The Journal

Perimenopause

Perimenopause: the four levers I use with patients (gut, muscle, sleep and medicines)

Four levers: gut, muscle, sleep, and when medicines earn their place

Dr Amy Shacaluga·23 September 202620 min read

If you are in perimenopause, or close to it, you don't need another list of symptoms. You already know them by heart. What helps is a map you can actually use. Feeling different in your body in this transition is common: a softer middle, broken nights, food that no longer sits the same way, a brain that feels louder than it used to. None of that is a character flaw, and none of it is your fault.

This is the four-lever map I teach when there is time to do it properly. Lifestyle and Precision Health lead: gut, training and sleep first, then a clear place for regulated medicines when they earn it. Conventional UK care from NICE (NG23) and the British Menopause Society runs through all of it, and I say so wherever it applies. My earlier post on protein, muscle and sleep covered one part of this. Here I've set out the full picture, including what the gut science can and cannot yet tell us, and where the limits of HRT lie.

This article is general education, not personal medical advice, and it is not for emergencies. If you need urgent care, call 999 or NHS 111. Video consultations are UK based.

How I grade the evidence

I would rather you could see how confident I am than have to guess, so each claim carries a grade.

• 🟢 Green: strong enough that I teach it and act on it with confidence, within a plan that fits you.
• 🟡 Amber: useful, with caveats. I'll tell you what would make it greener.
• 🔴 Red: interesting, but not a first move yet.

Lever 1: your gut and the estrobolome

Perimenopause is about more than your ovaries turning the volume down. Your gut runs a quiet hormone workshop of its own. Researchers call it the estrobolome. That is a scientific term, not a brand name. It describes the set of bacterial genes that make enzymes, mainly β-glucuronidase, which help decide what happens to oestrogen your body has packaged up for removal. That oestrogen can be unpacked in the bowel and recycled into the bloodstream, or it can stay on its way out [1,2].

The pathway is simple enough to sketch. Your liver packages oestrogen, bile carries it into the gut, gut enzymes can unpack it, and the freed oestrogen can then be reabsorbed. As midlife hormones shift, the gut community often shifts with them. Women tell me about bloating, a change in bowel habit, a different waist, brain fog, or food that no longer sits the way it used to. 🟢 for the enzyme mechanism. 🟡 for the link to symptoms.

I start with this lever because Precision Health looks at the whole person, and lifestyle medicine gives you something you can do this month. Fibre is the main food for these microbes. You don't digest most of it yourself. Your gut bacteria ferment it into short-chain fatty acids such as butyrate, which help keep the gut lining calm and support metabolic health. In observational studies, higher-quality fibre and carbohydrate patterns have been linked with fewer physical and psychological menopause symptoms [3]. That is an association, not a randomised cure. It supports a food-first approach, but it does not prove that fibre stops flushes. 🟡.

You don't need a boutique fibre powder on day one. You need variety you can keep up:

• oats and other whole grains, if you tolerate them

beans and lentils

vegetables, and fruit with the skin on where you can

nuts and seeds

resistant starch from cooled potatoes or rice, when that suits you

If your gut is reactive, build up slowly. Work gently towards the UK recommendation of 30 g of fibre a day from food, with plenty of fluid, so you don't swap one kind of bloating for another. Fermented foods are optional and personal. Everyone's tolerance is unique, start with a food diary and see what types of fibre you can tolerate coupling with fluid to gently move it through the gut.

Here are three bacteria I name in clinic. They aren't a shopping list.

Bifidobacterium comes up often in midlife gut conversations. It responds to fermentable fibres such as inulin, found in onions, garlic, leeks, slightly under-ripe bananas, beans and chicory, if you tolerate them.

Butyrate producers, especially Faecalibacterium and Roseburia, are fed by a wide range of plant fibre and resistant starch.

Akkermansia muciniphila lives in the gut's mucus layer and has been found at lower levels after menopause in some studies. I support it with plant diversity, polyphenol-rich foods (berries, colourful plants, cocoa if it suits you), fibre and movement. Pasteurised Akkermansia has attracted early interest in metabolic trials, but it is not a proven hot-flush treatment.

🟡 for these food-first approaches. 🔴 for any probiotic product sold as a menopause treatment. Probiotics have their place but need to be used appropriately.

