16: Why ‘Normal’ Labs Don’t Mean You’re Fine: Metabolic Health in Perimenopause Part 1

Introduction: The Crinkly Paper Gown Moment

Picture this: You’re sitting in that crinkly paper gown, waiting for your yearly lab results. Same healthy-ish lifestyle, same general habits, maybe even eating better than you were five years ago.

Then your doctor walks in with That Look and starts talking about statins and pre-diabetes like you’ve been living on donuts and Netflix for the past decade.

What. The. Hell.

If this sounds familiar, you’re not alone and you’re definitely not crazy. You just got blindsided by perimenopause, and nobody bothered to give you the memo.

I’m Megan Pfiffner, and this is Mornings with Megan, where we talk about what’s actually happening in your body during perimenopause – without the BS.

Today we’re diving into metabolic health and why perimenopause is the metabolic inflection point that nobody warned you about.

The Setup Nobody Told You About

Here’s something that should make you angry:

In your 20s and 30s, you had less heart disease than men. Estrogen was protecting you. Your lipids looked good, your blood pressure was fine, your glucose was stable.

And because everything looked fine, many of you probably stopped seeing your doctor regularly after your last child was born – if you had children – or sometime in your late 30s. There wasn’t a reason to go, right?

Then you hit your 40s and suddenly – seemingly out of nowhere – you have high lipids, high blood pressure, high glucose.

Your doctor acts like you’ve been doing something wrong. But you haven’t changed anything.

What happened?

Women catch up to men in heart disease risk by the end of menopause. We end up with the same lifetime rate of cardiovascular disease as men – we just get there differently, and we get there faster once perimenopause starts.

And here’s what nobody prepared you for: Perimenopause is like pregnancy – it’s a physiological stressor.

If you haven’t been prepped for it – meaning if you aren’t metabolically well-managed before perimenopause – things can go sideways fast. Your body wasn’t prepared for the stressor, so it struggles more.

And life stage contributes to this. Perimenopause often coincides with older children, career advancement, aging parents, more responsibilities. No one gave you a memo in your early 30s saying “let’s set you up for success.” So by your 40s, you’re playing catch-up.

Dr. Eve Henry – a physician who specializes in women’s cardiovascular health – calls ages 40 to 48 a period of “medical vulnerability” for women. This is when everything can shift, and most women have no idea it’s coming.

The Truth About Your Metabolism

Let me start with something that might blow your mind: Your metabolism didn’t actually slow down.

Your resting metabolic rate stays pretty much the same until your early 60s.

So what’s really happening?

Hormones. All of them. Having a complete meltdown.

During perimenopause, estrogen and progesterone don’t just drop – they fluctuate wildly. And these hormones affect every system in your body, particularly your liver.

Your Liver: The Key Player

Your liver is a key player here. It clears and makes cholesterol. When estrogen is high, it clears more cholesterol and makes less. When estrogen drops, the receptors that help clear cholesterol decrease in number. So your liver starts making MORE cholesterol and clearing LESS.

Your liver also drives changes with glucose. With less estrogen, your liver produces more glucose when stimulated and is slower to clear insulin from your bloodstream.

The Cascade Effect

At the same time, several other things are happening:

Your insulin sensitivity decreases. Your cells become more resistant to insulin’s signal.

Your ability to remove and use fat for energy decreases. But your rate of fat storage stays the same. So you’re storing fat at the same rate but burning it more slowly.

You start storing fat in a more inflammatory way. Visceral fat – the dangerous fat around your organs – can increase 2-3 times from before menopause. With no lifestyle changes.

Your total body inflammation increases. This creates a cascade effect – inflammation drives insulin resistance, which drives more inflammation, which affects your lipid metabolism, which increases cardiovascular risk.

It’s like we’re set up for failure. All the tricks that worked to lose weight in your 20s and 30s stop working in perimenopause.

The SWAN Study

There’s this incredible study called the SWAN study – it followed women for 18 years through the perimenopause transition. The results showed exactly this pattern: body composition changes, insulin resistance climbing, inflammation increasing, hot flashes correlating with insulin resistance.

Why This Matters More Than You Think

Women catch up to men in cardiovascular risk incredibly quickly after menopause. And cardiovascular disease – heart disease, stroke, metabolic disease – is the number one killer of women in the United States.

When you look at the top 14 causes of death in women, all but accidents are directly or indirectly related to metabolic health.

