Case Study: The Unraveling — Perimenopause, Panic Attacks, and the Midlife Awakening

Category: Case Studies | All Four Directions | Composite Clinical Case

DISCLAIMER: This is a composite fictional case study based on common clinical patterns observed across integrative and functional medicine practice. It does not represent any single real patient. All names, identifying details, and specific circumstances are invented. The clinical patterns, lab values, treatment protocols, and healing trajectories described reflect well-documented presentations in the literature and are intended for educational purposes.

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Presenting Complaint

Hoa, a 47-year-old Vietnamese-American woman, arrived at the initial consultation in visible distress. She had experienced her first panic attack six months prior while driving on the freeway — sudden onset of racing heart, shortness of breath, chest tightness, derealization (“everything felt unreal”), and the conviction she was dying. She pulled over, called 911, and was taken to the ER where cardiac workup was negative. Since then, she had experienced 2-3 panic attacks weekly, along with pervasive anxiety, insomnia (difficulty falling asleep, then waking at 2-3 AM drenched in sweat and unable to return to sleep), and episodes of rage that frightened her — snapping at her teenage children over minor infractions, slamming doors, once throwing a plate.

“I don’t recognize myself,” she said. “I’ve always been the calm one. The steady one. Now I feel like I’m losing my mind.”

Her PCP had run a basic workup: CBC, CMP, TSH, and EKG — all “normal.” The diagnosis: “perimenopause and anxiety.” The prescription: sertraline 50mg and a referral to a psychiatrist for possible benzodiazepine. Hoa took the sertraline for three weeks, experienced worsening insomnia, sexual side effects, and emotional blunting (“I stopped feeling the rage but I also stopped feeling everything”), and discontinued it.

Additional symptoms upon detailed inquiry: hot flashes (8-12 daily, severe at night — the night sweats), periods becoming irregular (cycles 21-40 days, some heavy with clotting, some scanty), vaginal dryness, decreased libido (from “healthy” to “nonexistent” over 18 months), joint pain in hands and knees (new onset, no prior history), heart palpitations (independent of panic attacks — random, brief, frightening), brain fog (“I walk into a room and forget why I’m there — ten times a day”), weight gain of 12 pounds concentrated abdominally despite no change in diet or exercise, and a persistent, low-grade depression that she described not as sadness but as flatness: “It’s like the color has drained out of everything.”

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History

Medical History

Three pregnancies, three vaginal deliveries. Gestational diabetes with third pregnancy (resolved postpartum, but a significant risk factor for metabolic dysfunction at perimenopause). History of postpartum depression after second child (managed with talk therapy and time, no medications). Appendectomy at age 19. Otherwise unremarkable medical history through her 30s and early 40s.

Family History

Mother: early menopause (age 44), osteoporosis, anxiety disorder (untreated — “Vietnamese women don’t go to therapists”), hypertension. Father: Type 2 diabetes, coronary artery disease (stent at 62). Maternal aunt: breast cancer (age 58). Family history notable for metabolic syndrome on both sides and early menopause on the maternal line.

Social History

Hoa was born in Houston, Texas. Her parents arrived from Vietnam in 1978 as boat people — a journey she knew about only in fragments, as her parents never spoke of it directly. She was the eldest of four children and assumed the caretaker role early: cooking for her siblings while her parents worked, translating at parent-teacher conferences, mediating family conflicts. She married Dũng, a Vietnamese-American physician, at age 24. The marriage was stable but had become, in her words, “a business arrangement — we manage the house, the kids, the finances. We don’t talk about anything real.”

She had three children: a daughter (22, in college), a son (17, junior in high school), and a daughter (15, freshman). The eldest had just left for university — Hoa’s first experience of the empty nest, and it had rattled her more than she expected.

Hoa’s identity for 22 years had been organized around motherhood. She left her career as a physical therapist when her first child was born and never returned. When asked what she did for herself — hobbies, passions, friendships — she paused for a long time. “I used to paint. In college. I was good at it.” She hadn’t picked up a brush in over twenty years. “There was never time. The kids needed me.”

Emotional History

Hoa presented as composed and articulate, but beneath the composure was a woman in crisis. The rage episodes terrified her because they violated her core self-image: calm, nurturing, in control, selfless. The Vietnamese cultural framework she had internalized demanded that mothers be patient, sacrificing, and emotionally steady. The rage felt like evidence that she was failing as a woman, a mother, and a person.

