Awake at 3am, foggy by 10, flooding by 3, furious by 6?You can navigate perimenopause with a plan from the Menopause Biologist to help your body adapt to changing hormones.Sleep deeply, think clearly and feel better than you have in years. Yes you can.
Sandra IshkanesFunctional medicine practitioner · BSc · MA · DipIONBrighton, and online worldwide
Are you feeling the fear? Like I did years ago, for your health and your future?
Are you wondering when this will get better, or whether it will just keep getting worse? Do you feel helpless? Like no one's coming? I was so alone with this for so long, but you don't have to be. I'm here, for all of it.
Sandra Ishkanes
The Menopause Biologist
BSc · MA · DipION · ANP member
I've been where you are, and I've come back with a map
I discovered the existence of perimenopause purely accidentally via my acupuncturist. Just as I was leaving, I had mentioned my recent spate of unusually heavy irregular periods, at which point he said – well you’re coming up to that age. I’m thinking – I’m sorry, what age might that be? You know, he replied. I’m thinking, no, not really?? Then he says, you know, menopause. I was absolutely livid. How dare he talk to me like that?! I’m only 45! Isn’t menopause for half-dead old women? Or something? I left his clinic and furiously didn’t return for 2 years.
A few days later, after I'd calmed down, I looked it up on Google. Bloody hell. The fear was real. It seeped into my soon-to-be osteoporotic bones. Apparently my rapidly approaching future looked like this:
I wouldn't be able to sleep all night because of something called night sweats, and when I woke up tired as hell, my energy would get lower over the whole day until I collapsed on the sofa for a comatose nap. The day would be peppered with something called hot flushes, described as random, humiliating, and like swallowing a furnace. Then anxiety would take over, for no reason at all, or possibly because I was wondering why I was putting on so much weight. Also, was I dying? Was it cancer? What sort of cancer? Or maybe it was brain fog, which meant I would finally find my hairdryer in the fridge. All this accompanied by heart palpitations, although GPs invariably do tests and say there's nothing to worry about, so that's okay. Or is it? And good luck holding down a job. Oh, and if I fell and broke my hip, I'd die a lot earlier than I otherwise would have. That's menopausal osteoporosis for you.
I would lie in bed at night with the fear like a boulder on my chest. I'd already been diagnosed with fibroids and adenomyosis, early-stage perimenopause had me flooding everywhere, and now this nightmare was around the corner. I still had two years of functional medicine training to go. Was it worth continuing if my clinical work would be impossible the moment I started?
I was frightened, and I was on my own with it. No one was coming. No one was saying "this is what's happening and here's the way through." Instead, the oestrogen deficiency narrative was making no sense to me. If declining oestrogen is normal, how can it be a deficiency? This meant HRT wasn't an option for me. You can't replace something that doesn’t need to be replaced, and expect healing. And I believe the body wants to heal. It is designed to heal; it just needs the right conditions. So I did what I've always done, and I started asking questions. Armed with a degree in molecular biology, a functional medicine way of thinking, and a deep belief in biology's spirit, I set out to find out what was really going on. Ten years of clinical work with 100+ women later, I know why. I was so alone for so long. You don't have to be. I'm here, for all of it, and I'll help you not just get through this but thrive.
Here's what I found.
Mapping Perimenopause
Every woman I worked with told me the same thing: it felt like nothing made sense. The sleep, the mood, the weight, the periods, none of it seemed connected. But it is connected.
2hormonal phases
4metabolic shifts
Once I went beyond the story of one missing hormone, reams of research showed why symptoms appear in clusters, and how hormonal changes connect to every one of them through the transition. Your body moves through 2 hormonal phases and 4 metabolic shifts. Each one changes how your body works, which is why everything from how you sleep to how you think can feel different.
Your foundations
These shifts put new demands on the foundations of our lives: nutrition, blood sugar, stress, sleep and liver detoxification.
- Nutrition
- Blood sugar
- Stress
- Sleep
- Liver detoxification
↗Without the right support, symptoms flare.
✓With it, your body adapts more easily.
Early perimenopause
1. The Progesterone Shift
Late 30s or early 40s, while your periods still look normal
Rage at the smallest thing. Waking at 3am, heart racing. Breasts too tender to touch. Periods that flood.
You've probably been told your oestrogen is low. It's the opposite. Ovulation becomes unreliable, so progesterone crashes while oestrogen spikes up to three times higher. Too much, with nothing to balance it.
