Menopause & Perimenopause

Jill Gustafson, CNM is a Certified Menopause Practitioner, a leading menopause expert in Idaho, and a dedicated menopause educator. She is certified by the North American Menopause Society (NAMS), the leading non-profit organization dedicated to empowering healthcare professionals to improve the health of women during the menopause transition and beyond. She provides full spectrum menopause services, including hormone replacement therapy, for Boise, Idaho and surrounding areas. Each woman's experience with menopause is different, so Jill offers personalized menopause services for each patient she sees. Whether you are looking for guidance about what to expect, or are experiencing daily symptoms that pull your focus and joy away - we have solutions.

Menopause Q & A

What is Menopause?

menopause | perimenopause

Menopause is the time in a woman's life when she is finished with ovulating and having periods. Once we reach menopause, our bodies stop producing the hormones necessary to reproduce. The hormones we "miss" the most are estrogen, progesterone, and testosterone. The transition to menopause is not smooth – our hormone levels fluctuate wildly for months or even years, similar to what happens during the hormonal on-boarding of adolescence. These dramatic ups and downs in hormone levels cause uncomfortable symptoms for many women. We can start feeling the effects of hormone changes many years before menopause is reached, on average 3-10 years before menopause is reached! This time period before we reach menopause, when we start feeling the effects of hormonal changes, is called perimenopause. There are many aspects of our lives that can be affected by hormonal changes of menopause- for example, sleep, mood, sex, metabolism, skin, bones, and hair. There are also safe and effective treatments for all of these, which we specialize in at Quantum Women's Health.

Once a woman reaches menopause, which doctors define as 12 consecutive months without a menstrual period, hormone fluctuations and their associated symptoms begin to smooth out.

What happens after I reach Menopause?

menopause | perimenopause

After about four to five years into menopause, women can begin to notice permanent changes to their vulva and genital tract. The cells of the vagina, urethra, and vulva are highly sensitive to estrogen and testorone, and the withdrawal of those hormones naturally results in atrophy of these tissues for most women. This condition is called genito-urinary syndrome of menopause, and it can cause painful sex, vaginal dryness or vaginal atrophy, increased urinary tract infections, and increased vaginal infections.

Quantum Women's Health offers evidence-based treatments and lifestyle counseling for perimenopause, menopause, and genitourinary syndrome of menopause to help women thrive in midlife and beyond.

What is Perimenopause?

The gradual transition between the reproductive years and menopause (the cessation of menstrual periods) is called perimenopause (literally meaning "around menopause"). It is generally a transition that is many years long and can be associated with shorter menstrual intervals, irregular menses, night sweats, and other symptoms. In some women, these symptoms are troublesome enough to need medical intervention. We specialize in support and education for women going through perimenopause - check out our Classes section for more information.

What do Menopause Services include?

At Quantum Women's Health, at your first visit we do a comprehensive review with you on your health history to date, including any lab work, past procedures, or diagnoses. Then we dive into whatever symptoms or concerns you have now, and we create a treatment plan together based on your goals. For many midlife women that includes a full discussion of hormone therapy, the different types, the risk and benefits for you, best practices for optimal results, etc.
Not everyone wants or can use hormones, so there are many herbal, supplement, and lifestyle supports that we can discuss at length if relevant for you. We will also discuss preventative health and anti-aging supports to help you cultivate longevity. If it’s been a long time since you had yearly, preventive labwork or a Pap smear, we can take care of that during your appointment. If you need a mammogram, colonoscopy, bone scan, ultrasound, or other health screenings, we can send those referrals for you at any time once you become a patient.
Usually with the treatments we prescribe for menopause concerns, people start noticing improvements right away in sleep, energy, mood, sexual problems, genito-urinary health, hot flashes, or pain levels. Often there is some trial and error as people get used to their new protocol, and it sometimes takes a couple of months and a few rounds of different doses/formulations to find the optimal regimen for an individual. We always aim to prescribe the most cost-effective medications possible when that’s a concern (it is for most people), and many patients are happy to know that there are a few good hormone therapy options that are FDA approved and covered by standard insurance plans.
Whether or not you need lab work really depends on your symptoms, what kind of treatment you are wanting, and where you are in your hormone journey. If your situation is more complex or we need more data, we offer very affordable pricing on lab work in our office. We also offer DUTCH testing (urine hormone testing) if you need a very comprehensive look at all your hormones.
If we recommend physical therapy or counseling services, we have many colleagues in the Treasure Valley with whom we refer to on a regular basis for sexual and pelvic health concerns. Once we have done our initial assessment, we will help you find the right fit for these practitioners so that you can get the best results for your particular problem.