Deeper exploration revealed: the rage was not new. It was newly expressed. Hoa had been suppressing anger for decades — anger at her husband for emotional absence, anger at her parents for the weight of caretaking they placed on her as a child, anger at the cultural expectations that required her to dissolve herself into the family. The perimenopause hormonal shift had thinned the wall she had built around this anger, and it was erupting.

She also described a growing, nameless grief — not for anything she had lost, but for something she had never had: a life of her own. “I spent my whole life taking care of everyone else. And now that the kids are growing up, I look in the mirror and I don’t know who’s there.”

Spiritual History

Hoa attended a Vietnamese Buddhist temple with her mother-in-law monthly, more from obligation than devotion. She found the rituals comforting but the doctrine abstract. She had no personal spiritual practice. However, she described an experience from six months earlier that she had told no one about: during a particularly severe night sweat episode, lying awake at 3 AM, she felt a sudden, inexplicable expansion — as if the walls of the room and the walls of her identity dissolved simultaneously, and she was vast, undefined, and at peace. It lasted perhaps thirty seconds. Then terror replaced it, and she had her second panic attack.

This experience was significant. It suggested that the perimenopause crisis was not merely hormonal and psychological — it was also a spiritual emergence, a cracking open of the identity structure that had contained her for decades.

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Assessment Through Four Directions

Serpent / Rắn (South) — Physical Body

Perimenopause is not a disease — it is a normal developmental transition. But “normal” does not mean “insignificant.” The hormonal shifts of perimenopause are among the most dramatic physiological changes the body undergoes outside of puberty and pregnancy, and they interact with every system in the body.

Hoa was experiencing the classic perimenopause presentation: declining and fluctuating progesterone (the first hormone to decline, often years before estrogen drops — creating a state of estrogen dominance relative to progesterone), erratic estrogen fluctuations (the brain’s thermostat loses its reference point, driving hot flashes and night sweats), progesterone’s loss of its calming GABA-receptor activity (progesterone metabolites — specifically allopregnanolone — are potent GABA-A receptor agonists; their decline directly causes anxiety, insomnia, and irritability), and the downstream effects on cortisol (which rises to compensate for declining ovarian hormones, creating or worsening HPA axis dysfunction).

The hot flashes were not merely annoying — they were driving severe sleep deprivation, which was compounding the cortisol dysregulation, worsening the mood instability, accelerating cognitive decline, and creating a self-reinforcing crisis loop.

The history of gestational diabetes was a red flag for insulin resistance at perimenopause — the declining estrogen removes a protective effect on insulin sensitivity, and women with a history of GDM often develop metabolic syndrome in the perimenopausal years.

Jaguar / Báo (West) — Emotional Body

The Jaguar direction revealed the emotional earthquake beneath the hormonal shift. Perimenopause, for many women, functions as a truth serum — the progesterone that once buffered emotional reactivity (via GABA-A activity) thins, and everything that was suppressed rises to the surface. This is not pathology. It is revelation.

Hoa’s rage was not a symptom to be medicated. It was decades of suppressed anger finally reaching the surface because the hormonal wall that contained it was dissolving. The anger was information: about boundaries never set, needs never expressed, a marriage that had become emotionally empty, a life structured entirely around others’ needs.

In IFS terms, a Manager part — “The Perfect Vietnamese Wife and Mother” — had been running Hoa’s system for 22 years. This part suppressed anger, suppressed desire, suppressed any impulse that might disrupt the family equilibrium. The perimenopause hormonal shift weakened this Manager’s grip, and the exiled rage — decades of stored anger — began breaking through. The panic attacks were the system’s alarm response to these breakthrough emotions: the Manager’s terror at losing control.

The empty nest was the trigger that gave the emotional crisis its existential dimension. When the primary purpose that organized Hoa’s identity (mothering) began to end, the question “Who am I?” stopped being philosophical and became visceral.

Hummingbird / Chim Ruồi (North) — Soul

At the Hummingbird level, Hoa was in the midst of what James Hollis calls “the second adulthood” — the midlife passage in which the ego structures that served the first half of life must be dismantled so the soul’s deeper purposes can emerge. This is not a crisis of aging. It is a crisis of meaning.

The question “Who am I beyond mother and wife?” was the Hummingbird’s central inquiry. The abandoned painting practice was a clue — the soul had been trying to express itself through art for decades, and the caretaking identity had consistently overridden that call.

