Perimenopause Passage

By Dr. Alexandra Cope 

Image by Marta Pucci

Menopause experiences are varied and individualized and are often precipitated by a healing crisis related to perimenopause. 

Menopause, defined, is when a woman’s menstrual period has been absent for an entire year, whereas perimenopause is the time leading up to menopause.  The pause that perimenopause is known to cause is where healing can be harvested.  The average age of crossing from perimenopause to menopause is age 51.  Some women simply stop bleeding and that is it.  Others have symptoms roar and an entire new depth of healing is to be had and/or explored. 

What is going on beneath the surface during perimenopause? 

Physiologically, the pituitary, one of the mother hormonal glands in the brain, begins to signal to the ovaries to slow down the production of estrogen. 

The stories that we hear about- perimenopausal “surges” are due to communication loops between ovaries and the brain.  As the ovarian reserve begins to decline, the granulosa cells have less estrogen to produce.  As estrogen levels decline in the body, the pituitary begins to scream to the ovaries to wake the eff up.  A sudden surge of estrogen may appear and then decline and appear again, which can cause an array of symptoms.  Many of these symptoms are unpredictable, seemingly random and make it very difficult to track. 

Though, I must say that if you are a tracker, then there are apps such as the Lilly app that can provide some clarity in a time of confusion.  

Estrogen is the hormone that gives us women our juiciness.  Estrogen is responsible for healthy supple tissue; soft skin, supple vaginal tissue, cervical mucus, healthy brain function and healthy laxacity muscles and ligaments. 

Without estrogen, we can dry up. Estrogen is one reason why women are often naturally more flexible than men. When the pituitary ovarian connection results in a decline of estrogen, perimenopause enters. Though many symptoms point to an estrogen connection, it is important to scan for whole health. 

Often, I see many women that have imbalanced cortisol, emotional health issues, thyroiditis, low progesterone, and stealth infections that are magnified by perimenopause.

The pause I witness in perimenopause is generally from the following symptoms: Lack of sleep,  hotflashes, painful sex, brainfog, migraines, fatigue and so much more!  

It is important to remember that our endocrine system (hormones) is a complex symphony of over 200 hormones.  And if one is off key, it can throw the entire song out of tune.  For instance, I often see hot flashes associated with stress levels, which is a cortisol connection.  Also, it is important to ensure that the Thyroid gland and other endocrine organs are assessed during this time.  The Parathyroid is responsible for healthy bone density along with Vitamin D (a hormone) and Vitamin K2.  These are few of many components to consider during your healing journey of the perimenopausal passage. 

In perimenopausal years, women walk through a rite of passage.  There is a freedom to find as monthly cycles come to an end.  Any cycling woman knows how dramatically different you feel day to day according to your hormonal cycle (and moon cycle).  When that ends, you have a chance to open into a wise woman role.  This does not diminish the perimenopause experience that I witness in my clients.  Each womxn has a unique experience of symptoms and emotional growth.  

I asked some of my favorite clients to contribute gifts they have received during this transition of life and the answer was always the same.  A renewed sense of what health means to them… 

Choosing to go through perimenopause and not staying on the Pill until reaching menopause has given me the gifts of acceptance of my life-stage and saying Goodbye to my fertile self. I have often thought that by staying on the Pill and by-passing these invaluable gifts, I would have short-changed myself! Not only would I not have reached this acceptance, but I would not have learned to give myself permission to take care of myself. I would not have a new understanding of women’s health and menstrual cycles that I can pass on to my daughter. 

In spite of some challenging symptoms associated with this phase, my overall physical health has been elevated to a level above what I could have ever imagined.“ -CL

When asking my client about her experience vs her friend's experience, she reported that, “So my journey has looked very, very different from that of women who have received allopathic treatment of menopausal symptoms. In fact, when I first began to ask about the possibility of discontinuing the Pill a few years before actually taking the step, my allopathic practitioner at the time had simply asked me, “Why would you want to do that?”

