Perimenopause is a "Diagnosis of Exclusion," so What Does That Mean?

In medicine, there’s something called a “diagnosis of exclusion.” Meaning, symptoms may point to a certain diagnosis but since there isn’t a definitive “yes or no” test AND there are a number of other possible diagnoses with major implications, we have to make sure it ISN’T one of those first.

Here’s an example: Irritable bowel syndrome (IBS) presents with abdominal pain, gas, bloating, and some combination of diarrhea or constipation or both. We don’t have a blood test to confirm IBS, and many of the symptoms can overlap with diagnoses such as Crohn’s disease, ulcerative colitis, or colon cancer. So for some patients with certain worrisome symptoms (like blood in the stool or weight loss), we must rule out these other possibilities (which require a very different, very specific treatment) before a diagnosis of IBS can be made. Sometimes that work-up is costly and takes a few different appointments for blood tests, stool studies, a colonoscopy, and possibly even a referral to a gastroenterologist. And then, when it ISN’T one of those other diagnoses, we can say with some certainty. Yep, it’s IBS!

Often patients grow frustrated wondering, Why did my doctor do all those expensive tests? Why didn’t they know? Are they stupid? It was IBS!! I said that all along! And even another practitioner might agree after looking over all the results, silly doctor! Everything was normal. It was IBS!

But there is a REASON for that work-up. And one of your doctor’s jobs is to rule out worst case scenarios so they don’t miss something that can be very serious or even deadly. What else could this be? What is the diagnosis I absolutely can’t miss?

Perimenopause is a little like that.

Yes. The hormonal changes associated with the menopausal transition in your forties create a whole host of predictable (though highly variable) symptoms. However, those symptoms can sometimes overlap with other possible diagnoses and can be unique to each woman. We don’t have a specific blood test to confirm perimenopause since hormone levels fluctuate with the menstrual cycle day to day. And a woman in perimenopause may still have normal periods AND symptoms like fatigue, brain fog, mood changes, heart palpitations, sweating, joint pain, weight gain, etc.

We first have to make sure it ISN’T a thyroid problem or carcinoid syndrome or even a pituitary adenoma or cancer or supraventricular tachycardia or a number of other possible diagnoses depending on the presenting symptoms BEFORE we chalk it up to perimenopause (a diagnosis of exclusion) and begin very specific treatment options for perimenopause.

It’s frustrating, I know. But your doctor isn’t an idiot or missing something or unaware of perimenopause or just trying to waste your time and money on an expensive work-up.

Your doctor cares very deeply about you and about doing the right thing and about helping you feel better and about not missing a diagnosis with very serious implications AND about not wasting money, time, or resources on expensive tests that aren’t necessary (like hormone testing which actually isn’t indicated unless you are under the age of 45 and have missed three periods in a row).

It’s a delicate balance…but with patience and good communication, you and your provider can work together to find the right treatment plan for YOU!