Awake at 3am, foggy by 10, flooding by 3, furious by 6?You can happily navigate perimenopause with a plan from the Menopause Biologist that helps your body adapt to changing hormones.

Your symptoms are connected across multiple metabolic shifts in perimenopause. I use functional medicine to reveal the root causes of your pattern and give you a plan so you can sleep deeply, think clearly and feel better than you have in years.

Book a free 30-minute strategy call Take the perimenopause clarity quiz
Sandra Ishkanes

Sandra IshkanesFunctional medicine practitioner · BSc · MA · DipIONBrighton, and online worldwide

Tired of making decisions, going to the doctor and spending money on things that haven't helped?

You've been doing everything you can to feel better, but you're still struggling with symptoms and wondering what to try next.

Perimenopause doesn't have to be miserable.

Your body can adapt to changing hormones, and I can help you make that transition easier.

Whether through one-to-one consultations or online courses, I offer practical plans to support your body's changing needs, so you can spend less time searching for answers and more time feeling well.

  • For complex cases

    One-to-one consultations

    If you have several symptoms at once, a complicated health history, or you've already tried a lot, we'll build a personalised plan together.

    • In-depth review of your history and symptoms
    • Functional testing where it's useful
    • Ongoing support as your body adapts
    Explore consultations Or book a free discovery call
  • Who you'll work with

    Meet Sandra

    A molecular biologist turned functional medicine practitioner, with a master's in social anthropology and over 10 years of clinical experience supporting women through perimenopause and beyond.

    • BSc · MA · DipION · ANP member
    • Science-led, practical and personal
    Meet Sandra
  • Not sure where to start?

    Take the symptom quiz

    68 symptoms, four shifts. In a few minutes you'll see the pattern behind your symptoms and whether a course or a consultation is the right next step.

    • Straightforward pattern: start with a course
    • Complex pattern: book a consultation
    • Personalised results sent to your inbox
    Take the quiz

Why don't the usual approaches 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

But 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 to hormonal changes.

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.

I look at your health through a biology-first lens.

Hi, I'm Sandra Ishkanes

The Menopause Biologist

BSc · MA · DipION · ANP MEMBER

I'm a molecular biologist turned functional medicine practitioner, with a master's degree in social anthropology and over 10 years of clinical experience.

My background shapes how I understand menopause. As your ovaries produce less oestrogen, your body undergoes remarkable biological changes. Understanding how those changes affect your health, and how to support your body's ability to adapt, is at the heart of my work.

I bring that science into everyday life, helping women find practical ways to feel well through perimenopause and beyond, whether through one-to-one consultations or online courses.

Meet Sandra

Perimenopause can feel like chaos, but your body isn't failing.

It's responding logically to needs that have changed, and most women are never told what those needs are.

2hormonal phases

4metabolic shifts

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 your foundations: 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.

The four shifts

Illustration of the progesterone shift

Early perimenopause

Progesterone shift

Oestrogen spikes up to 3 x higher and progesterone crashes as ovulation becomes unreliable. It starts in your late 30s or early 40s, while your periods are regular and get shorter.

What your body needs now

Help to clear excess oestrogen through your liver and gut, so it stops overpowering the progesterone you still make.

Foundations to support

  • Liver detoxification
  • Blood sugar

How lack of support can show up

Explore the progesterone shift
Illustration of the energy shift

Late perimenopause and menopause

Energy shift

As ovarian oestrogen falls, your brain has to switch fuel from glucose to ketones. A modern, carb-heavy diet keeps that switch from happening.

What your body needs now

Steady blood sugar and food that helps your brain learn to burn fat for fuel.

Foundations to support

  • Blood sugar
  • Nutrition

How lack of support can show up

Explore the energy shift
Illustration of the oestrogen shift

Late perimenopause and menopause

Oestrogen shift

Oestrogen production moves from the ovaries to organs (brain, bones, vaginal tissues), built from adrenal DHEA. Each organ needs the right nutrients to make oestrogen and testosterone.