At that time, I could not have known all of the benefits of discontinuing the Pill, even at age 47. But I knew enough to know that I wanted to stop taking the fake hormones. And I knew that if I stopped, I was not going to find the support I would need from the conventional medicine world. I took the step to make an appointment with a naturopathic physician. This was my very first step of a life-changing journey that not only elevated my physical health, but has also led me to understand the realm in which physical and spiritual health overlap. This has transformed my life in ways beyond what I could have ever imagined!” 

I have been working with CL for three years now.  Her tenacity to heal at all depths is what holistic health is all about.  I witnessed her start a successful preschool, develop healthier relationships with her family, mentor her daughter through her health, and step gracefully into the woman she was becoming.  After the DUTCH test, nutritional recommendations, and custom herbal formulas healed her physical symptoms, she began 5-element Flower Essence Therapy and Somatic Experiencing with me. 

In each session, she turned the confusion of this transition inward and began to look for the nooks within to heal.  Each boundary and realization that she experienced has brought her closer to who she is meant to be in this world.  As a fertility specialist that witnesses many gateway transitions of womxn, I humbly take great joy in witnessing her “becoming”.  

Symptoms of perimenopause are simply your body yelling for you to slow down and care for yourself during this time.  Each pain and ailment is a signal to heal.  As much as they can wreak havoc on your daily life and relationships, there are many different nutritional supplements and botanical medicines that can be your best ally.  These tools relieve symptoms for you to get through the day to day life and for you to turn inward and ask yourself, “okay, what is next to focus on in my healing journey?” 

Often in allopathic medicine, more extreme solutions are advised such as hysterectomies and heavy hormone replacements. What are some lifestyle or naturopathic alternatives to support this transitional time?

Unfortunately, I often see women after they have already had a procedure. The most common procedure I see in standard american medicine is an ablation, which is a surgical procedure that destroys the lining of the uterus to stop periods.  I have seen hysterectomies decline the past 5 years.  Another common option is that women are told to begin (or continue) is hormonal contraception (birth control) in order to control their bleeding.  A birth control period is not a true period. Hormonal Contraception decreases the amount of progesterone in your body, which is a protective hormone and often helps decrease symptoms of perimenopause. Many naturopathic and functional medicine doctors use bioidentical progesterone to treat perimenopausal symptoms.  

Bioidentical Progesterone reduces heavy bleeding, eliminates hot flashes, and improves sleep. The Pfizer manufactured drug used to treat hot flashes, Duavee, increases the risk of endometrial cancer.

Herbal Remedies

  • HPA axis balancing herbs focus on cortisol and stress responses and are key during the menopausal transition.  A few of my favorites are Tulsi, Motherwort, Milky Oats, and Rose.  
  • Sage, Rose, and Milky Oats is my magical blend for hot flashes. 
  • Black Cohosh, Vitex, Maca and Red Clover along with liver cleansing herbs are essential to balance Estrogen and Progesterone. Each of these herbs support healthy hormone levels from your brain to your ovaries.  

Research is often conducted on these herbs, but not funded because there is not a fiscal value to discovering medicines that grow in your backyard. 

Medicines from the earth are often difficult to patent in order to reserve Indigenous rights, our original medicine people. A few notable studies include Black Cohosh. Black Cohosh has been found to be as effective at relieving perimenopausal symptoms as Hormone Replacement Therapy.

One study of 60 menopausal women showed Black Cohosh improved psychological symptoms. significantly. 1 Another study of 60 menopausal women showed Black Cohosh  to relieve symptoms within 4 weeks, and cause no side effects.2  Both of these controlled, clinical trials showed Black Cohosh to be as effective as pharmaceutical Estrogen.