In Vietnamese cultural context, this passage is particularly fraught because the culture does not have a framework for midlife individuation. The Vietnamese woman’s role trajectory is typically: daughter → wife → mother → grandmother. There is no culturally sanctioned phase of “woman discovering her own identity.” Hoa was blazing a trail that her culture had not mapped.

Eagle / Đại Bàng (East) — Spirit

The 3 AM experience — the expansion, the dissolution of boundaries, the momentary peace followed by terror — was a classic description of what contemplative traditions call a “glimpse experience” or what Grof and Grof (1989) would term a “spiritual emergency element.” The ordinary ego structure temporarily dissolved, revealing the vastness beneath it. The terror was not about the experience itself — it was the ego’s response to its own dissolution.

This experience suggested that the perimenopause crisis was, in its deepest dimension, a spiritual awakening in process — an invitation to move from identity-as-role to identity-as-awareness. The panic attacks themselves might be understood, in part, as the ego’s fight-or-flight response to its own transformation.

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Testing & Diagnosis

Functional Medicine Laboratory Workup

Hormonal Panel (DUTCH Complete):

• Estradiol: fluctuating — two samples showed 48 pg/mL and 182 pg/mL within the same cycle (the chaotic estrogen fluctuations of perimenopause)
• Progesterone metabolites: severely low — pregnanediol at 18% of expected mid-luteal value (confirms anovulation or severely deficient ovulation)
• Cortisol pattern: reversed — low morning (blunted CAR at 22%), elevated evening cortisol, elevated bedtime cortisol
• Total cortisol metabolites: elevated (body is producing cortisol, but the rhythm is wrong)
• DHEA-S: 108 mcg/dL (low for age — depleted)
• Melatonin metabolite (6-OH-melatonin sulfate): low (circadian rhythm disruption)
• Estrogen metabolites: 4-OH estrone elevated relative to 2-OH estrone (unfavorable estrogen metabolism — higher breast cancer risk pathway)

Interpretation: The classic perimenopause DUTCH pattern — progesterone collapse, estrogen chaos, cortisol dysregulation (the adrenals attempting to compensate for ovarian decline), depleted DHEA, and disrupted circadian rhythm. The unfavorable estrogen metabolism (elevated 4-OH pathway) is clinically relevant given her family history of breast cancer.

Blood Work:

• TSH: 3.8 mIU/L (functional red flag — thyroid declining, likely dragged down by perimenopause hormonal shifts and cortisol dysregulation)
• Free T4: 1.1 ng/dL (low-normal)
• Free T3: 2.3 pg/mL (low — impaired conversion)
• TPO antibodies: 48 IU/mL (mildly elevated — early Hashimoto’s, not uncommon in perimenopause when immune dysregulation occurs)
• Fasting glucose: 96 mg/dL
• Fasting insulin: 14.2 uIU/mL (elevated — insulin resistance developing)
• HOMA-IR: 3.36 (elevated)
• HbA1c: 5.5%
• Lipid panel: Total cholesterol 232, LDL 148, HDL 48, Triglycerides 180 (all worsening — estrogen decline removes cardiovascular protection)
• hs-CRP: 3.1 mg/L (inflammatory)
• Vitamin D: 24 ng/mL (insufficient)
• Ferritin: 32 ng/mL (low — heavy periods depleting iron)
• RBC Magnesium: 3.8 mg/dL (depleted)
• Homocysteine: 12.4 umol/L (elevated — cardiovascular risk, methylation impairment)

DEXA Scan:

• T-score: -1.3 at lumbar spine (osteopenia — bone loss already beginning, consistent with estrogen and progesterone decline)

TCM Assessment

Tongue: red, thin coat, especially red on the sides (Liver Fire rising) and tip (Heart Fire) Pulse: wiry and rapid, thin at the Kidney position Pattern: Kidney Yin Deficiency with Liver Yang Rising, Heart-Kidney Disharmony (Heart Fire / Kidney Water imbalance)

This is the classic TCM menopause pattern: Kidney Yin (the cooling, moistening, anchoring force) declines with age. Without sufficient Yin to anchor the Yang, Liver Yang rises (the rage, the heat, the headaches). Without Kidney Water to cool Heart Fire, the Shen (spirit/mind) becomes agitated (the anxiety, insomnia, palpitations). The night sweats are Yin Deficiency Heat — the body’s cooling system can no longer contain the heat.

