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Rage, fatigue, mood swings, memory loss, hot flashes, itchy ears, inability to sleep, loss of libido, hair thinning, depression, weight gain, sore knees, night sweats, incontinence.

These are all symptoms of perimenopause — or possibly just occupational hazards of midlife.

As Generation X and millennials ease into their 40s and 50s, they are ready to shake off the stigma around menopause and the time leading up to it — called perimenopause — in favor of embracing treatment. An army of influencers are pushing diet supplements and other products promising to help women through this phase.

But how do you know if you are even in perimenopause?

Unlike menopause — defined by the cessation of menstruation — perimenopause can be sneaky and hard to pinpoint. There’s no one definitive test for it, and disentangling the symptoms from other factors can make it hard to treat. Here’s how to sort out your symptoms and consider your treatment options.

Be persistent in seeking care, and consider a specialist 

When Michelle Rockwell started struggling with sleep, perimenopause was not the first thing her primary care doctor suspected. “ They said, ‘You’re too young,” says Rockwell, who is now 40, and started seeking medical care a year ago. “It’s easy to discount the symptoms. Doctors will say ‘It’s just stress or whatever,'” she says.

Rockwell did not dispute that her life was stressful — she was working full time as a forensic scientist, raising a daughter, and competed in powerlifting. But she says something felt drastically wrong.

“I literally had this feeling of like, I don’t know who I am anymore,” she says. “I was like, I don’t recognize myself. I’ve since come to figure out that we have these levels of hormones and they affect your brain.”

Rockwell saw two different providers — a primary care doctor and a holistic practitioner — before she found a doctor online who specializes in menopause care. The Menopause Society provides this online database of doctors who are trained and certified in treating menopause and perimenopause.

After much course correction and fine tuning with a specialist, Rockwell is now using hormone therapy, which she says has helped significantly. “ I feel better now than in a long time,” she says.

General practitioners often aren’t afforded the time to thoroughly evaluate their patients for perimenopause, says Dr. Monica Christmas, associate medical director of the Menopause Society.

Specialists, she says, not only have more knowledge about this condition but are also not subject to the same time constraints.

Accept the uncertainty of it all 

Perimenopause is often thought to be a problem of a deficit of estrogen, but that is not necessarily the case, says Christmas. The transition into menopause, she explains, is characterized by fluctuations in hormones, which is why many people’s experiences can be inconsistent and rocky.

“ Perimenopause is the most tumultuous time for many people,” says Christmas.

Once people get through this phase and into menopause, when their ovaries aren’t making any estrogen anymore, says Christmas, “many actually feel better.”

Moreover, she points out, it’s impossible to disentangle perimenopause from the overall process of aging, which can be a time of significant physiological change. Add to that the pressures of career, family, caretaking responsibilities, financial stress — and midlife can be a roller coaster of uncertainty and stress.

Christmas cautions that a certain amount of acceptance of this chaos is necessary for getting through it. She says some of her patients tell her: “The fact that you told me that these mood swings and this brain fog is real, that I’m not imagining it, that’s actually enough for me.'”

Others will go on to pursue treatment options. “Some people have very few symptoms, if any at all,” says Christmas, while others “might have every possible symptom that you could think of. Most of us are somewhere in between.”

Get tested for other conditions 

Some clinicians suggest a strategy of first testing for a range of other conditions before considering whether perimenopause is the culprit.

“The 40s are a time in life when a lot of different autoimmune diseases can begin to show up,” says Nanette Santoro, a gynecologist in Colorado who treats menopause. Often, she says, other conditions can have similar symptoms to perimenopause — many of them easier to diagnose.

“Quite often I’ll do a miniature workup to make sure there’s no signs of early diabetes, which happens in this age group,” says Santoro. Thyroid problems, she says, can also make an appearance during this time, as can rheumatoid arthritis, osteoporosis, hypertension and fibromyalgia.

Mental health concerns like anxiety and depression are also worth considering as well.

Santoro says she’s often more inclined to test for and treat these conditions than she is to measure hormone levels, which isn’t necessarily that helpful. “ If it’s not well timed to the menstrual cycle, you may get misleading tests,” she says, “and even then, you still may get misleading tests because they vary from month to month.”

Understand treatment options 

Hormone therapy to treat especially troubling symptoms like severe hot flashes and crippling mood swings has been a subject of much debate in recent decades. While many providers who treat menopause say it can be helpful or even life changing for some patients, many stress that more research is needed.

“ I would love to be able to say that hormone therapy reduces cardiovascular risk or cognitive decline later on in life,” says the Menopause Society’s Christmas, “or all the miraculous anti-aging properties that people are claiming.”

Some evidence suggests hormone therapy could have long-term benefits, she says, but research is not definitive enough to recommend it for all women in perimenopause.

In 2002, the Women’s Health Initiative study halted hormone therapy among its participants due to concerns about increased cancer risk and stroke. But since then, scientists have reassessed the data and new types of hormone therapy have become available.

As a result, many experts now say past concerns about these elevated risks were overblown.

Still, says Christmas “ it’s a low risk, but it’s not zero.” Clinicians warn that people need to take into account things like family history and other factors for cancer when considering hormone therapy.

Hormone therapy also does not work for everyone.  ”I have patients who try hormones for a couple of months and come back and say — we’re doing something else,” says gynecologist Santoro. Some patients, she says, complain of weight gain, breast tenderness or “all kinds of annoying PMS symptoms.”

Hormone therapy may be especially beneficial for those who reach perimenopause earlier in life. “It has been helping tremendously,” said Krista Russell-Adams, who hit perimenopause at the age of 37 and experienced anxiety, brain fog, persistently itchy ears and darkening of skin, called melasma.

Christmas says there are other pharmaceutical options that she prescribes patients to address specific symptoms. Frequent, heavy bleeding during periods for example — which can lead to anemia and fatigue — can be addressed with birth control or an IUD, which may even stop their periods.

“I think of it as a really nice way of cheating the menopause transition,” she says.

Embrace healthy aging habits

Some symptoms associated with perimenopause may have more to do with the aging process. Research suggests that in both men and women, there are jumps in aging that happen around the ages of 45 and 60. “A lot of women will notice a change in metabolism,” says Santoro. “It’s not all menopause.”

Because of these changes, says Santoro, it’s especially important to double down on healthy habits including diet, exercise — especially resistance training, for maintaining muscle — and healthy sleep. “ Pretty much what your mother told you — just do more of it,” says Santoro.

Christmas advises her patients to “be very meticulous about what we’re fueling our bodies with. As we age, we’re not getting another one.”

People who may have been able to “get away with not exercising as much or eating whatever we wanted in our younger years” may have to make some significant changes to maintain health, she says.

Those kinds of behavioral adjustments, she says, can have profound impacts “that just giving somebody a pill” can’t match.