Other clinical investigations have shown Black Cohosh to be useful in controlling symptoms while weaning from H.R.T.35 and in reducing menopausal symptoms following ovarian surgery.3

Vaginal Care

Vaginal steams, suppositories, and lube and more lube

One of the most devastating parts of moving into menopause is that you can finally have sex without the worry of an unplanned pregnancy, yet your vaginal tissue thins and your cervical mucous lessens, so sex is just not as enjoyable. 

Also, because the tissues are thinner, the friction can cause bacteria to adhere to vaginal walls and make you more susceptible to urinary tract infections.  Vaginal steaming is an old practice that helps bring blood flow to deliver healing cells to your lady bits. 

Also, the aromatics released from herbs deliver medicine directly to your tissues.  My favorite suppositories for lubrication are Bezwecken DHEA suppositories.  These soothing cocoa butter-based inserts not only help tissue moisture, but also assist your adrenal glands in testosterone and cortisol production. 

The O-shot is a recent procedure developed by the same Doctor that founded the Vampire Facial.  Platelet Rich Plasma (PRP) helps regenerate tissues when injected into joints or other areas of the body.  With the O-shot, PRP is injected into the G-Spot and has been one of the most profound treatments I have witnessed for incontinence and orgasms. The more that you have sex, the more tissue turnover in your vaginal canal, therefore you will enjoy sex more because your vaginal wall is not too thin or dry to take penetration.  If you are partnered with a woman, be sure to use toys that are penetrative with lubricant to preserve your precious vagina.  

Sleep Hygiene

Sleep becomes elusive as we age.  If night sweats are your ailments, I suggest keeping a sage and rose tincture and a lovely fan. Bamboo sheets may become your favorite linens. Try to get to sleep by 10p, stop screen time by 8p, as blue light interferes with melatonin, the sleep hormone.  If you are having issues falling asleep, get up, listen to an audiobook and try again.  Ask your Doctor about oral Progesterone. 


Food AND Exercise

Eating healthy decreases inflammation.  Ensure you are consuming healthy food daily, which means organic when possible, plant-based and whole foods.  Half of your plate should be vegetables.  The rest, protein and a starch.  I have seen symptoms decrease with a simple shift to an anti-inflammatory diet. Depending on your food intolerances, this could mean cutting dairy, gluten, eggs, and or pork out of your kitchen.  Remove those along with sugar and refined carbohydrates for three weeks and introduce one food  off of that list a week.  Take note.  

The best exercise? The one you enjoy!  Bone density building exercises include weight lifting, HIIT, and pilates.  

If you or someone you know is struggling with this transition, I assure you it is the best worst gift ever!  The healing that can be harvested during this time can go as deep as you are ready.  Finding a holistic practitioner who can order hormone tests, prescribe progesterone (and estrogen if necessary), and nutritional guidance is key.  What are your experiences? What lessons have you harvested as you move through this passage?  


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Boketto’s in-house Naturopath, Dr. Cope, is a trauma-trained physician with a professional background, including a 5 year Medical Degree and Naturopath License from The National University of Natural Medicine, 2 years of clinicals with an ENT Naturopath, 2 years of clinicals in Transgender Medicine, a homeopathic certification from the New England School of Homeopathy, as well as Food Sovereignty Training. Dr. Cope strives to inspire empowerment on all levels, focusing on womxn’s health, libido, fertility, and contraceptive options. She specializes in fasting, digestive health, microbiome restoration, and the fertility journey before and after motherhood. Her line Copesthetic Health Biphasic Collection was designed to help support hormone health. 


Warnecke G. Therapie klimakterischer Beschwerden durch ein Phytotherapeutikum. Med Welt. 1985;36:871-874.

Stoll W. Phytotherapeutikum beeinflusset atrophisches Vaginalepithel: Doppelbindversuch Cimicifuga vs. Ostrogenpraparat.

Therapeuticon. 1987;1:23-31.

Lehmann-Willenbrock E, Riedel HH. Klinische und endokrinologische Untersuchungen zur Therapie ovarieller