What your body needs now

The right nutrients, matched to your symptoms and blood tests, so each tissue can make the hormones it needs.

Foundations to support

  • Nutrition
  • Stress

How lack of support can show up

Explore the oestrogen shift
Illustration of the identity shift

Late perimenopause and menopause

Identity shift

Your nervous system reorganises. As oxytocin fades and cortisol rules, the old way of coping, absorbing everyone else’s strain, stops working, and something freer can take its place.

What your body needs now

Support for a nervous system that's rewiring, and permission to set new boundaries.

Foundations to support

  • Stress
  • Sleep

How lack of support can show up

  • Anger that is hard to place
  • Losing patience with old roles
  • Withdrawal that surprises you
  • Carrying everything, and no longer willing to
Explore the identity shift

Results from women who chose the natural route

Case studies with full histories, test results, protocols and progress, step by step.

POST MENOPAUSE · Brain fog · Fatigue

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
A woman with a backpack walking in the mountains

PERIMENOPAUSE · STRUGGLING ON HRT · Hot flushes · Night sweats

80%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
A woman smiling over lunch at an outdoor table

Why this actually works (even if nothing else has)


If you have already spent hundreds of pounds on random vitamins, menopause books, or quick-fix supplements that promised the world and delivered nothing, you are right to be cautious.

These approaches fail because they treat peri/menopause as a generic guessing game. My approach is entirely different because it replaces guesswork with precise, molecular-level data - and leaves no room for locked-in, high-risk financial packages.

The Rushed Guesswork (Typical Care)The Root-Cause Resolution (With Me)
The Timeline Rushed, 15-minute conversations that leave you feeling dismissed, anxious, and unheard. A 90-minute biological deep dive where your entire medical history is evaluated.
The FocusQuick prescriptions or generic, one-size-fits-all supplements.Finding the biological drivers behind your unique symptom pattern.
The TestingStandard, basic panels rule out disease but completely miss the nuance.A deep 80-marker panel evaluating your hormones, liver, and stress pathways together.
The CommitmentEndless financial trials on new fixes, or dependency on standard external patches.No locked-in contracts. We work session-by-session, only for as long as you need it.
The OutcomeA temporary “Band-Aid” fix that ignores why your body is pushing back in the first place.A permanent roadmap to health, built to restore your body’s natural resilience within 4 weeks.

80blood test markers direct your health optimisation plan

Red and white blood cells, platelets, sex hormones, cortisol, thyroid, inflammation, iron, lipids, blood sugar, liver, kidneys, proteins, vitamins, minerals and enzymes, read together as one picture.

What do we look at? See the full 80-marker panel breakdown

Red blood cells Haematocrit Haemoglobin MCH MCHC MCV RDW-CV Red blood cells (RBC)

White blood cells White blood cells (WBC) Neutrophils (count) Neutrophils (%) Lymphocytes (count) Lymphocytes (%) Monocytes (count) Monocytes (%) Eosinophils (count) Eosinophils (%) Basophils (count) Basophils (%) Neutrophil to lymphocyte ratio Monocyte to lymphocyte ratio

Platelets Platelets Mean platelet volume (MPV) Platelet to lymphocyte ratio

Sex hormones Oestradiol (E2) Progesterone Testosterone FSH LH Prolactin SHBG Free androgen index DHEA-S

Stress hormone Cortisol

Thyroid TSH Free T4 Free T3 Total T4 Free T3 to free T4 ratio TPO antibodies Thyroglobulin antibodies

Inflammation CRP hs-CRP LDL to HDL ratio Monocyte to HDL ratio

Iron Iron Ferritin Total iron binding capacity Transferrin saturation

Lipids Total cholesterol HDL cholesterol LDL cholesterol Non-HDL cholesterol VLDL cholesterol Triglycerides Total cholesterol to HDL ratio Triglyceride to HDL ratio

Blood sugar Glucose HbA1c Estimated average glucose Triglyceride-glucose index

Liver ALT ALP GGT Total bilirubin

Kidneys Creatinine eGFR Urea Urea to creatinine ratio

Proteins Total protein Albumin Globulin Albumin to globulin ratio

Vitamins Vitamin D Vitamin B12 Active B12 Folate

Minerals Magnesium

Metabolic Creatine kinase (CK) Uric acid

Enzymes Alpha-amylase

Consultations

Symptoms and conditions I work with every day

Most women come to me with several at once, often treated separately by different specialists, with no one connecting the dots. Seen together, they tell a story about what your body is going through.

