What I Always Check for My Patients Entering Perimenopause
Perimenopause and women’s hormones
Let's face it, things change as we enter perimenopause. I have so many conversations with friends and my patients, and they all go somewhat like this: I am doing everything right, I work out, I eat clean, and I meditate, but I can't seem to shed these few extra pounds. This conversation became the norm in my practice, and I always remind my patients they are not alone! I always check for insulin resistance, whether there is a family history of metabolic syndrome and diabetes, or if this is something new that surfaced. Insulin resistance means your cells have trouble using insulin, so your body needs more of it, increasing your risk for metabolic problems.
Checking for insulin resistance in women entering perimenopause is crucial due to the profound hormonal changes and increased risk of metabolic disturbances during this life stage. Here's why:
1. Hormonal Changes Drive Increased Risk
As women approach perimenopause, levels of estrogen and progesterone fluctuate and then decline, reducing insulin sensitivity. Estrogen, in particular, is protective against insulin resistance; its loss leads many women to become more insulin-resistant—even those with healthy lifestyles or body weight.
These changes contribute to a higher likelihood of accumulating abdominal fat, which is itself a risk factor for cardiometabolic disease.
2. Connection to Metabolic Syndrome and Cardiometabolic Risk
Insulin resistance in this period overwhelms pancreatic insulin production, raising blood sugar over time and increasing the risk for prediabetes, type 2 diabetes, non-alcoholic fatty liver disease, and metabolic syndrome.
Undiagnosed insulin resistance can silently progress to overt disease, with cardiovascular disease risk rising sharply after menopause for women.
3. Worsening of Perimenopausal Symptoms
Insulin resistance itself can aggravate common perimenopausal complaints, such as weight gain (especially centrally), brain fog, fatigue, hot flushes, and heavy periods. It can also interfere with hormonal signaling, increasing inflammation and worsening sleep disturbances and mood symptoms.
Addressing insulin resistance often improves the spectrum of perimenopausal symptoms and aids in achieving/maintaining metabolic flexibility and weight control.
4. Screening is Needed Due to Silent Onset
Many women with insulin resistance have few or no symptoms early on. Traditional (and outdated) metrics like BMI do not capture risk for all; lean women with genetic or epigenetic predispositions may also be affected.
Early screening can identify risk and enable timely intervention—even before glucose is overtly elevated.
5. Therapeutic Implications
Early identification allows for targeted interventions: lifestyle changes (nutrition, exercise) and stress management. Emerging research shows hormone therapy may reduce insulin resistance in healthy perimenopausal and postmenopausal women, especially when started early in the transition.\
Precision medicine approaches to female health recognize the value of individual risk assessment, including a history of PCOS, PMS/PMDD, and family history of diabetes or metabolic disease.
The hormonal milieu of perimenopause makes women more vulnerable to developing insulin resistance, with wide-reaching effects on both present quality of life and future cardiometabolic health. Proactive screening and management of insulin resistance during this transition are central to optimizing health outcomes and reducing long-term disease risk.
Interested in learning more?
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Be well,
Dr. Talina Hermann
