At 48, Alison Gary was waking up at 3 AM most nights, sometimes soaked in sweat. She was struggling to finish sentences, losing track of her work, and getting hurt doing workouts she had done for years. She suspected perimenopause. It took three clinicians before someone saw the whole picture.
Alison is a 51-year-old working mom, wife and the creator behind Wardrobe Oxygen, which she has run since 2005. On Seen & Heard, a series from Perry's Perimenopause WTF? podcast, she tells her story to Dr. Harita Raja, a women's psychiatrist, Menopause Society certified practitioner and founder of Bethesda Women's Mental Health. Together they talk about perimenopause and mental health, brain fog and ADHD, and what it took for Alison to feel like herself again.
Listen to the full episode, or read the highlights below.
The symptoms that didn't add up
It started around 2021, during the pandemic. Alison, her husband and their teenage daughter were all working and schooling from a small row house, and, in her words, the house started to feel very small. Her relationship felt strained, work felt harder, and she didn't recognize her own body.
The list grew: trouble falling asleep, waking at 3 AM, night sweats, hot flashes, racing thoughts, brain fog, even itchy ears. The biggest change was joint pain. Alison had gone to the gym five days a week before the pandemic. Now she injured her back, her knee and her ankle, and later tore her meniscus and her Achilles. Every injury took a long time to heal.
"I was having a hard time finishing sentences. I was having a hard time looking people in the eye. I was not understanding what was going on with my body. It felt like it was breaking down."
Three appointments, three different answers
Alison brought her list to her gynecologist at her yearly well-woman visit. The gynecologist focused on the racing thoughts and poor sleep and set the rest aside. Like many women in larger bodies, Alison was told she would probably feel better if she lost weight, even though she worked out regularly. She was referred to the practice's menopause specialist.
That specialist decided it wasn't perimenopause. Alison left with a prescription for an antidepressant (bupropion), a suggestion to try couples therapy, and the title of a book. In the parking lot she looked it up: it was about assertive speaking.
Dr. Raja called it what it was: being "siloed into one sort of group of symptoms." She explained that women who have had depression before are at much higher risk of depression in perimenopause. Alison had a family history but no history of her own, so depression wasn't the only thing worth looking at.
"We have to consider reproductive stage as a vital sign. It is so important to know where a woman is in her cycle, and what's new, what's changed. It's usually multifactorial. There's not one size fits all here." — Dr. Harita Raja
Her message to other clinicians is simple: if you don't know perimenopause, that's okay, but refer to someone who does.
Finding a provider who saw the whole picture
Alison went back to her research. She found The Menopause Society (then called the North American Menopause Society), searched for a practitioner by zip code, and found a midwife in a nearby city who focuses on women in midlife. Insurance didn't cover the visit. By then, she says, she was willing to pay anything to find an answer.
The first appointment lasted about an hour and a half. The midwife asked about everything, not just the symptoms Alison thought might be hormonal, and gave her a journal to take notes in.
"I was crying in the car afterwards because it was finally that somebody got it."
Together they started hormone therapy, with an estrogen patch and progesterone, and later added testosterone. They checked in again after three months and have adjusted the plan over the years, including a switch to a hormonal IUD. Within a couple of weeks, Alison noticed her sleep first: it was easier to fall asleep, she often slept through the 3 AM wake-up, and her dreams were less intense. Over time she was able to recover from her injuries and work out again.
She kept taking bupropion at the same time. Dr. Raja says that is a common misunderstanding: treatment is not always one thing or the other. "Hormones are amazing. They're not for everyone and they're not to treat everything. But [they are] a very important part of our toolbox. But so are other medications, therapy" and other approaches.
This is Alison's own plan, worked out with her clinicians over several years. It is not a recommendation for anyone else. A provider can help you find what fits you.
Grief in midlife, and making space to feel it
In 2023, Alison's mother died unexpectedly at 80. Alison was raising a teenager, running a business and serving as executor of the estate, so she kept going and didn't grieve. Seeing a therapist gave her that space.