Here’s a statistic that puts this in perspective: You are 13 times more likely to die of metabolic disease than breast cancer.

The Silent Disease

And here’s what makes this even more urgent: About one-third of first heart attacks in women result in death.

Heart disease in women is often a silent disease. You don’t get the classic chest-crushing pain that men get. Women are more likely to experience nausea, upset stomach, and arm pain. Symptoms that get dismissed as indigestion or anxiety.

Unless you’re tracking your labs, you may have no idea what’s building in your arteries.

Know Your Metrics Early and Often

This is why knowing your metrics earlier and often is so critical. We need to start seeing the pattern shift before it becomes disease.

Your HbA1C, for instance, is personalized to you – especially if you can track it when you’re earlier in the process and healthier. Then you know what YOUR optimal baseline is, not just what the “normal range” says.

And if you really want to understand your patterns, a continuous glucose monitor can give you even more precise data about how your body responds to food, stress, and sleep.

The Key Metabolic Markers

These are the metabolic markers that tell me the most about what’s actually happening in your body:

Number 1: Fasting Insulin – The Gold Standard

Your sweet spot? Under 10.

Most standard lab work doesn’t even include fasting insulin. But this is the FIRST marker to show problems – years before your glucose becomes elevated.

When fasting insulin is elevated, your cells are resisting insulin’s signal. This creates that blood sugar roller coaster that has you reaching for emergency snacks all day.

You know that feeling when you eat lunch and you’re hungry again 90 minutes later? Or when you crash so hard at 3pm you’d commit crimes for a cookie? That’s insulin resistance starting to show up.

You can have perfectly “normal” fasting glucose and still have insulin working overtime behind the scenes.

This is the test you need to request specifically. It’s worth the push-back from your doctor.

Number 2: HbA1C – The Three-Month Average

This measures your average blood sugar over the past three months.

Generally, you’re looking at a range of 4.5 to 5.5, depending on your patterns.

Standard ranges go up to 5.7, but for sustained mental clarity and stable energy, you want this in that lower range.

The Nuance About HbA1C

Now here’s the nuance: HbA1C is based on red blood cell turnover – typically about 90-120 days. If your red blood cells turn over faster or slower than average, it can skew the results. This is why you need to look at the pattern across HbA1C, fasting glucose, and fasting insulin together.

Number 3: Triglycerides – The Early Warning Sign

Triglycerides are an early warning sign of insulin resistance.

• Less than 50? Beautiful.
• Between 50 and 100? Watch your other metrics closely.
• Over 100? You’ve got an issue.

There can be genetic factors that affect triglycerides, but for most women, elevated triglycerides signal that your body is struggling with insulin sensitivity.

The Backup: TG:HDL Ratio

If you absolutely cannot get fasting insulin ordered, you can use your TG:HDL ratio as a proxy marker for insulin resistance.

Take your triglycerides, divide by HDL. Goal: 1 or less.

Above 1.5? You’re likely dealing with insulin resistance.

Population Considerations

This ratio is validated for European and Asian populations. It’s less reliable for African American populations, so if you’re African American, push for fasting insulin directly.

But let me be clear: fasting insulin is the gold standard. TG:HDL is the backup plan when you can’t get the test you actually need.

Understanding Your Lipid Panel: The Transport System

Now let’s talk about cholesterol. Your total cholesterol number means almost nothing.

Let me give you an analogy:

The Delivery and Recycling Trucks

Think of LDL and HDL as transport trucks.

LDL is the delivery truck. It brings cholesterol to damaged arteries and blood vessels for repairs. Your body needs cholesterol – it’s essential for hormone production, cell membranes, and repairing damage.

HDL is the recycling truck. Once repairs are made, HDL takes leftover cholesterol back to the liver to be recycled or eliminated.

Higher HDL is protective – you’ve got more trucks picking up excess cholesterol and clearing it out.

What Causes Plaque and Heart Attacks?

Dr. Eve Henry has a brilliant way of explaining this. She describes LDL particles like tiny bouncing balls in your bloodstream. Think of blood pressure like water pressure in a hose – the more pressure, the more likely those balls hit the artery wall with force and get stuck.

The Pimple Analogy

When a small, dense LDL particle gets into the artery wall and becomes oxidized and inflamed, Dr. Henry describes it like this:

Think of plaque like a pimple. The oxidized LDL is like the “schmutz” – the gunk. Your immune system sees this damage and paves over the schmutz with cement to contain it. That’s the plaque.