Who can benefit from Menopause services?

menopause | perimenopause

Everyone who is born with ovaries will eventually enter into menopause. While the average age is 45-55, menopause services are appropriate for anyone who is experiencing symptoms of menopause, such as hot flashes, night sweats, changes in the menstrual cycle, moodiness, vaginal changes, fatigue, weight gain, and more. Even women who do not suffer from uncomfortable symptoms benefit from screenings and wellness checks including in menopause services. These screenings and checks can reduce every woman's risk for the thinning and weak bones of osteoporosis, colon cancer, gynecological problems and other health conditions.

What is hormone replacement therapy?

Hormone therapy (HRT) (also called "bio-identical hormone replacement therapy") are prescription hormones used most often to treat the symptoms of menopause and the genitourinary syndrome of menopause (GSM), which includes vaginal dryness, after menopause. For hot flashes and sleep problems, hormones can be given in pills, patches, sprays, gels, or a vaginal ring that delivers hormones throughout the body—known as "systemic" therapy. For genitourinary symptoms, hormones are given in creams, pills, or rings that are inserted into the vagina. (An approved pill is also available to treat genitourinary symptoms that is not considered a hormone but does affect estrogen receptors, mostly in and around the vagina.)

Systemic hormones include estrogens—either the same or similar to the estrogens the body produces naturally—and progestogens, which include progesterone—the progestogen the body produces naturally—or a similar compound. Another approach to systemic hormone therapy is a pill that combines conjugated estrogens (those in the brand Premarin) and a compound known as a "SERM" (selective estrogen receptor modulator) that protects the uterus but is not a progestogen. Women who have had a hysterectomy (had their uterus or womb removed) can use estrogen alone to control their symptoms, but women who still have a uterus need to take estrogen + progesterone together.

HRT is very effective for insomnia, brain fog, hot flashes, and muscle/joint pain, and when it is taken within 10 years of your Final Menstrual Cycle there are other benefits, such as prevention of osteoporosis, slowing the progression to diabetes, and reduced mortality from heart attacks and strokes. Newer studies have also shown that women who take HRT may have a lowered risk of dementia as well.


Vaginal estrogen therapy for GSM after menopause is administered in the vagina and is effective for both moisturizing and rebuilding tissue. Very little goes into blood circulation, so the risks are far lower.

Book a menopause consultation with our menopause specialist to discuss your individual risks and preferences with us to determine whether hormone therapy or alternatives, including FDA-approved non-hormonal therapies, are right for you.

Are what are the risks of HRT?

For most women, the benefits of HRT far outweigh the risks. There are very few true contraindications for HRT. Unfortunately in mainstream culture, the risks of HRT have been far overstated and many providers themselves are not well-educated about modern hormone therapy. As a result, many women have been discouraged from using these critically important treatments. We are trying to change that!

Blood clots: In general, transdermal (patch) estrogen is preferred over oral (pill) estrogen because there is a slightly increased risk of blood clots when you take estrogen in pill form. The increase in risk of a blood clot when taking oral estrogen for HRT may be more significant for some women than others, especially if you have underlying risk factors for a blood clot such as hypertension or immobility. Fortunately, there is no elevation in risk of a blood clot when estrogen is used transdermally - as in patches, gels, or sprays. Many women have been told that estrogen causes blood clots, but when taken transdermally, these risks are nullified. The risks of a blood clot for everyone do go up as we age, so it is important to speak with your provider about your individual risk of a blood clot and take appropriate precautions when flying or undergoing surgery, regardless of whether you take HRT or not.

Endometrial cancer: It is well known that estrogen causes growth of your uterine lining, which if it unchecked, can cause heavy vaginal bleeding. Indeed, when you start taking estrogen after a period of time of not cycling, it is common to experience some mild cramping and tenderness in your uterus and breasts for the first couple of days after starting estrogen. These side effects usually subside quickly once your body becomes adjusted to the medicine. However, if you have a uterus and you are taking estrogen for HRT, it is critically important that you always take progesterone in addition to your estrogen. This is because progesterone slows the growth of the uterine lining. If unchecked, estrogen will cause overgrowth of the uterine lining which in some women can lead to endometrial cancer. Fortunately, this is very easily prevented with correct use of the medications. For many women, a Mirena IUD is an easy way to ensure that you are getting the progesterone you need to counter the estrogen in your HRT. Another option is to take oral progesterone for at least 15 days out of the month - this is usually enough to ensure that you are balancing your estrogen adequately with progesterone. Most women do enjoy the health benefits of progesterone (improved sleep, reduced inflammation,  balanced moods), and so many menopause experts recommend you take oral progesterone every day as part of your HRT regimen. In summary, the risk of endometrial cancer can be eliminated with correct usage of your HRT. That being said, sometimes your body can shift in how it processes hormones over time, so it is critically important to promptly report any increased vaginal bleeding after menopause to your provider.