Where the power is
Your liver and gut clear excess oestrogen. Support them, steady your blood sugar, and the imbalance eases.
You haven't become difficult. Your hormones have lost their balance, and balance can be rebuilt.
Foundations to support
- Liver detoxification
- Blood sugar
How lack of support shows up
- Heavy periods
- Flooding periods
- Rage
- Irritability
- Breast tenderness
- Bloating
- Cyclical anxiety
- 3am waking
- Heart racing
Late perimenopause and menopause
2. The Fuel Shift
As oestrogen falls
Hot flushes in the supermarket queue. Brain fog mid-sentence. A flutter in your chest for no reason. Weight that arrives despite eating the way you always have.
Your brain is running low on fuel. Oestrogen helped it run on glucose. As oestrogen falls, it has to switch to ketones, made from fat. A carb-heavy diet keeps the glucose coming, so the switch never happens.
Where the power is
Steady blood sugar and the right food teach your brain to switch. It's one of the most trainable shifts.
It isn't a failing body or a failing diet. Your brain is waiting to be shown a new way to eat.
Foundations to support
- Blood sugar
- Nutrients
How lack of support shows up
- Hot flushes
- Night sweats
- Brain fog
- Palpitations
- Anxiety
- Low mood
- Fatigue
- Weight gain
Late perimenopause and menopause
3. The Oestrogen Shift
After the ovaries step back
Aching joints. Stiff mornings. Thin, crepey skin. Dryness, recurrent UTIs, muscle that disappears however hard you train.
Your body hasn't stopped making oestrogen. It has moved the factory. Your brain, bones and vaginal tissues start making their own, built from adrenal DHEA. But a factory needs raw materials, and many women arrive short of them.
Where the power is
The right nutrients, matched to your symptoms and blood tests, give each tissue what it needs.
You're not falling apart. Your tissues are waiting for supplies.
Foundations to support
- Nutrients
- Stress
How lack of support shows up
- Joint pain
- Morning stiffness
- Thinning skin
- Crepey skin
- Vaginal dryness
- Recurrent UTIs
- Muscle loss despite training
Late perimenopause and menopause
4. The Identity Shift
Underneath it all
Anger you can't place. Losing patience with roles you've held for decades. Withdrawing in ways that surprise you. Suddenly unwilling to carry everything.
This isn't you losing your temper. It's a boundary arriving. As oxytocin fades and cortisol takes the lead, your nervous system reorganises, and absorbing everyone else's strain stops working. Your body is refusing it.
Where the power is
A rewiring nervous system needs rest, sleep and permission to set new limits. Something freer is on the other side.
You're not breaking. You're being released from something you were never meant to carry forever.
Foundations to support
- Stress
- Sleep
How lack of support shows up
- Anger you cannot place
- Losing patience with old roles
- Withdrawal that surprises you
- Unwillingness to carry everything
Perimenopause is a transition with four shifts, and each one has many levers. That's why the usual approaches don't always work
The usual approach
Much of the advice about perimenopause starts with the same idea: your oestrogen is declining, and your symptoms are the result of a hormone deficiency.
HRT can help many women, but it doesn't address every factor contributing to their symptoms. And another supplement, diet or menopause remedy isn't necessarily the answer either.
What's really happening
Perimenopause is more complicated than that. Your hormones fluctuate, ovulation becomes less predictable, and your body is adapting to the changes brought about by declining ovarian oestrogen production. These changes can affect everything from your sleep and energy to your mood and menstrual cycle.
The missing piece is often how well your body is adapting. That depends on the foundations underneath: your nutrients, blood sugar, liver detoxification, stress and sleep.
That's where my approach is different. Rather than trying to restore your hormones to their younger levels, I focus on supporting the biological processes that help your body adapt.
Because the goal isn't to get your old hormones back. It's to feel well with the hormones you have now.
What Happens Next
One-to-one Consultations:
Let's work togther.
The four shifts are common to every woman, but how they show up in your body is different. Two women with the same symptoms can have very different things driving them: one is struggling with blood sugar and cortisol, another with her liver's handling of oestrogen, another with low iron and an underactive thyroid. The same supplement or the same prescription won't suit both of them.
That's why I don't start with a protocol. I start with you: your history, your results and the pattern that's specific to your body. Then I work out what's driving your symptoms, and in what order to address it.
Here's how it works.