• Soft plaque is just schmutz and pus.
• Hard plaque is paved-over schmutz.

A heart attack happens when that pimple explodes. The immune system sees the schmutz all over and reacts like it’s an emergency – it forms a clot. The fuss about the explosion, combined with the inflammation and the blockage from the clot, is what causes the heart attack.

The tiniest vessels are easiest to block – in your heart and brain. An explosion and blockage in the brain is a stroke. In the heart, it’s a heart attack.

Why Particle Size Matters

This is why particle size matters. Large, fluffy LDL particles generally stay in the bloodstream doing their transport job. Small, dense particles are more likely to penetrate the artery wall and cause problems.

And this is why inflammation matters so much. The more inflamed your system, the more likely LDL particles are to become oxidized and trigger that immune response.

The Advanced Markers That Matter

ApoB – Apolipoprotein B

ApoB is a better marker than LDL-C because it measures the actual number of atherogenic particles in your blood – the particles that can cause plaque buildup.

About 25% of the population has “discordance” between their LDL-C and their ApoB. Your standard LDL might look fine, but your ApoB could be elevated. Or vice versa.

Target: Less than 80 lowers your risk significantly.

If you have a family history of high cholesterol, if imaging shows issues, or if you’re on statins, sometimes the goal is even lower. That’s a conversation to have with your doctor about how you need to get there.

Lp(a) – Lipoprotein(a)

This is a genetic marker – you only need to test it once in your lifetime.

About 20% of the population has elevated Lp(a), and it’s an independent risk factor for cardiovascular disease. There are different tests with different ranges depending on the lab, but what matters is knowing if yours is elevated so you can discuss more aggressive prevention strategies with your doctor.

Inflammation and Metabolic Stress Markers

hs-CRP – High-Sensitivity C-Reactive Protein

This measures inflammation in your body. Inflammation is what makes LDL particles more likely to get oxidized and stuck in your artery walls – creating that “schmutz” Dr. Henry described.

Target: Under 1.0 mg/L for optimal cardiovascular health

What drives hs-CRP up? Chronic stress, poor sleep, blood sugar dysregulation, gut issues, excess body fat. All things that get worse during perimenopause.

Uric Acid

This reflects metabolic health, inflammation, and kidney function.

• Optimal: Less than 5.5 mg/dL
• Above 7: Some concerns to watch

Uric acid is particularly sensitive to fructose consumption – especially in drinks and alcohol. If your uric acid is elevated, take a hard look at sweetened beverages, juice, and alcohol.

A Note on Advanced Imaging

You might hear about tests like CAC scans – coronary artery calcium tests. These give you a picture of how much calcified plaque you have, relative to your age.

Women in their 40s typically don’t have much calcified plaque yet – it’s mostly soft plaque at this stage. Usually doctors wait until mid-50s to see what has calcified, because of that catch-up phenomenon after hormones drop.

If you’re higher risk, your doctor might order a CT angiogram with dye to get a more detailed picture.

There’s also carotid ultrasound, which is low risk and has no radiation, but it doesn’t usually catch early disease.

I’m not going to go deep into these tests because as much as I want to help you build a good foundation, if these imaging tests come back showing significant plaque, you probably need medication to manage your risk. And that’s outside my scope as a nutritionist.

What I CAN do is help you track your labs so you catch problems early, before you need advanced imaging.

Medication Options: A Reality Check

Let’s talk about medication for a minute, because I know many of you are terrified of statins.

First, let me be clear: I can’t prescribe medication. But I can tell you that there are options besides statins, and medication isn’t the failure many women think it is.

The important thing is to weigh the risk of heart disease against your options.

Dietary Changes: The Variability

If you need to lower your cholesterol, there’s huge variability in how people respond to dietary changes – particularly saturated fat reduction. Some people see changes, some don’t. And many women replace saturated fat with carbs, which isn’t always a great trade-off for metabolic health.

Medication Options

Omega-3s

Can provide moderate lowering of triglycerides. They’re not great at lowering LDL, but they can be used in combination with other supports.

Red Yeast Rice

This is actually what statins are based on. Taking red yeast rice is essentially like taking a low-dose statin.

Zetia (Ezetimibe)

Blocks absorption of cholesterol in your gut. It helps the recycling mechanism your body uses. It doesn’t work as well solo, and for some people it doesn’t work well at all, but it has very low side effects. You need to track liver enzymes, try it for 3 months, and it can be used in combination with lower-dose statins to help minimize statin side effects.

