Peri-panic: When Normal Gets Medicalized

Today a 35-year-old patient came to my office for the sole purpose of creating an “action plan” (her words, not mine) for her perimenopause. I stared at her in semi-bewilderment because her periods are monthly, and her only symptoms are fatigue, insomnia, and brain fog (she has a 9-month-old and a toddler). Of course, I understand her instinct- as humans, we tend to adhere to a principle called Occam’s razor; we search for a simple, unifying diagnosis to explain our otherwise disparate symptoms.

In recent years, perimenopause has become the hottest topic in health media and wellness circles and the explanation du jour for otherwise seemingly inexplicable symptoms in women.  Celebrities, influencers, and health brands are rallying behind the cause, urging women to recognize, diagnose, and treat the symptoms of estrogen fluctuations. This rise in attention has done crucial work in dismantling the shame around women’s midlife health. But as perimenopause moves from obscurity to ubiquity, do we risk swinging the pendulum too far? Not every ache, mood swing, or disrupted night of sleep should be interpreted as a sign of hormonal decline. In our eagerness to validate women’s experiences, we may be treating Occam’s Razor as a law rather than a useful tool.

Throughout history (and certainly my years as a physician), society has pathologized fatigue and brain fog.  One of the earliest and most enduring fictitious conditions was “vapors,” a diagnosis popular in Europe from the Middle Ages through the 19th century. Women were thought to suffer from vapors, an ill-defined affliction supposedly caused by emanations from the womb rising into the brain. Typical symptoms of ‘vapors” included dizziness, fatigue, forgetfulness, and a general lack of vitality.  

In the late 19th century, a new diagnosis emerged: neurasthenia. Coined by an American neurologist George Beard in 1869, neurasthenia was thought to result from the depletion of "nervous energy" due to overstimulation by modern life. Sufferers reported fatigue, poor concentration, anxiety, and insomnia. It was seen as a disease of the “civilized”, disproportionately affecting middle-class women overwhelmed by societal expectations. Treatments included enforced bed rest, electric stimulation, and admissions to sanitariums.

In the 1970s, another controversial diagnosis, "T3 deficiency," took root.  To this day, it is promoted by some integrative practitioners who argue that standard thyroid tests- which usually measure TSH (thyroid stimulating hormone) and T4 (thyroxine)- miss a subset of patients who have normal lab values but still suffer from fatigue, brain fog, weight gain, and depression. These practitioners often prescribe liothyronine (T3 hormone) in addition to, or instead of, conventional thyroid replacement therapy despite minimal safety or efficacy data.

The 1990s and early 2000s saw the emergence of “adrenal fatigue,” a diagnosis never accepted by endocrinologists like myself but popular in alternative health communities. Proponents claim that chronic stress overworks the adrenal glands, leading to fatigue, poor concentration, and mood swings. Studies have shown no evidence that adrenal glands function abnormally in these patients.

Meanwhile, our new nominee for Surgeon General, Casey Means, is so convinced that insulin resistance is the root cause of all things evil (fatigue, headaches, DEATH) that she dropped out of a six-year residency just months before graduating to devote her life to tackling this hidden enemy and restoring health not only to the mind, body and spirit but also “the planet”! Insulin resistance clearly exists in a subset of patients but the restoration of insulin sensitivity is unlikely to result in world peace.  

Over the past 20 years of doctoring, I’ve witness countless dubious conditions born out of a desire to give shape to invisible, diffuse suffering. Perhaps, how we explain our exhaustion says as much about our society as it does about our bodies.

While perimenopausal symptoms are clearly not fictitious, we are diagnosing it with reckless abandon in women who are nowhere near that particular stage of life. This catch-all framing is problematic. It risks simplifying complex medical, psychological, and lifestyle factors into a single explanatory cause. Not every woman in her late 30s or early 40s is in perimenopause. Many won’t experience significant symptoms until their late 40s or early 50s. Others will never experience discernible symptoms at all. Yet the current discourse often implies that if you aren’t “tuning in” to your perimenopausal state- and acting on it with supplements, bioidentical hormones, or lifestyle overhauls- you’re neglecting your health. This can lead to unnecessary anxiety, self-monitoring, and in some cases, overtreatment.

Part of the issue is that the concept of perimenopause, while medically valid, is incredibly broad and poorly defined. Hormonal fluctuations can begin a decade before menopause, but they are not linear and not always symptomatic. There's no simple test to diagnose perimenopause (labs typically remain normal until periods are absent for several months), and its symptoms overlap with countless other conditions—stress, thyroid issues, sleep disorders, depression, and more. By focusing so intently on perimenopause, we may miss these other root causes, or worse, dismiss women’s concerns as “just hormones”.

There’s also the commercial dimension to consider. The wellness industry has eagerly latched onto the perimenopause conversation, launching products, programs, and platforms tailored to “hormonal balance.” While some of these offerings may be helpful, many are based on thin evidence and designed more to sell than to heal.

After an hour with my 35-year-old patient, we developed an action plan but not the hormone-infused one she originally envisioned. Instead, we discussed self- care, sleep hygiene, dietary changes, hobbies, and mental health. Women deserve informed, personalized care that respects lived experiences and addresses health needs at every stage of life. But we also need space for complexity. Sometimes a mood swing is just a bad day. Sometimes fatigue stems from burnout, not estrogen decline. We should celebrate the progress we’ve made in bringing perimenopause into the open, but we must be wary of turning awareness into a monolith. Health is not one-size-fits-all, and the solution to years of underdiagnosis is not overdiagnosis—it’s nuance, balance, and trust in the diversity of women’s experiences.