actually tell a patient: an honest, evidence-based bottom line

Key Takeaways

• The WHI's real numbers are absolute, not relative: about 8 additional breast cancer cases per 10,000 women per year in the combined-therapy arm, not the large-sounding relative-risk percentage that made headlines in 2002.
• Estrogen-alone therapy showed fewer breast cancer cases in the WHI, a reduction that reached statistical significance in longer-term follow-up along with a reduction in breast cancer mortality.
• Today's typical prescription, transdermal estradiol with micronized progesterone, is a different drug, different route, and different population than what the original WHI tested.
• A new Stanford study (Neurology, August 2026) found estrogen-only hormone therapy associated with a roughly 35 percent lower likelihood of Alzheimer's pathology markers on autopsy, plus supporting signals in dementia diagnoses and biomarkers. It is observational, not a randomized trial, and it could not address combined therapy either way due to sample size.
• The dementia-risk signal from the 2003 WHI Memory Study traces specifically to oral conjugated equine estrogen plus medroxyprogesterone acetate, not to progesterone or progestins as a category. Whether the micronized progesterone used today carries the same risk is a genuinely open question, not a settled no.
• Formulation matters. Ask your provider exactly what you are being prescribed, oral versus transdermal estrogen, and bioidentical micronized progesterone versus a synthetic progestin.

Research and Sources Mentioned

• HHS: Advances Women's Health, Removes Misleading FDA Warnings on Hormone Replacement Therapy
• NPR, August 7, 2026: Everyone's talking about hormone therapy for menopause. Should I be on it?
• STAT News, January 8, 2026: Hormone therapy for menopause is being overhyped, again
• Stanford Medicine, August 2026: Study ties estrogen-based menopausal hormone therapy to lower Alzheimer's risk
• National Cancer Institute: Menopausal Estrogen Therapy Benefits and Risks Vary by Age (WHI analysis)
• International Menopause Society: Lessons from KEEPS, the Kronos Early Estrogen Prevention Study
• Shumaker et al., JAMA, 2003: Estrogen Plus Progestin and the Incidence of Dementia and Mild Cognitive Impairment (WHI Memory Study)
• Barth et al., Lancet Diabetes & Endocrinology, 2023: Sex Steroids and the Female Brain Across the Lifespan
• Vinogradova et al., BMJ, 2021: Use of menopausal hormone therapy and risk of dementia (UK QResearch/CPRD cohort)
• Savolainen-Peltonen et al., BMJ, 2019: Use of Postmenopausal Hormone Therapy and Risk of Alzheimer's Disease in Finland
• Gleason et al., PLOS Medicine, 2015: Effects of Hormone Therapy on Cognition and Mood (KEEPS-Cognitive and Affective Study)

A Note on This Episode

This episode is for educational purposes and reflects Dr. Jill and Dr. Ade's read of the current evidence. It is not personalized medical advice. Hormone therapy decisions depend on individual history, and listeners should talk with their own healthcare provider before starting, stopping, or changing any hormone therapy.

Connect With Us

Have a question about your own hormone therapy, or a topic you want us to cover? Email [email protected] or visit www.modernmidlifecollective.com for links to everything mentioned in this episode.

If this episode was useful, follow or subscribe wherever you listen, and consider leaving a rating and review. It genuinely helps other midlife women find the show.

One completely ordinary glass of wine.

Then suddenly you’re awake at 3 a.m., your heart is racing, you’re hot, your sleep is wrecked, your stomach feels off—and the next morning feels suspiciously like a hangover that should have required a much bigger night out.

Sound familiar?

In this episode of The Modern Midlife Collective, Dr. Jillian and Dr. Ade explore why many women notice that alcohol affects them differently during perimenopause and menopause.

And while hormones are part of the conversation, the answer is much more nuanced than “your estrogen dropped.”

Alcohol is landing in a body that may now have different body composition, total body water, sleep architecture, medications, metabolic demands and nervous-system vulnerability—all while estrogen is becoming increasingly unpredictable during the menopause transition.

This episode is about recalibration, not perfection.

No shame. No judgment. No gold stars for abstinence.

Just better information.