Early perimenopause

  • Heavy periods, flooding and clotsHeavy and flooding periods in early perimenopause occur because anovulatory cycles allow the womb lining – the endometrium – to thicken without progesterone to provide the scaffolding. When that lining sheds as a period, the bleed is heavier, longer and more chaotic. The solution is to remove excess oestrogen via liver detoxification.
  • AnxietyAnxiety and worsening ADHD in early perimenopause are driven by a biochemical traffic jam. As progesterone drops and heavy bleeding drains iron, chaotic oestrogen spikes actively suppress the COMT enzyme, trapping adrenaline in your body. This hormonal bottleneck happens to everyone, but having a genetic Slow COMT variant makes it significantly worse by amplifying the panic and shattering focus. You can clear this backlog and reclaim calm by using magnesium, choline and targeted dietary shifts.
  • BloatingBloating appears because the gut is exquisitely sensitive to progesterone loss – as anovulatory cycles increase, gut transit slows, gas accumulates, and mast cell reactivity in the gut wall drives histamine-mediated distension. This hormonal gut disruption responds to addressing excess oestrogen to balance progesterone loss.
  • Sore breastsBreast tenderness in early perimenopause is caused by the Progesterone Shift: oestrogen continues stimulating breast tissue while progesterone – normally produced after ovulation to moderate that effect – is absent or insufficient, producing swelling, heaviness and sensitivity worst in the week before your period. Addressing the oestrogen dominance through the Progesterone Shift protocol is what resolves it.
  • Itchy skinExcess oestrogen releases excess histamine into your tissues. This sudden histamine spike can cause unexplained itching, flushing and hives. Some women experience a prickly sensation, “pins and needles”, or a feeling like something is crawling on the skin rather than a standard itch.

Complex conditions

  • FibroidsFibroids feed on oestrogen — and early perimenopause is when oestrogen runs highest and least opposed. As ovulation skips and progesterone crashes (the Progesterone Shift), oestrogen dominates, and the growth it drives is amplified by anything that raises oxidative stress in the uterus or slows your ability to clear oestrogen: insulin, alcohol, a struggling gut, low vitamin D and the Slow COMT gene. Most of those drivers are identifiable and addressable.
  • EndometriosisWhen two oestrogen-driven conditions meet, the result is not relief — it is amplification. The Progesterone Shift lands on lesion tissue that already produces its own oestrogen via local aromatase and is structurally resistant to progesterone — a double hit to the same imbalanced hormonal axis. For many women, perimenopause is the hardest chapter of the disease, and navigating it requires clinical support that addresses the hormonal terrain.
  • AdenomyosisEarly perimenopause worsens adenomyosis because erratic hormonal fluctuations trigger high spikes in oestrogen without enough progesterone to balance it. This “oestrogen dominance” directly stimulates the displaced endometrial tissue inside the uterine wall, causing it to swell and inflame. Combined with the increasingly irregular, heavier and more frequent menstrual cycles typical of early perimenopause, the uterus is forced to contract against stiff, inflamed muscle tissue, leading to significantly worse pelvic pain, debilitating cramps and severe bleeding.
  • PCOSWhat was once an evolutionary survival benefit is now causing havoc due to high testosterone driven by sugar and insulin. Intermittent periods, acne, weight gain and unwanted hair can improve in early perimenopause, but get worse in late perimenopause when dropping oestrogen magnifies insulin resistance.
  • PMDDPremenstrual 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.