Dr. Raja sees this often: women lose a parent, or slowly lose one to dementia, at the same time their own bodies are changing. Midlife can bring several big transitions at once, and each one makes the others harder.
Perimenopause and ADHD: when the old systems stop working
Alison always suspected she had ADHD, but as a Gen X woman she was never tested. A high school teacher helped her build systems, like an agenda book and a daily journal, and they carried her through her career. During the pandemic those systems fell apart. She couldn't finish a sentence, let alone a task, and she would hyperfocus on the wrong thing, once spending 16 hours building a capsule wardrobe when other work was waiting.
Dr. Raja explains that ADHD is a neurodevelopmental condition, and it is a misconception that you must be diagnosed as a child. In midlife, women's roles and responsibilities pile up, and their ability to manage symptoms they once coped with goes down. Part of that is stress, and part is biology: Dr. Raja points to brain-imaging research by neuroscientist Dr. Lisa Mosconi showing changes in the brain during perimenopause and after menopause that can help explain shifts in focus, planning and memory.
Alison found a therapist who works with women with ADHD. Her therapist was a psychologist and couldn't prescribe, so Alison passed updates between her therapist and her midwife. "Even though they didn't know each other, we kind of all worked together as a team." They tried different antidepressants. One left her so numb that she noticed it in her work and her friendships, and she changed course. Earlier this year she started ADHD medication, and found she could stay on track, close the laptop at the end of the day and keep the parts of her life separate.
"I am at a place now where I feel confident in my brain and my body again."
Alison grew up wary of medication and was afraid of the side effects she had seen in her father. Now she talks about it openly, because she knows other women worry that medication will numb them or dull their creativity. Dr. Raja's point: feeling numb is a side effect, not the goal of the medication, and it is worth raising with your clinician.
Siloed care and the "just lose weight" answer
For her injuries, Alison saw an orthopedist, used telehealth for her ankle and saw a chiropractor for her back. None of them asked whether hormones might play a part. Most told her to lose weight.
"You don't know how I eat. You don't know how I work out. You're not even asking me these things. And then, hey, look, I am a woman in midlife."
Her midwife was the one who connected her joint pain to perimenopause. Dr. Raja calls this the "primary care of perimenopause": one clinician who puts the whole picture together, so a woman doesn't feel broken or feel she has to see ten providers on her own. Today, she says, that kind of care mostly goes to women who know to look for it. It should be the standard.
Alison's advice if you think perimenopause has started
- Look it up and listen to real women. Hearing others describe the same thing shows you that you're not alone, you're not imagining it, and some symptoms have simple fixes.
- Don't stop at the first answer you find. Many businesses now profit from perimenopause. Alison read Facebook groups and Reddit and followed several experts, rather than sticking with one person who seemed convincing.
- Find a clinician who knows perimenopause, and do it early. Her only regret is not searching sooner. Alison used The Menopause Society's practitioner search. In the Perry directory, every provider has completed the Perry Academy Perimenopause Certificate®, and you can search by specialty, state or virtual visits.
- Share what helped you. Alison's two best friends now see the same midwife. "When you find someone good, you share it."
- Ask for help. "It's okay to ask for help. It's okay to get therapy. It's okay to get medication. And it doesn't have to be permanent."
What Dr. Raja wants clinicians to know
Listen to your patient. "Just taking those two minutes to listen goes a long way." Ask where she is between puberty and menopause, because it tells you a lot about what she is going through. And remember that every woman's experience is different: some sail through perimenopause, others find it the hardest thing they have faced.
Like puberty and pregnancy, perimenopause is a big hormonal change. It is a stage you pass through, and there are tools to help. As Alison puts it: "It's not in our heads."
Keep reading
This article shares one woman's experience and a clinician's general perspective. It is not medical advice.
Topics: Beauty, Brain Fog, Essentials, Food & Fitness, Joint Pain, Lifestyle, Medical, Mental Health, Real Voices, Sex, Sleep, Symptoms, Treatments, Well-Being, Wellness