IN THIS EPISODE

Dr. Jillian and Dr. Ade discuss:

• Why alcohol may suddenly feel stronger in midlife
• Why perimenopause is better described as hormonal turbulence than a simple estrogen decline
• How alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH2) metabolize alcohol
• Why genetic differences can dramatically affect alcohol tolerance
• How lower total body water can contribute to higher blood-alcohol concentrations
• Age-related changes that may affect the “bounce-back”
• Why alcohol may make you sleepy while still disrupting restorative sleep
• REM sleep and those notorious 3 a.m. awakenings
• “Hangxiety” and the nervous-system rebound after alcohol
• Alcohol as a potential hot-flash or night-sweat trigger
• Why different drinks may feel different—even though ethanol is still ethanol
• Histamine, sulfites and why red wine may suddenly make some women miserable
• Why “red wine is good for your heart” deserves more nuance
• Alcohol and breast-cancer risk
• Alcohol’s effects on appetite, weight-management goals and training recovery
• What to consider if you are taking a GLP-1 medication
• Bladder urgency, frequency and menopause-related genitourinary symptoms
• Why new medications may change your alcohol tolerance
• What we know—and still don’t know—about alcohol and the gut microbiome
• Hormonal and evidence-based nonhormonal options for bothersome hot flashes and night sweats
• The Two-Week “Does Alcohol Actually Like Me?” Experiment
  
  

KEY TAKEAWAYS

1. It probably isn’t just one hormone.

Estrogen and alcohol do interact, and research has found associations between alcohol exposure and estradiol levels. But current evidence does not support reducing midlife alcohol intolerance to a simple story in which fluctuating estrogen directly “switches off” ADH or ALDH2.

Aging, genetics, body composition, sleep, medications, liver physiology and the menopause transition can all overlap.

2. The same drink may be landing in a different body.
Alcohol distributes through body water. Changes in body composition with aging—including loss of lean tissue when muscle is not actively preserved—can change the physiologic context in which alcohol is consumed.

That is one more reason strength training, protein intake and maintenance of lean mass matter in midlife.

3. Being able to “hold your liquor” doesn’t make alcohol harmless.
Tolerance describes how intoxicated you feel. It does not mean other physiologic effects disappear.

4. Alcohol may help you fall asleep—but that doesn’t make it a sleep treatment.
A 2025 systematic review and meta-analysis of 27 studies found that alcohol altered sleep architecture, including delayed REM onset and reduced REM sleep. REM disruption was seen even at relatively low doses and worsened as alcohol intake increased. (PubMed⁠)

5. Red wine is not cardiovascular medicine.
Some observational studies historically suggested cardiovascular benefits from light-to-moderate alcohol use, but newer analyses have challenged a clear protective effect. The American Heart Association advises people who do not currently drink not to start drinking for health benefits. (professional.heart.org⁠)

6. Alcohol and breast-cancer risk deserve an honest conversation.
Alcohol is a known human carcinogen. NIAAA currently notes that even approximately one drink per day is associated with a 5% to 15% higher breast-cancer risk compared with women who do not drink.

That statistic describes population-level risk. It does not mean one glass of wine “causes” breast cancer in an individual woman. It is information women deserve when deciding what level of alcohol exposure feels acceptable to them. (NIAAA⁠)

7. Know what “one drink” actually means.
In the United States, one standard drink contains approximately 14 grams of pure alcohol:

• 12 oz regular beer at about 5% ABV
• 5 oz wine at about 12% ABV
• 1.5 oz distilled spirits at about 40% ABV

A cocktail, restaurant pour or large home wine glass may contain more than one standard drink. (NIAAA⁠)

8. You do not have to simply tolerate disruptive hot flashes.
Hormone therapy remains the most effective treatment for bothersome vasomotor symptoms for appropriate candidates. Women who do not want—or are not candidates for—hormone therapy also have evidence-based nonhormonal choices. (The Menopause Society⁠)

Newer nonhormonal options include neurokinin-targeting therapies. Fezolinetant is FDA approved for moderate-to-severe menopausal hot flashes and carries a boxed warning regarding rare serious liver injury. Elinzanetant received FDA approval on October 24, 2025, for moderate-to-severe vasomotor symptoms due to menopause. (U.S. Food and Drug Administration⁠)

THE TWO-WEEK “DOES ALCOHOL ACTUALLY LIKE ME?” EXPERIMENT

For 14 days, eliminate alcohol—or reduce it enough to create a meaningful comparison.

Track:

1. Sleep quality
 How quickly did you fall asleep? Did you stay asleep? How rested were you the next morning?

2. Hot flashes/night sweats
 Frequency, intensity and nighttime awakenings.

3. Morning energy
 Clearheaded? Sluggish? Headache? Puffy?

Hormone pellets are everywhere—from social media ads to hormone clinics promising more energy, better libido, improved strength, and an easier way to manage menopause symptoms.

But are hormone pellets actually right for you?

In this episode of The Modern Midlife Collective, Dr. Jillian Woodruff and Dr. Ade Akindipe take an evidence-based look at bioidentical hormone pellets—what they are, how they work, where they may be helpful, and the important trade-offs you should understand before having one inserted.

They also tackle one of the biggest misconceptions in hormone therapy: the word “bioidentical.” Bioidentical doesn't automatically mean safer, more natural, or customized. It describes the molecular structure of the hormone—and many FDA-approved hormone therapy options are bioidentical too.