Late perimenopause and menopause

  • Brain fogBrain fog — losing words, forgetting why you walked into a room, reading the same line three times — has a specific, physical cause: the brain running short of the energy it needs for you to think clearly. As ovarian oestrogen declines, it takes with it the ability to use sugar for energy — if you’re not burning fat, you will experience a severe energy deficiency.
  • Fatigue and energy crashes
  • Anxiety and mood swings
  • 3am waking
  • Hot flushes and night sweatsNot every woman gets hot flushes, even with the same fall in oestrogen — and that is the clue to what actually drives them. A flush is produced by the brain’s temperature centre, but what sets that centre firing is the shift in oestrogen together with the brain’s fuel and stress state. Here is the science underneath hot flushes, and what brings them down.
  • Weight gain and meno-belly
  • Joint painWaking up with stiff, painful joints in menopause? Discover the real root cause of menopause joint stiffness and how to reverse it without an HRT prescription.
  • Vaginal dryness and recurrent UTIsGenitourinary Syndrome of Menopause (GSM) isn’t a hormonal deficiency — it’s a progressive tissue and circulatory breakdown affecting up to 84% of women. By understanding how to protect the microbiome and intracrinology — how oestrogen can be made in the vaginal tissues — you can activate the body’s natural adrenal pathways to heal pelvic tissue from the inside out, completely independent of hormone prescriptions.
  • Bone health
  • Heart health

HRT support

ill woman red face peri
Point at a symptom to see it
Explore the knowledge hub

Wherever you are with HRT, I'll meet you there

HRT lays oestrogen over a transition that is already under way. In some women it relieves some symptoms. In many, it pauses or distorts the change the body was trying to complete.

Illustration of a woman holding up her hand to refuse HRT pills, patches and gels

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, and you can feel vibrant and confident in your health without it.

Menopause without HRT: how to come through it well
Illustration of a frustrated woman with her hand to her forehead, surrounded by HRT pills and patches

Why isn't my HRT working?

HRT is in place, but your symptoms haven't resolved or the side effects are too much. Coming off well is a process, not an event, and stopping suddenly can cause more problems. We prepare your body first, then plan a gradual step-down together.

Your HRT is not working and you want to come off
Illustration of a distressed woman holding her head, with HRT pills spilling from a bottle

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 struggling

Curious about your symptom pattern?

You've spent long enough treating these as separate problems. My 68-symptom quiz shows how they connect.

The peri/menopause clarity quiz: 68 symptoms gather into one pattern across four shifts

  • Where you are in the transition

    Early perimenopause, late perimenopause or postmenopause.

  • What is draining your energy

    How blood sugar, cortisol and thyroid function affect your energy and the hormones available to you.

  • Why your symptoms make patterns

    And what those patterns reveal about the systems struggling to adapt.

  • Why some things helped and others didn't

    And why the effects may not have lasted.

  • 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.

No hormones: start the quiz Yes: book a strategy call

“I felt better within a week, and 3 weeks later all my symptoms were almost gone. I came off HRT and my vitality is back. Transformative!”

Heidi B. Perimenopause symptoms reversed · via Google
  • 100+women supported
  • 10+years in clinical practice
  • 4weeks to first results
  • 1:1every consultation
  • I now understand and can control the flushes! And I have shifted 16lbs and feel better than ever.
  • I couldn’t believe how Sandra resolved my vaginal dryness so quickly and easily.
  • I have lost 2 stone, and haven’t had a migraine for 11 weeks! That has not happened since I was 15.
  • Within just a week I was feeling much healthier, clearer headed, and energised.
  • Menopausal symptoms can be resolved, there are many roads. I am eternally grateful as now I know how to take care of my health.
  • I’d recommend it to any woman, not as a diet, but as a way of rethinking how your body works and how to fuel it properly.
  • I was amazed at how quickly my weight started dropping and soon my migraines all but disappeared.
“Having guidance that doesn’t automatically lead to HRT, but instead looks at the whole picture of health, has been incredibly valuable.”
Ida F. Nature connection facilitator · via Google
“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.”
Danielle B. CEO, Black Minds Matter UK · via Google
“Absolutely mind-blowingly good. Patient, responsive, open, thoughtful. I’ve already suggested my daughters talk to her.”
Caron B. CEO, Charity Finance Group · via Google

Start with a free strategy call and feel better within 4 weeks

Tell me what has been happening and what you most want help with, and we'll put together a strategy to get your energy, mind and vitality back.