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Before we meet
You complete a detailed health assessment and keep a three-day food and lifestyle diary. I review them alongside your previous tests and draft your protocol, so the work has started before we speak.
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Your 90 minutes with me
We go through your history and work out what's driving your symptoms. I order your 80-marker blood test and tell you whether you need anything deeper: DUTCH hormone testing, cortisol, neurotransmitters, or gut and vaginal microbiome.
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Your personal plan
A written protocol with step-by-step directions: nutrition, supplements and lifestyle, built around your own results. You can start straight away.
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Support while your body adapts
We review every four weeks and adjust as you improve, with check-ins in between.
Discovery call: free
First consultation: £365
for 90 minutes by video.Follow-ups are £165 for 45 minutes, and check-ins between consultations are included.
No fixed packages, and payment plans are available.
Ready?
Let's see if we are a good fit
Book a free discovery call30 minutes by phone, free. Tuesday to Thursday, 8 to 10am and 2 to 5pm (UK time)
What women find
Testimonials
“It’s like my brain energy’s switched back on — I can think clearly and enjoy life again. My specialist menopause plan concentrated on my nutrition and supplements personalised to me to support me – it has seen my whole health and mindset change.”
- 100+women supported
- 10+years in clinical practice
- 4weeks to first results
- 1:1every consultation
“Having guidance that doesn’t automatically lead to HRT, but instead looks at the whole picture of health, has been incredibly valuable.”
“Thank you Sandra. You have helped me get back in control of my life. No exaggeration. This has set me on a course for health for the rest of my life.”
“Absolutely mind-blowingly good. Patient, responsive, open, thoughtful. I’ve already suggested my daughters talk to her.”
Case studies
85%fewer symptoms in 8 weeks
Linda, 59: brain fog cleared
Linda arrived with severe brain fog and low energy affecting her work and daily life. We mapped her metabolic patterns, addressed insulin and liver function, and built a brain-fuel protocol. By week 8 her energy was back and the fog had cleared.
“I finally have a roadmap. For the first time in years, I know what my body needs, and why.”Read Linda’s case study

Complex history? This is where I can help most.
Many of the women I see have been through years of appointments and been told there's nothing more to be done. By the time they find me, I'm often their last resort.
That is exactly the work I do. These conditions shape how your hormones, immune system and metabolism behave, and perimenopause lands on top of all of it.
Choose what you're living with
Endometriosis
Severe pain, nausea and bloating at menstruation, caused by inflammation from internal bleeding of uterine tissue, laid down during foetal development. Excess oestrogen and inflammatory foods make it worse.
The extreme pain and inflammation from the very first period can flare in early perimenopause when ovarian oestrogen starts spiking. Careful hormonal management can quieten the flares and resolve pain.
Recognise your story?
Start with a free discovery call“I had been to see many doctors and was prescribed lots of different drugs and treatments, including painkillers, pills, hormone treatments and surgery. But nothing seemed to improve it and I was in crippling pain every month… I have had a drastic improvement since following the plan. I really believe that seeing Sandra has changed my life.”
Adenomyosis
Adenomyosis consists of muscle knots in the uterus which can cause severe pain throughout the cycle and heavy bleeding; they are wounds that won’t heal. Root causes include uterine infections and oestrogen levels that are too high.
Recognise your story?
Start with a free discovery callPCOS
What was once an evolutionary survival benefit is now causing havoc due to high testosterone driven by sugar and insulin. Intermittent periods, acne, weight gain, unwanted hair can improve in early perimenopause, but get worse in late perimenopause when oestrogen dropping magnifies insulin resistance.
Recognise your story?
Start with a free discovery call“I asked Sandra to help me with PCOS problems I’d been struggling to manage for a few years.
Following her advice has resulted in a very marked improvement in almost all of the symptoms I was experiencing. I feel about 15 years younger, with far greater energy, far less pain and a sense of health that’s been missing for some time now. I’m now implementing her recommendations on a long term health plan. The future is bright!”
Fibroids
These silent benign tumours in/around the uterus are driven by high oestrogen levels and vitamin D deficiency.
Fibroids affect more than 40% of women in perimenopause and are a common cause of heavy bleeding. Stopping their growth and slowing the bleeding makes for an easier transition to menopause when they finally quieten.
Recognise your story?