And there’s another important consideration with pellets: once a pellet is inserted, the dose cannot simply be turned down or adjusted the way it can with a patch, gel, or pill. You're committing to that delivery method for the life of the pellet.

That doesn't mean pellets are inherently bad. For the right patient, with thoughtful dosing and appropriate monitoring, they may be a useful option.

The key word is individualized.

✨ Hormone therapy should fit the patient—not the clinic's business model.
✨ “Bioidentical” doesn't automatically mean “safer.”
✨ And no single hormone delivery method is right for every woman.

In this episode, we discuss:

• What bioidentical hormone pellets actually are and how they work
• What “bioidentical” really means—and what it doesn't
• The difference between compounded pellets and FDA-approved hormone therapy
• Why pellets can sometimes produce supraphysiologic, or above-normal, hormone levels
• The biggest limitation of pellets: why dosing can't easily be adjusted once they're inserted
• Why appropriate monitoring matters throughout hormone therapy
• The importance of progesterone when estrogen is used in women with a uterus
• The potential role of testosterone in libido, energy, and muscle strength
• Why the goal of testosterone therapy should be symptom improvement—not chasing the highest hormone level
• Who may be a good candidate for hormone pellets
• Questions to ask before choosing a hormone delivery method
• Why a clinic that offers the exact same treatment to every patient should make you ask more questions

The truth about hormone pellets

Hormone pellets aren't automatically “good” or “bad.”

They're one delivery method among several.

The right hormone therapy depends on your symptoms, medical history, individual risk factors, treatment goals, response to therapy, and appropriate clinical monitoring.

Pellets also come with a unique trade-off: unlike some other hormone delivery methods, the dose cannot be easily changed after insertion.

That's why an informed conversation before treatment matters.

If every patient who walks through a clinic's door is offered the same hormone treatment—regardless of her history, symptoms, or individual needs—that isn't truly personalized hormone care.

You deserve to understand your options, the benefits, the limitations, and the risks before making your decision.

Key Takeaway

There is no one-size-fits-all approach to hormone therapy.

Pellets may be appropriate for some women, while patches, gels, creams, oral medications, or other approaches may make more sense for others.

The goal isn't to choose the trendiest delivery method.

It's to choose the right treatment, at the right dose, for the right patient—with appropriate follow-up and monitoring.

🎧 Considering hormone pellets—or already using them? Listen before your next appointment and bring your questions with you.

If this episode helped clarify your options, share it with another woman navigating hormone therapy in midlife.

Download Your Free Hormone Therapy Methods Guide

📩 Have a question or topic you'd like us to discuss?

Visit modernmidlifecollective.com or email us at [email protected].

Resources Mentioned

• The Menopause Society — Hormone therapy information and clinical guidance
• American College of Obstetricians and Gynecologists (ACOG) — Guidance on compounded bioidentical menopausal hormone therapy
• Women's Health Initiative — Research and long-term follow-up on menopausal hormone therapy
• Reviews published in American Journal of Obstetrics & Gynecology and Obstetrics & Gynecology addressing compounded hormone therapy and endometrial safety

#HormonePellets
#BioidenticalHormones
#HormoneTherapy
#HRT
#Perimenopause
#MenopauseSupport
#HormoneHealth
#WomenOver40
#MidlifeWellness
#ModernMidlifeCollective

Is that brain fog… or something more? Dr. Jillian and Dr. Ade break down how to actually tell the difference between perimenopausal brain fog, adult ADHD, and the surprisingly common overlap between the two — plus why so many women are only being diagnosed with ADHD for the first time in their 40s and 50s. They walk through the clues that separate the two, the estrogen-dopamine connection driving it all, how it shows up in relationships and parenting, and exactly what to say at your next appointment.

SHOW NOTES

If the brain you’ve relied on for decades suddenly feels unreliable, you’re not lazy, careless, or incapable — and you may be one of three things: experiencing genuine perimenopausal brain fog, uncovering ADHD that’s been masked for decades, or dealing with both at once. In this episode, Dr. Jillian and Dr. Ade walk through the exact framework they use in clinic to help you tell the difference.