  1. Book your free strategy 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.

  2. Get your personal plan

    A 90-minute deep dive into your biology, plus functional testing, maps out your nutrition, supplement and lifestyle protocol.

  3. Feel the difference within 4 weeks

    Most women notice changes in energy, clarity and pain within 4 weeks, while we build long-term resilience for your brain, bones and heart.

On your free strategy 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

Calls Tuesday to Thursday, 8 to 10am and 2 to 5pm (UK time). 30 minutes, free, by phone.

Choose a time for your free call
Sandra Ishkanes smiling on a phone call at her desk

Questions women
ask me

Yes. While oestrogen decline is a fact of menopause, the symptoms are driven by how your body handles that shift. Many of the most severe symptoms - hot flushes, brain fog, broken sleep - are signals that the brain is struggling to switch fuel sources as oestrogen drops. When we support that metabolic shift directly, alongside gut and adrenal function, the symptoms that were signalling the crisis resolve. This is what I see in clinic, repeatedly.

Yes — if you are open to coming off HRT, as a goal once your biology is steady. I do not provide support designed to help women stay on HRT long-term; that is not where my clinical work sits. Many of the women I work with came to me on HRT and prepare to come off well and to avoid a return of symptoms. If this direction of travel feels right to you, we are well-matched.

That uncertainty is very common—and it is not a reason to wait. Perimenopause can begin years before periods stop, and the metabolic shifts it triggers are often already well underway before a GP would consider a diagnosis. If you are noticing changes in sleep, mood, or cognitive clarity, the biology is already shifting. Waiting for certainty usually means waiting for things to get worse.

Most appointments are 10–15 minutes and focused primarily on symptom management via HRT. My initial consultation is a 90-minute deep dive focused on your full history and biology. Standard clinics aim to manage symptoms; my aim is to optimise your health by changing the biological conditions that are producing those symptoms in the first place.

Standard blood panels rule out disease; they don’t map a biological transition. They test a narrow range of markers at a single point in time. Many drivers of menopause symptoms—like hormone metabolism, adrenal function, or gut health—simply don't appear in routine GP tests. “Normal” means nothing was flagged as pathological; it doesn't mean the biological picture is complete. As a health detective, I look for the logic in the data that standard tests leave behind.

Most women notice meaningful change within 4 weeks—typically in energy, brain fog and sleep first. Almost all symptoms resolve within 8 – 12 weeks. I will give you a clear, honest picture of your timeline at your first consultation. I do not make promises I cannot keep, and I do not take on clients I do not think I can help.

The initial consultation is £365 (90 minutes) and follow-up sessions are £165 (45 minutes). I do not lock clients into fixed packages; the work continues only for as long as it is useful. I also offer payment plans for those with constrained budgets. Consider this an investment in a roadmap that finally makes sense of your body, rather than continuing to spend on "Band-Aid" fixes that don't work.

Consultation fees do not include laboratory testing costs, which are paid directly to the lab. Blood testing is almost always required and highly targeted - I only recommend what is necessary to solve your specific "detective" case. Advanced tests (like the DUTCH test or microbiome mapping) range from £150 to £400 depending on the complexity of symptoms.

I clients online only. Using a secure telehealth platform, I provide the same level of deep-dive clinical support and functional testing analysis regardless of your location. You can access specialist menopause care from the comfort of your own home.

From the knowledge hub

Understand what your body is doing

Browse all articles