Breast cancer: Many studies have shown that estrogen by itself does not appear to cause an increased risk of breast cancer for women who have never had breast cancer. Progesterone, however, does appear to carry a slightly increased risk for breast cancer for post-menopausal women after 5 years of use. However, this increase in breast cancer risk is very slight. It is roughly equal to the increased risk of breast cancer that is associated with lifestyle factors, such as drinking 7 or more servings of alcohol per week. When discussing health risks of HRT, it is important to keep in mind that the biggest killer of women is cardiovascular disease, not breast cancer. Many studies have shown that women who take HRT within 10 years of their final menstrual cycle have a decreased risk of overall mortality from cardiovascular disease. It is also true that all women in the United States have a baseline risk of breast cancer, and that individual risk varies depending on age, family history, and lifestyle factors, Everyone's situation is unique, so your decision about whether or not to take HRT is best discussed with your provider in the context of your overall health history and goals. Statistically speaking, the most effective ways to reduce your risk for breast cancer are to avoid smoking, reduce alcohol consumption, avoid exposure to environmental estrogens in chemicals and plastics, and reduce your body weight if overweight or obese. The best way to prevent death from breast cancer is early detection - which is a very good reason to keep up with regular breast exams and mammograms.

Is there a test for Menopause?

There is no singular "menopause test" that works for every person, as every person's journey to menopause is unique. There are specific clinical signs of reproductive aging, such as changes in your menstrual cycles and the presence of classic symptoms (hot flashes, insomnia, vaginal dryness, brain fog, etc), which we use to help us identify which stage of the menopause transition you are in. There are also certain lab tests that can tell us if you are in menopause. Depending on your specific situation, there are blood tests, saliva tests, or urine tests that look for the presence of certain hormones in your body and help identify if you have a hormone imbalance. Taken together with a comprehensive health history, all of this information helps us identify which stage of menopause you are in, and which treatments will be most effective for you.

What are the stages of Menopause?

Everyone who is born with ovaries will eventually go through puberty (ovaries begin producing hormones), followed by the reproductive stage (ovaries capable of sustaining a pregnancy), followed by menopause (ovaries stop producing hormones). Menopause is usually a gradual progression for most people, although in some cases the onset of menopause can be abrupt. You are more likely to have an abrupt onset of menopause if you have gone through surgery to remove your ovaries, chemotherapy or radiation that damages the ovaries, or if you take certain medications (ex. Lupron, GnRH agonists, or aromatase inhibitors) that induce temporary menopause symptoms in order to treat certain diseases such as infertility, breast cancer, or endometriosis.  Smoking, other health conditions, or severe stress can also lead to an abrupt menopause in some cases.

For everyone else, the progression to menopause starts in midlife (average age 41) and follows a predictable pattern of signs and symptoms.

Stages of Gradual Menopause:

  • Very Early Perimenopause (cycle length decreases, mood changes, and other subtle symptoms start approximately 10 years before the Final Menstrual Cycle, or FMC)
  • Perimenopause (skipping periods, heavier bleeding, insomnia, hot flashes, mood changes, joint and muscle pain, brain fog start approximately 3-5 years before the FMC)
  • Menopause (the final stage is reached after 12 months with no cycles; symptoms slowly improve over 1-3 years, but genitourinary changes worsen after the FMC if not treated with with vaginal estrogen)

The average age when women reach their Final Menstrual Cycle in the United States is 51. The average age when very early perimenopause symptoms start is 41.

How do I cope with hot flashes?

menopause | perimenopause

Hot flashes occur in up to 75% of women, and although most women experience them for 6 months to 2 years, some women may experience bothersome hot flashes for 10 years or longer. Hot flashes can be especially bothersome if they disrupt your sleep, night after night, for years on end.

Lifestyle changes, including keeping core body temperature low, maintaining a healthy body weight, refraining from smoking, exercising regularly, and practicing relaxation techniques, may provide some relief.

Nonprescription remedies such as soy, isoflavone supplements, black cohosh, vitamin E, and omega-3 fatty acids are generally low risk, but randomized-controlled trials show that their efficacy is like a placebo. This means that you may expect some relief from taking these over-the-counter remedies for about 3 months, but not much longer than that.

Balancing your hormones with hormone replacement therapy has been shown to be the most effective treatment for vasomotor symptoms and sleep problems in midlife. There are many options and there is no one-size-fits-all approach. Hormone balancing must be completely tailored to the individual, taking into account their unique health history, health goals, and previous experiences.

Book your menopause consultation to learn how you can find the best tools for your unique situation.