In this episode:

• What ADHD actually is: current presentations (predominantly inattentive, predominantly hyperactive-impulsive, combined), and why “ADD” is now called ADHD, predominantly inattentive presentation
• The three-bucket framework: perimenopausal cognitive change, undiagnosed ADHD surfacing, or both together
• Four clues that help separate them — timing and history, how broad the symptoms are, where they show up, and how much effort it’s taken to compensate
• The estrogen-dopamine connection: why hormonal transition changes the environment attention and executive function operate in
• Why so many women are only recognizing ADHD in midlife, and the historical gap in how girls were diagnosed
• How this shows up at the kitchen table — in marriages, parenting, and intimacy
• What actually helps, and exactly what to say at your next appointment

By the numbers:

• Nearly 60% of perimenopausal women report real memory complaints, per the Study of Women’s Health Across the Nation (SWAN)
• A 2025 population-based study of over 5,300 women (the Icelandic SAGA cohort) found 54.2% of women with a self-reported ADHD diagnosis experienced debilitating perimenopausal symptoms, compared to about a third of women without ADHD

Resources & sources referenced:

• Study of Women’s Health Across the Nation (SWAN) — longitudinal research on cognition and symptoms across the menopause transition
• Weber, M. T., Maki, P. M., & McDermott, M. P. (2014). Cognition and mood in perimenopause: A systematic review and meta-analysis. The Journal of Steroid Biochemistry and Molecular Biology.
• Jakobsdóttir Smári, U., et al. (2025). Perimenopausal symptoms in women with and without ADHD: A population-based cohort study. European Psychiatry.
• Kooij, J. J. S., et al. (2025). Research advances and future directions in female ADHD: The lifelong interplay of hormonal fluctuations with mood, cognition, and disease. Frontiers in Global Women’s Health.
• Osianlis, E., et al. (2025). ADHD and sex hormones in females: A systematic review. Journal of Attention Disorders.
• DSM-5-TR. American Psychiatric Association. (2022). ADHD diagnostic criteria and presentation terminology.

Have a question or want to learn more? Reach out at [email protected].

DR. JILLIAN

“If the brain you have relied on for forty years suddenly feels unreliable, you are not becoming lazy, careless, or incapable.”

“The coping did not fail. The floor moved. Now the support system has to move with it.”

DR. ADE

“Success does not rule out ADHD. The more useful question is: what did that success cost?”

“You do not need to be falling apart dramatically before asking for help. Quietly working twice as hard to maintain the same life is enough.”

If you're in your late 30s or 40s, waking up at 3 a.m., and wondering why your anxiety is through the roof and your cycles are changing — this episode is for you. Dr. Jill and Dr. Ade break down everything you need to know about perimenopause and progesterone: what progesterone actually does (hint: it's way more than a "pregnancy hormone"), why bioidentical progesterone is different from synthetic progestins, and the clinical decision framework for when to start. Real science. No fear. Just answers.

In Episode 37, Dr. Jill Woodruff (gynecologist and certified menopause practitioner) and Dr. Ade Akindipe (DNP, functional medicine specialist) tackle the most common question they hear from women in their 40s: "I think I'm in perimenopause — when do I start progesterone?"

This episode covers:

• What perimenopause actually is and when it starts (hint: much earlier than you think)

• Why progesterone is often the first hormone to decline — and what that means for your sleep, mood, and cycles

• The critical difference between bioidentical progesterone and synthetic progestins

• Why the Women's Health Initiative doesn't apply to modern bioidentical hormone therapy

• Three clinical scenarios where progesterone is indicated in perimenopause

• How to talk to your provider and advocate for the care you deserve

GUEST DETAILS:

This is a co-host episode featuring Dr. Jillian Woodruff, MD, FACOG, NCMP (CMO, Modern Gynecology & Skin) and Dr. Ade Akindipe, DNP, MBA, APRN, FNP-C (Founder, Rejuvenate Health and Wellness).

What happens when a patient decides she deserves better?

After experiencing years of frustrating symptoms and feeling dismissed by the healthcare system, Angela Jackson, LMSW, turned her own journey into a mission to help other women.

 In this episode, Angela shares the story behind her graduate capstone project—a comprehensive Perimenopause & Menopause Toolkit designed to educate women, improve communication with healthcare providers, and empower patients to become active participants in their own care. The toolkit is available as a free download in the resources below.

Together, Dr. Jillian Woodruff and Dr. Ade Akindipe explore why so many women remain undiagnosed during perimenopause, the importance of recognizing early symptoms, racial disparities in menopause care, and how patients and providers can work together to create better outcomes.

This conversation is a reminder that menopause isn't simply something to survive—it's a life transition women can navigate with knowledge, partnership, and confidence.

What You'll Learn

• Why women are frequently dismissed during perimenopause
• The hidden symptoms many women overlook
• How to prepare for your next healthcare appointment
• Why patient self-advocacy changes healthcare outcomes
• The importance of provider-patient collaboration
• What health equity means in menopause care
• Why thriving—not suffering—should be the goal

Featured Guest

Angela Jackson, LMSW

Angela Jackson recently earned her Master of Social Work and developed a Perimenopause & Menopause Toolkit as her graduate capstone project. Grounded in trauma-informed care, patient empowerment, and health equity, the toolkit helps women understand symptoms, prepare for medical appointments, and confidently advocate for their healthcare needs.