There is an important caveat. A 2026 systematic review and meta-analysis found no consistent microbial "fingerprint" that reliably separates women with low oestrogen from premenopausal women [4]. Much of the microbiome story is still about associations and function, not a tidy checklist of bugs. So I won't claim that a probiotic will stop your flushes, and I won't recommend a "menopause microbiome kit". Stool tests and branded estrobolome scores are optional curiosities. They are not part of the NICE pathway, and you don't need one to start eating fibre well. 🔴 as a first test. 🟢 for building fibre diversity from food over a month while you notice how your energy and bowels respond.

Start with food you can sustain. Go easier on alcohol and heavily processed food.

Lever 2: lift something, move something, do both

In the run-up to menopause, many women notice that the same food and the same week now leave them with a softer middle, afternoon energy crashes and blood sugar that feels less steady. You are not imagining it, and it is not a willpower problem. As oestrogen falls and fluctuates, muscle becomes easier to lose, fat moves towards the waist, and cells can become less responsive to insulin, so they take up glucose less readily. Around the final menstrual period, body-scan (DXA) data from the SWAN study show fat mass rising faster and lean mass falling, even when the scales barely move [5]. So the real conversation is about body composition and function, not willpower. 🟢.

Muscle is one of the biggest places your body stores glucose. When you keep or rebuild it, carbohydrate has somewhere to go after meals. That supports steadier energy and a kinder trajectory for your waistline, and it lowers long-term heart and metabolic risk. NICE asks clinicians to explain how important it is to maintain muscle mass and strength through physical activity as part of menopause care [6]. The UK bone health consensus, Strong, Steady and Straight, also recommends progressive resistance training plus suitable impact and balance work, because bone and muscle go together [7]. 🟢.

Strength training is the non-negotiable part. Lifting, pushing and pulling, working your large muscle groups two to three times a week, tells your body to keep its muscle. In a Swedish randomised trial, progressive resistance training three times a week reduced moderate-to-severe hot flushes by around 44% over 15 weeks, compared with carrying on as before [8]. That is a useful and specific finding, but it won't apply to everyone. The benefit was still visible at around six months, but it was not clearly maintained at two years in women who stopped training [9]. I think that detail matters. Training is a practice you keep up, not a one-off prescription. For insulin and midlife metabolism, the bigger win is the muscle you keep. 🟢 for body composition and NICE's muscle advice. 🟡 for fewer flushes, which is a welcome bonus rather than a guarantee.

Cardio is strength training's partner, not its rival. Brisk walking, cycling, swimming and similar activity improve fitness, blood pressure and heart-metabolic markers after menopause in pooled trials, although the certainty for some outcomes is low [10]. The large MsFLASH aerobic exercise trial found no fewer flushes than usual activity, but sleep and mood moved in a helpful direction [11]. So if cardio hasn't stopped your flushes, it hasn't failed you. It still earns its place for your heart, mood and insulin sensitivity alongside the weights. 🟢 for heart and metabolic health. 🔴 as a treatment to stop flushes.

This week, aim for two to three strength sessions you can keep up, plus aerobic activity you will actually do. Start where your joints, pelvic floor and diary allow. Doing it consistently beats a perfect programme you abandon. Protein and creatine are worth discussing alongside training, but they don't replace the sessions. The same goes for HRT and other medicines: when they earn their place, they sit within this map and don't replace the muscle you build. If you remember one line, make it this one: in this transition, muscle is medicine for insulin. Lift to keep the glucose store, move to keep the engine running, and do both.

Lever 3: protect the night

Sleep is my third lever because broken nights are what bring so many women to my clinic, often after midnight internet searches and before early meetings. Perimenopause fragments sleep through night sweats, anxious thought loops, early waking and a body clock that feels less steady than it did in your thirties. That is not "just stress", and it is not a personal failing. When sleep unravels, mood, appetite, gut comfort and hot flushes often get worse, and each makes the others harder.

NICE now asks clinicians to consider menopause-specific cognitive behavioural therapy (CBT) for sleep problems linked to hot flushes and night sweats. It can be used alongside HRT, or instead of it when HRT isn't right for you, and NICE also recommends it for low mood linked to the menopause [6]. In a strong randomised trial of postmenopausal women with insomnia, CBT for insomnia (CBT-I) far outperformed sleep-hygiene leaflets, and the gains lasted [12]. In the MsFLASH trial, CBT-I delivered by telephone produced large improvements in insomnia severity that held at 24 weeks. The number of flushes didn't change, but women reported that flushes disrupted their lives less [13]. Pooled MsFLASH data also ranked CBT-I as the standout option for insomnia in women who also had hot flushes [14]. Treating sleep and treating flushes are related levers, but they are not the same thing. 🟢.

