Ep. 62 Perimenopause and Menopause: What You Need to Know With Dr. Kelly Casperson

Menopause, Reframed: Dr. Kelly Casperson on Brain Fog, Bone Health, and the Case for Proactive Hormones

Why This Conversation Matters Now

Perimenopause is finally having its moment—and Dr. Kelly Casperson (urologist, author, and host of You Are Not Broken) wants women to have the data—and the options—to navigate it confidently. In this episode of Insights from the Couch, we unpack what perimenopause actually is, why “sex hormones” do far more than sex, and how proactive hormone therapy can protect your brain, bones, sleep, mood, and long-term health.

Perimenopause 101: It’s Not Just Hot Flashes

Menopause is defined as 12 months without a period, but that date stamp misses the bigger picture: a profound hormonal transition that starts years earlier. Perimenopause is a clinical diagnosis—there’s no single lab or scan that stamps it “official.” Classic hot flashes affect many women, but not all. Brain fog, word-finding trouble, 3 p.m. energy crashes, and sleep disruption are just as common—and just as real.

Big reframe: periods can continue and you can still have hormone deficiency symptoms. Lack (or presence) of a bleed isn’t a reliable “you’re fine” signal.

“Sex Hormones” Do Brain Work

Calling estrogen and testosterone “sex hormones” undersells their job description. They’re neuroactive—supporting cognition, mood, and sleep quality—and they’re also involved in muscle, joints, eyes, oral health, and metabolic function. That’s why so many women report “I feel like myself again” when hormones are optimized.

Timing Matters: Prevention Beats Catch-Up

Hormones are excellent at preventing disease; they’re less effective at treating entrenched disease. Bone loss, for example, accelerates in the two years before the final period. Sleep declines can precede hot flashes. Waiting until symptoms are severe or bone density has already declined is the classic “come back when you’re sicker” model. Dr. Casperson argues for informed, proactive decisions—sooner conversations, earlier baselines, and individualized choices.

A Smart Baseline Plan

• Ask for a DEXA scan (bone density) earlier than the default. It’s inexpensive in many markets and gives you a starting point.

• Track sleep quality (wearables can help) and note cognitive changes, mood shifts, and exercise recovery.

• Discuss transdermal estradiol and oral micronized progesterone with a knowledgeable clinician if you’re symptomatic—or if you want to explore preventive benefits.

Testosterone in Women: Not “For Men Only”

Women make testosterone, and many experience a gradual, decades-long decline. It supports motivation, mental clarity, muscle maintenance, energy, and libido. Despite decades of clinical use, access barriers remain (no FDA-approved female-dose product yet in the U.S.), but female-dose transdermal approaches (compounded creams or micro-dosed male products) are common, effective, and typically well-tolerated.

What About Pellets?

Pellets can create big peaks and slow tapering lows. Some women love them; others chase the “high” and see side effects like hair changes when the rate of change is abrupt. Dr. Casperson’s pragmatic advice: earn the pellet—start with physiologic, low-dose transdermal and titrate thoughtfully before considering a long-acting route.

Clearing the Fog Around HRT Safety

If you were told hormones are categorically dangerous, you likely heard a simplified echo of early 2000s headlines. Modern practice favors transdermal estradiol (patch/gel) and micronized progesterone, which have different risk profiles than the older oral combinations that grabbed headlines years ago. For many women, transdermal estradiol does not raise stroke or clot risk, and vaginal estrogen is considered low-dose, local “skincare for the vulvovaginal tissues”—safe at virtually any age and especially useful for dryness, pain, and recurrent UTIs.

Quick nuance: “Hormones” is not a single thing. Local vaginal estrogen, systemic estradiol, progesterone, and testosterone each have distinct roles, doses, and safety profiles. A good clinician treats them like a menu, not a monolith.

Brain, Bones, and Longevity: The Bigger Why

The goal isn’t only symptom relief—it’s functional longevity. Think:

• Brain: better sleep architecture, mood support, cognitive steadiness.

• Bones: reduced fracture risk; hips keep women out of hospitals.

• Metabolic health: signals around insulin sensitivity and inflammation.

• Sexual health: blood flow, lubrication, comfort, and desire—core to quality of life.

Women who started and stayed on hormones in midlife often describe aging differently than peers. It’s not about chasing youth; it’s about preserving function.

If You’ve Had Breast Cancer: Individualized, Not Exiled

There are ~4 million breast cancer survivors in the U.S., and many are suffering without help. One critical distinction: food doesn’t cause monsters, but monsters eat food—hormones may fuel certain tumors, but that doesn’t mean hormones caused them. Decisions after cancer are individualized risk-benefit calls with an expert. Importantly, vaginal estrogen is widely considered safe and under-utilized in survivors for quality-of-life issues. Testosterone may be breast-protective in some data, but this area deserves more research and specialist guidance.

How to Find a Clinician Who Actually Knows This Stuff

Look for a menu mentality (transdermal, oral, local, testosterone options) rather than a one-trick model (e.g., “pellets only”). Online menopause clinics can expand access; local specialists in menopause and women’s sexual health often understand testosterone, pelvic health, and nuanced HRT protocols. Ask direct questions: What are my actual risks? What are the alternatives? How will we monitor and adjust?

Advocate Like a Pro: Questions to Bring to Your Appointment

• Can we review transdermal estradiol and micronized progesterone options for sleep, mood, and bone protection?

• What’s your approach to testosterone for cognitive energy, muscle, and libido? Do you use female-dose transdermal?

• May I get a DEXA scan baseline now?

• If you’re concerned about risk, what study and which numbers are you referencing for someone like me?

• Can we consider local vaginal estrogen regardless of systemic HRT?

The Takeaway: Don’t Wait for the Cliff

Perimenopause isn’t a single symptom or a single lab value. It’s a whole-system transition—and you deserve clear information and a full toolkit. Whether you’re drowning in brain fog or quietly noticing sleep and stamina slipping, earlier, personalized conversations can change the trajectory of your 50s, 60s, 70s, and beyond.

About Our Guest

Kelly Casperson, MD is a urologist, author of You Are Not Broken, and host of the You Are Not Broken podcast. Her next book, Menopause Moment, arrives September 2025. Find her on Instagram @kellycasperson.md and at kellycaspersonmd.com.

Listen Now: Ep. 62 Perimenopause and Menopause: What You Need to Know With Dr. Kelly Casperson