Start with a free discovery call“Controlling the flooding means I don’t have to worry about going out anymore”
PMDD
Premenstrual Dysphoric Disorder causes severe irritability, depression, or anxiety in the week or two before the menstrual cycle starts. Because women with PMDD are hyper-sensitive to normal hormonal shifts, the unpredictable midlife hormonal rollercoaster triggers severe anxiety, rage, and depressive symptoms more frequently, stretching the suffering across unpredictable parts of the cycle.
Recognise your story?
Start with a free discovery call“Knowing what triggered the hormone imbalance and what I needed to do to balance it out again, was the biggest part of the jigsaw. Finally, I was able to take back control. I cannot thank Sandra enough for all of her help and input and would recommend her to any woman going through difficulties with a hormone imbalance.”
Case study
PMDD symptoms reversed – case studyWherever you are with HRT, I'll support you there
HRT lays oestrogen over a transition that is already under way. In some women it relieves some symptoms. But it can get in the way of the transition the body was trying to complete.

You can go through peri/menopause without HRT
Whether your reasons are medical or personal, there is real work we can do first: nutrition, gut health, stress physiology and targeted supplements. With root-cause care, HRT doesn't have to be the default.
Menopause without HRT: how to come through it well
Why isn't my HRT working?
If you're still struggling on it, or want to come off, there are usually reasons it isn't doing what you hoped, and they're worth looking at.
HRT not working? 5 places it gets stuck
Why have my symptoms come back after stopping HRT?
Coming off, by choice or necessity, can feel like the ground moving twice. I can help your body find its own footing, so you can move forward in health and confidence.
You’ve come off HRT and are struggling80%fewer symptoms in 4 weeks
Helen, 48: off HRT and feeling better than ever
Helen had already tried HRT and her hot flushes and night sweats were severe. We worked on the metabolic and inflammatory roots of her symptoms. By week 4 they were down 80%, she came off HRT without any problems, and she has stayed very well without it.
“I was told there was nothing else to try. There was.”Read Helen’s case study

Start with a free discovery call and start feeling better within 4 weeks
Tell me what's been happening and what you most want help with. In 30 minutes we'll see whether I can help and whether we're a good fit.
Book your free discovery call
A 30-minute phone call. We go through your symptoms, you get my first read on the root causes, and we see if this approach suits you.
Get your personal plan
A 90-minute consultation maps out your nutrition, supplement and lifestyle protocol, supported by functional testing.
Notice the difference
In my practice, women typically notice a significant change within the first four weeks, in their energy, clarity and pain. From there, we build long-term resilience for your brain, bones and heart.
Perimenopause doesn't pause while you decide. Every month of broken sleep, flooding and fog is a month you could have spent feeling better. You've spent long enough looking. Book your call and let's find out what's driving it.
On your call you will
- Understand why you have your symptom pattern
- See what testing and support could look like for you
- Ask anything, with no commitment and no pressure
- Leave with clear next steps
30 minutes by phone, free. Calls are available Tuesday to Thursday, mornings and afternoons (UK time). I work with women worldwide, and weekend or evening consultations can be arranged by prior arrangement.
If you're outside the UK, we'll find a time that works for both of us.
Choose a time for your free callPrefer to write first? Email me at sandra@sandraishkanes.co.uk and I'll reply personally

Curious about your symptom pattern?
68 symptoms. One pattern. Four shifts. The quiz shows how your symptoms connect: where you are in the transition, what is draining your energy, and what to look into next.

Where you are in the transition
Early perimenopause, late perimenopause or postmenopause.
Why your symptoms make patterns
And what those patterns reveal about the systems struggling to adapt.
What to look into next
Clear next steps, whatever you decide to do.
Are you taking any hormones?
HRT, the contraceptive pill, a Mirena coil, Letrozole and hysterectomy can change the symptom patterns the quiz reads.
Questions women
ask me
From the knowledge hub
Understand what your body is doing
Early perimenopauseSugar feeds oestrogen and turns bleeding into floodingRead
Oestrogen shiftRoot causes of vaginal dryness and Genitourinary Syndrome of Menopause (GSM)Read
Oestrogen shiftReverse Perimenopause Joint Pain Naturally (Without HRT)Read
HRTSymptoms After Stopping HRT — and How to Come Off WellRead
HRTMenopause Without HRT: How to Come Through It WellRead
HRTWhy HRT is not working and what you are missingRead
Complex conditionsFibroids in Perimenopause: Why They Grow and What Drives YoursRead
Energy shiftWhy You Have Hot Flushes — and How to Calm ThemRead