Practical night protection still earns its place alongside therapy:

• a consistent wake-up time

dimmer screens late in the evening

a cool bedroom

avoiding alcohol

Night sweats and racing thoughts are medical problems we can work on together, not tests of character you have failed. Body-clock (circadian) biology is a plausible target here, but menopause-specific trials are still much thinner than the evidence for CBT-I. 🟡 for sleep hygiene and body-clock tips as support. 🟢 for CBT-I as the treatment that lasts.

If sleep is what wrecks your week, I make it the priority in your plan before we pile on every other goal. Short courses of sleeping tablets are sometimes considered, case by case, but they don't retrain the insomnia loop. If flushes are what wake you, regulated HRT often improves sleep indirectly. If insomnia has become a learned pattern, you may still need CBT-I. NICE allows CBT with or without HRT [6].

A short note on libido

Women often raise this quietly, at the very end of an appointment, so I want to mention it plainly here. A change in sexual desire during perimenopause is common. It is rarely about one thing.

In SWAN, which followed women through the transition, sexual desire fell and pain with sex became more common in late perimenopause and after menopause, independent of age [18]. Several things usually contribute at once:

• Falling oestrogen can make vaginal tissue drier and thinner, so sex can become uncomfortable. When sex hurts, desire understandably follows.

Broken sleep and exhaustion leave little room for desire.

Mood changes, anxiety and body image in a body that feels unfamiliar play a real part.

Relationship dynamics and a very full life matter too. Always worth conversations with your partner as uncomfortable as they may feel.

Some medicines, including certain antidepressants, can dampen desire.

This is why the other three levers matter here too. Better sleep, steadier mood and feeling stronger in your body all count. Vaginal dryness and discomfort respond well to vaginal moisturisers and low-dose vaginal oestrogen [6]. If low desire is distressing and HRT alone hasn't helped, NICE allows testosterone to be considered [6]. The international consensus supports testosterone for postmenopausal women with low desire that causes distress, prescribed at female doses and with blood levels monitored. It also notes that the evidence in perimenopause is more limited [19]. 🟢 for treating vaginal symptoms and for testosterone in carefully selected postmenopausal women. 🟡 in perimenopause. 🔴 for unregulated "libido blends" sold online.

Supplements I sometimes discuss for libido

Women often ask me about supplements, so here is where the evidence stands. The trials are small and short, and most used a single standardised extract rather than the multi-ingredient blends sold online. So I treat these as possible add-ons after the bigger levers are in place, never as a replacement for vaginal oestrogen or testosterone when those are indicated.

Korean red ginseng (Panax ginseng). In a double-blind, placebo-controlled crossover trial in menopausal women, Korean red ginseng improved sexual arousal scores over eight weeks [21]. A 2021 meta-analysis of natural products also found that ginseng helped arousal and desire, while calling the evidence preliminary [20]. It can interact with warfarin and some diabetes medicines, and may unsettle sleep in some women. Never take it without a clinical discussion first. 🟡.

Maca (Lepidium meyenii). In a very small crossover trial in postmenopausal women, maca reduced sexual dysfunction and psychological symptom scores without changing oestrogen or testosterone levels [22]. It is generally well tolerated, but the evidence is thin. 🟡 at best.

Ashwagandha (Withania somnifera). A pilot randomised trial of 50 women with sexual difficulties found that root extract (300 mg twice daily for eight weeks) improved sexual function scores more than placebo [23]. The women were not specifically in perimenopause. Rare cases of liver injury have been reported, and it is not for pregnancy, thyroid conditions or anyone on thyroid or immune-suppressing medicines without advice. 🟡 in general, 🔴 for perimenopause specifically.

If we do try one in clinic, I choose one single-ingredient product from a reputable manufacturer, check it against everything else you take, give it eight to twelve weeks and review it honestly. If it hasn't helped by then, we stop.

Lever 4: Precision Health, and when medicines earn their place

Precision Health means I start with your story, your risks and a lifestyle plan you can live with. Medicines, including HRT, can be necessary and kind. They should sit within that plan, not replace it.

NICE is clear. In otherwise healthy women aged 45 and over, perimenopause is usually diagnosed from symptoms and changes in your cycle. There is no need to chase endless hormone panels to prove what your body is already telling you. AMH, inhibin, oestradiol and similar tests should not be used to make the diagnosis, and FSH is used only in defined younger groups [6]. NICE recommends offering HRT for hot flushes and night sweats, and asks clinicians to explain the benefits and risks in plain language. It states that the effectiveness and safety of unregulated hormone preparations are unknown. HRT should be reviewed at three months, then yearly. 🟢.