PCSK-9 Inhibitors

These are newer medications that block the breakdown of LDL receptors in the liver. This means more of the cholesterol that those HDL dump trucks bring back can actually be recycled and cleared. These are typically used for people with very high cholesterol or genetic conditions, but they’re another option in the toolbox.

About Statins

High-dose statins are more likely to cause side effects, but that doesn’t necessarily mean they will. Everyone responds differently. If you do need a statin, starting with a lower dose in combination with something like Zetia might be an option to discuss with your doctor.

The 3-Month Retest Protocol

The important thing: You have to check your labs again after starting any intervention – whether it’s lifestyle changes or medication – to make sure it’s working. Give it 3 months, then test again.

The Honest Truth

And here’s my honest take: Most of us will need some medication in our lifetime. It’s very hard to be medication-free when we’re living as long as we do with our modern lifestyle.

What I’m advocating for is this: Don’t wait until you have disease. We can know your metrics and support them early so you don’t get to disease in the first place. And if you do need medication eventually, you’ll be starting from a much stronger foundation.

Mammograms: The Other Critical Screening

Now, before we get into exactly what labs to request, I need to talk about something that isn’t a lab test but is just as critical.

Mammograms.

I usually only talk about things I can directly support – lab values I can help you improve. But breast health screening is outside my scope, and that’s exactly why I need to emphasize it.

Here’s the statistic I just shared: You’re 13 times more likely to die of metabolic disease than breast cancer.

That’s not me saying breast cancer doesn’t matter. That’s me saying BOTH matter, and we need to be proactive about both.

What Julie Dingui Wants You to Know

In preparing for this episode, I talked with mammographer Julie Dingui. She is incredibly passionate about women’s health, and I love the way she talks about how her work changes lives.

Here’s what Julie wants every woman to know:

Get a mammogram every single year.

Not every two years. Every year.

Why? Because there are many different types of breast cancer, and they all grow at different rates. Two years is too much time to let something undetected grow.

Some breast cancers are slow-growing. Others are aggressive. You don’t know which type you might develop, so annual screening gives you the best chance of catching something early.

Resources for Free/Low-Cost Screening

And if you don’t have health insurance or your insurance doesn’t cover mammograms, there are grants and organizations in almost every state that help cover the cost.

Don’t let cost be the barrier.

So yes, optimize your metabolic health with labs. But also schedule that mammogram. Both screenings save lives.

What to Actually Request

Here’s your metabolic health panel to request from your primary care provider:

The Core Metabolic Markers

• Metabolic Panel – kidney/liver function, electrolyte balance, baseline glucose
• Fasting Insulin – specifically request this, it’s worth the pushback
• Hemoglobin A1C
• Complete Lipid Panel (Total cholesterol, LDL, HDL, Triglycerides)
• ApoB – specifically request this
• Lp(a) – one time test
• hs-CRP
• Uric Acid

Lab Prep

• Go in the morning, fasted (nothing but water for 12 hours)
• Skip your workout that morning
• Stop biotin 2 weeks before
• Stay normally hydrated

Real Stories: Erica

Let me tell you about Erica.

She’d been diagnosed with PCOS, put on birth control and medication to lower her blood sugar. Her labs were “normal” by standard measures, but she felt terrible.

After 3 months working together, then 3 months on her own:

• Fasting glucose improved 4%
• HbA1C corrected and moving in the right direction
• Triglycerides dropped 34%
• TG:HDL ratio improved 27%

She’s no longer on that trajectory toward diabetes and heart disease. She changed the pattern before it became a crisis.

Closing: The Truth About Prevention

It’s much easier to prevent metabolic disease than to treat it.

Ages 40 to 48 are medically vulnerable years for women. This is when everything can shift. But it doesn’t have to be a crisis.

When you know your metrics earlier and track them often, you can see the pattern shift before it becomes disease.

A Year From Now

A year from now, one of two things will be true:

You’re still in the dark, still wondering why your body isn’t responding, still waiting for someone to connect the dots.

Or you finally understand what your body is trying to tell you. You have your baseline. You’re tracking your patterns. You have a plan.

The difference? One decision. Right now.

In the next episode, we’re covering thyroid function, nutrient deficiencies, inflammation markers, and how to look for patterns across all your results.

Download the free lab guide at meganpfiffnernutrition.com – link in the show notes.

You deserve answers, not dismissal.

I’m Megan Pfiffner, and I’ll see you in the next episode.