Key Takeaways

• You know your body better than anyone else.
• Your symptoms deserve to be taken seriously.
• Perimenopause often begins years before menopause.
• Being informed allows you to become an active participant in your healthcare.
• The best healthcare happens through partnership—not one-sided conversations.
• Every woman deserves to thrive during midlife.

Suggested Chapter Markers

00:00 – Why women often feel dismissed

02:45 – Meet Angela Jackson

06:00 – The inspiration behind the Menopause Toolkit

12:00 – Learning to advocate for yourself

16:30 – Building a toolkit for patients and providers

20:00 – Racial disparities in menopause care

24:00 – Why earlier conversations matter

30:00 – Practical advice for your next doctor's appointment

35:00 – Final reflections

Resources Mentioned

• Perimenopause symptom awareness
• Patient self-advocacy
• Shared decision-making between patients and providers
• Trauma-informed healthcare
• SWAN (Study of Women's Health Across the Nation)

Free Download

📥 Download Angela Jackson's Perimenopause & Menopause Toolkit

Angela created this comprehensive educational toolkit to help women better understand perimenopause and menopause, recognize common symptoms, prepare for healthcare appointments, and confidently advocate for their care.

Whether you're just beginning to notice changes or you're already navigating menopause, this free resource is designed to help you feel informed, empowered, and prepared.

👉 Download the toolkit here

Am I Crazy, or Is This Perimenopause?

The Modern Midlife Collective Podcast

Episode Overview

Have you been told your labs are normal -- but you still don't feel like yourself? Are you waking up at 3 a.m., snapping at people you love, forgetting words mid-sentence, and wondering what is happening to your body? Before you assume the worst, there's something you need to hear: you are not crazy. You may be in perimenopause.

In this foundational episode, Dr. Jillian Woodruff, MD, FACOG, MSCP, and Dr. Ade Akindipe, DNP, break down everything women need to know about the menopausal transition -- what it actually is, why it begins earlier than most women expect, and why the symptom list goes so far beyond hot flashes. They explain why perimenopause is a clinical diagnosis rather than a laboratory one, what the research actually shows about hormones and brain health, and what to do if you have already been dismissed by a provider who told you your numbers look fine.

This episode also addresses why so many perimenopausal symptoms are misattributed to anxiety, stress, or aging -- and what the full, evidence-based picture actually looks like. If you have been searching for someone to finally connect the dots, this is that conversation.

Key Takeaways
• Perimenopause can begin in the late 30s and lasts an average of four to ten years -- and women can be fully symptomatic while still having regular menstrual cycles.

• Hormone levels fluctuate dramatically during this transition. A single blood draw is a snapshot, not the full film. Perimenopause is a clinical diagnosis based on symptoms, history, and patterns over time.

• Estrogen receptors are found in the brain, bones, heart, blood vessels, bladder, skin, and muscles. When estrogen fluctuates, women feel it throughout their entire body -- which explains why the symptom list seems so disconnected.

• The SWAN Study (Study of Women's Health Across the Nation), one of the largest long-term studies of the menopausal transition, confirmed that sleep disruption, mood changes, cognitive complaints, and hot flashes commonly emerge during perimenopause -- often well before the final menstrual period.

• Cognitive changes -- word-finding difficulties, brain fog, and memory lapses -- are common during perimenopause and are typically temporary and hormone-related. They are not early dementia.

• Tracking your symptoms over four to six weeks -- including sleep, mood, energy, cycle changes, hot flashes, brain fog, and joint pain -- gives your clinician critical information that a single lab result cannot provide.

• Evidence-based treatment options exist. There is no clinical or moral virtue in suffering through this transition without support.

Topics Discussed
What perimenopause is and how it differs from menopause, why perimenopause can begin in the late 30s, the hormone fluctuation pattern during perimenopause and why it is not a steady decline, the full symptom spectrum of perimenopause including neurological, cardiovascular, musculoskeletal, urogenital, and metabolic symptoms, the SWAN Study and what it tells us about the menopausal transition, estrogen and the brain including research from Harvard Medical School and Brigham and Women's Hospital, the ACOG position on perimenopause symptom onset, why perimenopause is a clinical diagnosis and not a laboratory diagnosis, the limitations of hormone testing and what labs actually tell us, conditions that mimic perimenopause including thyroid disease, iron deficiency, and insulin resistance, why perimenopausal anxiety is frequently misattributed to stress, the cognitive changes of perimenopause and why they are temporary, building your midlife foundation using the CARESS framework, how to find a Menopause Society certified practitioner, listener questions addressing the most common perimenopause misconceptions

Your Five-Step Perimenopause Action Plan
1. Track your symptoms for four to six weeks. Include sleep, mood, energy, hot flashes, brain fog, cycle changes, joint pain, and libido. Patterns are data your clinician needs.