Regulated body-identical HRT is available through products licensed by the MHRA, the UK medicines regulator. The British Menopause Society does not recommend compounded "bioidentical" creams and pellets marketed as more natural when regulated alternatives exist [15]. Expensive saliva or dried-urine hormone panels are not a first-line way to diagnose perimenopause or to set your dose but they may sit within an experimental section of our Precision Health setting. The Endocrine Society advises against routine compounded bioidentical hormones and notes that saliva tests are not standardised for dosing [16]. The American College of Obstetricians and Gynecologists (ACOG) likewise finds no approved saliva or urine hormone tests for guiding menopausal hormone therapy [17]. The dose should be adjusted to your symptoms, with a clinician overseeing it. 🟢 as the UK and international position. 🔴 for compounded bioidentical hormones, and for saliva or DUTCH-style panels as a first test.

What precision means here:

• Mapping your perimenopause story against your cycle, sleep, waist, mood, gut comfort, bone health and heart-metabolic risk.

Lifestyle levers you can keep, graded herbal add-ons where they fit, and regulated HRT, vaginal oestrogen or non-hormonal options when they earn their place.

Shared decisions about the route (patch, gel or tablet), dose, type of progestogen and review dates.

What it doesn't mean:

• Collecting more lab numbers for their own sake.

A saliva or multi-hormone panel that claims to precisely personalise your treatment.

Compounded bioidentical hormones marketed as safer than regulated care.

A lifestyle plan that pretends severe flushes never need medicine.

If you want herbal remedies, they stay graded and never replace treatment you need. NICE notes that isoflavones or black cohosh may ease hot flushes for some women, but product quality, safety and interactions with other medicines remain uncertain [6]. Chamomile can be part of a bedtime routine. Magnesium is not a hot-flush treatment. St John's wort interacts with many medicines, especially antidepressants and tamoxifen, so please don't start it on the strength of a social media tip. 🟡 for selected herbal remedies, with caveats. 🔴 for casual use of St John's wort, and for anyone selling "natural" options as equivalent to HRT.

If HRT, vaginal oestrogen, non-hormonal treatments or other medicines become part of your plan, I choose regulated products and keep training, sleep, gut care and heart-metabolic health running alongside them. My aim is to keep you informed, not to sell to you. Medicines earn their place when your story, your examination and guideline-based choices line up.

Precision Health pearl

In perimenopause, precision isn't a shopping list of blood panels. It means matching your loudest levers (gut, muscle, sleep and, where they help, regulated medicines) to a plan you can live with. From 45, it means a clinical diagnosis without endless hormone tests, and regular reviews that are honest about what is 🟢, 🟡 and 🔴.

What actually helps: this week

If you take one thing from this post, choose one lever for the next seven days rather than all four at once.

• Gut: add one plant-fibre habit at lunch for a week. Build towards variety rather than a boutique powder.

Training: book two progressive strength sessions you can keep, plus cardio you will actually do.

Sleep: keep the same wake-up time for seven nights, cool the room and cut back on late alcohol. If nights are what wrecks your week, ask about menopause-specific CBT.

Medicines: if flushes, sleep, mood or libido need treatment, ask for regulated options and a three-month review.

One question to bring to clinic: which lever is loudest for me this season, and what should come next?

Clinician note

In clinic, I often suggest chamomile as an evening habit. Cover the cup or pot while it steeps so the aromatic oils stay in the tea rather than drifting into the kitchen. Five to ten minutes is plenty. Use hot water rather than water at a rolling boil. It is a small wind-down ritual that sits alongside sleep care. It is not a sleeping pill, and it is no substitute for CBT-I once insomnia has become established. If chamomile isn't for you, keep the same shape: a warm, caffeine-free last drink, lights down, phone out of the bedroom. 🟢 as a habit. 🟡 as sleep evidence on its own.

If you would like to take this further

If the four levers map landed for you, the perimenopause hub is where I set out how that work sits inside a consultation — your story, which lever is loudest, and whether lifestyle changes and regulated medicines belong side by side.

Perimenopause care

This article is general education, not personal medical advice. It is not for emergencies. For urgent care, call 999 or NHS 111. Video consultations are UK based.

References

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