2. Know your family history. Ask when your mother or sisters reached menopause and whether they experienced osteoporosis, heart disease, or cognitive changes.

3. Build your midlife foundation. Prioritize protein at every meal, resistance training two to three times per week, daily movement, stress management, and sleep. The CARESS framework is a place to start.

4. Find a clinician with menopause-specific training. The Menopause Society maintains a certified practitioner directory at menopause.org.

5. Give yourself grace. You are not weak. You are not lazy. You are moving through a transition -- and you deserve support during it.

Resources Mentioned
The Menopause Society certified practitioner directory: menopause.org

ACOG (American College of Obstetricians and Gynecologists): acog.org

SWAN Study (Study of Women's Health Across the Nation): swanstudy.org

Modern Gynecology and Skin: moderngynalaska.com

Rejuvenate Health and Wellness: rejuvenatehealthak.com

The Modern Midlife Collective: modernmidlifecollective.com

Contact us: [email protected]

**Watch on YouTube:** @drjillianwoodruff -- video available one week after audio release

**Connect with Dr. Ade:** @dr.adeakindipednp

Scientific References
1. Sowers MF, Crawford SL, Sternfeld B, et al. SWAN: A multicenter, multiethnic, community-based cohort study of women and the menopausal transition. In: Lobo RA, Kelsey J, Marcus R, eds. *Menopause: Biology and Pathobiology.* San Diego, CA: Academic Press; 2000:175-188.

2. Bromberger JT, Matthews KA, Schott LL, et al. Depressive symptoms during the menopausal transition: the Study of Women's Health Across the Nation (SWAN). *J Affect Disord.* 2007;103(1-3):267-272. doi:10.1016/j.jad.2007.01.034

3. Avis NE, Crawford SL, Greendale G, et al; Study of Women's Health Across the Nation. Duration of menopausal vasomotor symptoms over the menopause transition. *JAMA Intern Med.* 2015;175(4):531-539. doi:10.1001/jamainternmed.2014.8063

4. Harlow SD, Gass M, Hall JE, et al; STRAW + 10 Collaborative Group. Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging. *Menopause.* 2012;19(4):387-395. doi:10.1097/gme.0b013e31824d8f40

5. Brinton RD, Yao J, Yin F, Mack WJ, Cadenas E. Perimenopause as a neurological transition state. *Nat Rev Endocrinol.* 2015;11(7):393-405. doi:10.1038/nrendo.2015.82

6. Maki PM, Henderson VW. Hormone therapy and cognition: where do we go from here? *Menopause.* 2016;23(7):733-735. doi:10.1097/GME.0000000000000678

7. Weber MT, Maki PM, McDermott MP. Cognition and mood in perimenopause: a systematic review and meta-analysis. *J Steroid Biochem Mol Biol.* 2014;142:90-98. doi:10.1016/j.jsbmb.2013.06.001

8. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 141: Management of menopausal symptoms. *Obstet Gynecol.* 2014;123(1):202-216. doi:10.1097/01.AOG.0000441353.20693.78

About Dr. Jillian Woodruff, MD
Dr. Jillian Woodruff, MD, is a board-certified OB-GYN, gynecologic surgeon, and Menopause Society Certified Practitioner. She is the founder of Modern Gynecology...

I’m in Perimenopause — How Do I Know When It’s Time to Start Estrogen?

Episode Overview

In this solo episode, Dr. Jillian Woodruff tackles one of the most common and nuanced questions in menopause medicine: How do you know when it’s time to start estrogen?

Recorded while on a family vacation on the East Coast — because some topics are too important to wait — Dr. Jillian walks through the practical clinical framework she uses every day in her practice. She covers the signals she looks for, why laboratory results alone are not enough to guide this decision, and why perimenopause is often the optimal time to begin the conversation — not years later when symptoms have already disrupted sleep, mood, cognition, intimacy, and quality of life.

The episode also covers the relationship between estrogen and periods — including why estrogen can sometimes make bleeding worse in early perimenopause — the non-negotiable role of progesterone in any woman with a uterus on systemic estrogen, and a full discussion of Genitourinary Syndrome of Menopause (GSM) and why painful sex, vaginal dryness, and recurrent UTIs are treatable and should never be accepted as inevitable parts of aging.

Key Takeaways

• You do not have to wait until symptoms become severe before discussing hormone therapy.
• Perimenopause is often the ideal time to begin evaluating treatment options.
• New symptoms matter more than isolated laboratory values.
• Hot flashes and night sweats are more than inconveniences and can affect overall health and quality of life.
• Early bone loss may be an important reason to discuss hormone therapy.
• Mood and cognitive changes may have hormonal contributors.
• Progesterone is often the first hormonal intervention considered in early perimenopause.
• Women with a uterus who use systemic estrogen require endometrial protection with progesterone or a progestin.
• Vaginal estrogen is a separate treatment category from systemic hormone therapy and has a different risk profile.
• GSM is common, progressive, and highly treatable.

Resources Mentioned

• The  Menopause Society certified provider finder: www.menopause.org
• Send your questions: [email protected]
• Watch the video version: youtube.com/@drjillianwoodruff (available June 10, 2026)
• www.modernmidlifecollective.com

About Dr. Jillian Woodruff, MD

Dr. Jillian Woodruff, MD is a board-certified OB-GYN, gynecologic surgeon, and Menopause Society Certified Practitioner. She is the founder of Modern Gynecology & Skin in Anchorage, Alaska, and co-host of The Modern Midlife Collective podcast with Dr. Ade Akindipe, DNP.

SCIENTIFIC REFERENCES AND BIBLIOGRAPHY

Professional Guidelines

The Menopause Society. The 2022 Hormone Therapy Position Statement of The Menopause Society. Menopause. 2022;29(7):767–794.

American College of Obstetricians and Gynecologists. Hormone Therapy for Menopause. ACOG Practice Guidance and FAQ. Washington, DC: ACOG; updated 2022.

SWAN Study — Vasomotor Symptoms and Duration

Avis NE, Crawford SL, Greendale G, et al. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med. 2015;175(4):531–539.

SWAN Study — Vasomotor Symptoms and Cardiovascular Risk

Thurston RC, El Khoudary SR, Sutton-Tyrrell K, et al. Vasomotor symptoms and cardiovascular risk in midlife women. Menopause. 2011;18(2):146–151.

Perimenopausal Depression and PMDD History

Cohen LS, Soares CN, Vitonis AF, Otto MW, Harlow BL. Risk for new onset of depression during the menopausal transition: the Harvard Study of Moods and Cycles. Arch Gen Psychiatry. 2006;63(4):385–390.

Freeman EW, Sammel MD, Liu L, Gracia CR. Association of hormones and menopausal status with depressed mood in women with no history of depression. Arch Gen Psychiatry. 2004;61(1):62–70.

GSM — Management and Treatment

Faubion SS, Larkin LC, Stuenkel CA, et al. Management of genitourinary syndrome of menopause in women with or at high risk for breast cancer. Menopause. 2018;25(6):596–608.

Faubion SS, Sood R, Kapoor E. Genitourinary syndrome of menopause: management strategies for the clinician. Mayo Clin Proc. 2017;92(12):1842–1849.

Bone Loss and Estrogen in Perimenopause

Sowers MR, Zheng H, Jannausch ML, et al. Amount of bone loss in relation to time around the final menstrual period and follicle-stimulating hormone staging of the transmenopause. J Clin Endocrinol Metab. 2010;95(5):2155–2162.

Perimenopause as Clinical Diagnosis — Lab Limitations

Santoro N, Roeca C, Peters BA, Neal-Perry G. The menopause transition: signs, symptoms, and management options. J Clin Endocrinol Metab. 2021;106(1):1–15.

Endometrial Protection — Unopposed Estrogen

Grady D, Gebretsadik T, Kerlikowske K, Ernster V, Petitti D. Hormone replacement therapy and endometrial cancer risk: a meta-analysis. Obstet Gynecol. 1995;85(2):304–313.

You have been exhausted. You went to the doctor. Your labs came back normal. And somehow that made it worse — because now you have no explanation, no answers, and a quiet suspicion that something is still very wrong.

You are not imagining it. And this episode is where it finally gets addressed.

In the third and final episode of our fatigue series, Dr. Jillian and Dr. Ade deliver the complete clinical protocol: the labs that actually reveal what is driving your fatigue, the supplement stack with the full reasoning behind every ingredient, and the exact language to use when you sit down with your provider so you walk out with something more useful than a recommendation to sleep more.

This is the episode you bring to your next appointment.

Free Download Fatigue Protocol

Everything covered in today's episode — the complete lab panel organized by tier, the supplement stack with ingredient breakdown and dosing, patient advocacy language, and a quick-reference symptom guide — is available as a free download.

Get the Complete Fatigue Protocol at modernmidlifecollective.com/fatigue

Missed Parts 1 and 2?

Episode 31 — Why Am I Always Tired? The Root Causes of Fatigue Part 1 Covers: sex hormone dysregulation, thyroid dysfunction, and HPA axis dysregulation

Episode 32 — Why Am I Always Tired? The Root Causes of Fatigue Part 2 Covers: blood sugar dysregulation, nutrient deficiencies, and chronic low-grade inflammation

Labs Discussed in This Episode

Tier One — First Visit Essentials

Hormones: Estradiol (E2), Free and Total Testosterone, Progesterone, DHEA-S, FSH, LH, SHBG

Thyroid: TSH, Free T3, Free T4, TPO Antibodies

Metabolic: Fasting Insulin, Fasting Glucose, HOMA-IR, Hemoglobin A1c, Comprehensive Metabolic Panel, Fasting Lipid Panel

Nutrients: Ferritin (target 70 to 100 ng/mL), 25-OH Vitamin D (target 50 to 80 ng/mL), Vitamin B12

Inflammation: High-Sensitivity CRP (hsCRP)

Tier Two — Added Based on Clinical Picture

Thyroid extended: Reverse T3, Anti-Thyroglobulin Antibodies

Adrenal: 4-Point Salivary Cortisol and DHEA (functional lab — typically requires a functional medicine or integrative provider)

Metabolic extended: Continuous Glucose Monitor (CGM) trial

Nutrients extended: RBC Magnesium, Folate, Zinc, IGF-1

Gut: Comprehensive Stool Analysis (functional lab)

Supplements Discussed

Full supplement collection available through Dr. Jillian's professional dispensary: https://us.fullscript.com/plans/moderngynecology-modern-midlife-collective-s-fatigue-protocol

Magnesium Glycinate — sleep, nervous system support, restless legs. 300 to 400 mg at night.

Magnesium Malate — daytime energy and muscle function. 200 to 400 mg with food.

CoQ10 Ubiquinol — mitochondrial energy chain. Non-negotiable for statin users. 100 to 300 mg daily.

Berberine — insulin sensitivity and metabolic support. 500 mg with meals, titrate slowly.

Myo-Inositol with D-Chiro-Inositol (40:1 ratio) — insulin sensitivity and hormonal balance. 2 to 4 grams daily.

Ashwagandha standardized extract — HPA axis and cortisol rhythm support. 300 to 600 mg daily.

Rhodiola Rosea — cognitive fatigue and stress resilience. 200 to 400 mg in the morning.

Phosphatidylserine — evening cortisol reduction; wired-but-tired pattern. 100 to 300 mg at night.

Methylated B Complex — neurological energy and cortisol metabolism. Critical for women on oral contraceptives, PPIs, or metformin.

Vitamin D3 with K2 MK-7 — immune, hormonal, and energy support. 5,000 IU D3 with 100 mcg K2 daily with food.

Omega-3 EPA and DHA — anti-inflammatory and cardiovascular support. 2 to 4 grams of combined EPA and DHA daily.

Full curated supplement collection with professional-grade brands: modernmidlifecollective.com/fatigue

Research Cited

Women's Health (London) — 67% Fatigue Prevalence in Perimenopausal Women (n=3,000+) Menopause Journal (March 2025) — AUB, Iron Depletion and Fatigue During Perimenopause (n=2,300+) AIMS Molecular Science (2024) — Estrogens and Mitochondrial Biogenesis Frontiers in Endocrinology (2024) — Mitochondrial Dysfunction and Insulin Resistance The American Journal of Medicine (2025) — HPA Axis Dysregulation: Integrative Review PMC UK Survey (2025) — Fatigue in Treated Hypothyroidism (n=1,251; 89% abnormal fatigue) XX Midlife Women's Health Study — Stress-Fatigue Coupling Across Menopause Transition WellnessExtract Research (2025) — IL-6, TNF-alpha, and Perimenopause Inflammation

Connect With Us

Website: modernmidlifecollective.com
Free Fatigue Protocol: modernmidlifecollective.com/fatigue
Instagram: @modernmidlifecollective
Email: [email protected]

Work With Dr. Jillian Modern Gynecology and Skin | Anchorage, Alaska 

Instagram: @drjillianwoodruff
Transcend Retreat Waitlist: https://moderntranscend.com/retreat-waitlist

Website: www.moderngynalaska.com 

Work With Dr. Ade Rejuvenate Health and Wellness | Anchorage, Alaska  

Website: www.rejuvenatehealthak.com 

Download Dr. Ade’s Metabolic Reset Cheat Sheet https://rejuvenatehealthakrlt.com/metabolic-reset 

Take your Midlife Vitality Quiz https://dr-ade-the-vitality-gap-scorecard.scoreapp.com/ 

Instagram: @rejuvenate_health_wellness | @dr.adeakindipednp

Both practices serve patients in the state of Alaska.

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The Modern Midlife Collective Dr. Jillian Woodruff, MD, FACOG, MSCP x Dr. Ade Akindipe, DNP, MBA, APRN modernmidlifecollective.com