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Treatment Plan

Phase 1: Hormonal Stabilization (Months 1-3) — Serpent Priority

Bioidentical Progesterone:

• Oral micronized progesterone (Prometrium): 200mg at bedtime (physician-prescribed). This single intervention addresses multiple symptoms simultaneously: progesterone’s GABA-A receptor activity reduces anxiety and promotes sleep (the “Valium-like” effect of progesterone metabolites); it opposes estrogen dominance (reducing heavy bleeding, breast tenderness, and unfavorable estrogen effects); it supports bone density; and it has neuroprotective effects. The Prior protocol (Jerilynn Prior, MD, UBC) demonstrates that progesterone alone — without estrogen — is often sufficient for early perimenopause symptom management.
• Timing: at bedtime, because the GABA-A activity produces drowsiness. This directly addresses the insomnia.

Hot Flash Protocol:

• Black cohosh (Remifemin): 40mg daily (standardized extract). Meta-analysis demonstrates significant reduction in hot flash frequency and severity; mechanism likely involves serotonin receptor modulation rather than estrogenic activity (Borrelli & Ernst, 2008).
• Sage leaf extract: 280mg daily (standardized; a Swiss RCT by Bommer et al., 2011 showed 50% reduction in hot flash frequency at 4 weeks and 64% at 8 weeks)
• Rhapontic rhubarb extract (EstroG-100 or Rheum rhaponticum): 4mg daily (clinically studied for hot flashes with significant reduction vs. placebo)

Cortisol Rhythm Restoration:

• Phosphatidylserine: 400mg at bedtime (lower elevated evening cortisol)
• Ashwagandha KSM-66: 300mg twice daily (adaptogenic — normalizes cortisol rhythm, supports thyroid)
• Magnesium glycinate: 600mg at bedtime (GABA support, sleep support, muscle relaxation)
• L-theanine: 200mg at bedtime (alpha wave promotion, calms without sedating)

Nutrient Repletion:

• Vitamin D3: 5,000 IU daily + K2 (MK-7) 200mcg (bone support + immune modulation)
• Iron bisglycinate: 36mg daily (replenishing losses from heavy periods)
• B-complex with methylated B12 and folate (methylation support, homocysteine reduction)
• Omega-3: 3g daily EPA/DHA (anti-inflammatory, cardiovascular protection, mood support)
• DIM (diindolylmethane): 200mg daily (supports favorable estrogen metabolism — shifts metabolism toward protective 2-OH pathway and away from potentially harmful 4-OH and 16-OH pathways; Dalessandri et al., 2004)
• Calcium-D-glucarate: 500mg daily (supports estrogen clearance via glucuronidation)

Metabolic Support:

• Berberine: 500mg 2x daily (insulin sensitization — her HOMA-IR of 3.36 must be addressed before it progresses to diabetes, especially given her GDM history)
• Anti-inflammatory diet: Mediterranean-style with Vietnamese influences. Abundant vegetables, fatty fish, olive oil, nuts, seeds, bone broth. Reduce refined carbohydrates, sugar, alcohol (even small amounts of alcohol significantly worsen hot flashes and disrupt sleep architecture in perimenopause)

Acupuncture:

• Weekly for first 8 weeks, then biweekly
• Points: KI 3, KI 6 (nourish Kidney Yin), LV 3 (calm Liver Yang), HT 7 (calm Shen), SP 6 (hormonal regulation — the classic gynecological point), Yin Tang (calm mind), Du 20 (raise clear Yang)
• A Cochrane review and multiple RCTs demonstrate acupuncture’s efficacy for hot flashes, insomnia, and anxiety in perimenopause (Chiu et al., 2015)

Phase 2: Emotional Reckoning (Months 2-6) — Jaguar Priority

IFS Therapy (Weekly):

The Manager: “The Perfect Mother” This part had organized Hoa’s entire adult life. Its rules: never show anger, never prioritize yourself, always be available, always be patient, always sacrifice. It was terrified that the emerging rage would destroy her family. In IFS, the work was to help this part understand that it was exhausted, that its rigid rules were no longer adaptive, and that letting the Self lead would not result in the catastrophe it feared.

The Firefighter: “The Rage” The rage, when approached with curiosity rather than fear, revealed itself as a decades-old accumulation of unexpressed truth. It was not irrational. It was profoundly rational: the rage of a woman who had been giving for 22 years without receiving. The work was not to eliminate the rage but to metabolize it — to hear its message, to express the truths it carried, and to channel its energy toward change rather than explosion.

The Exiles:

• “The Parentified Child” — a 10-year-old part carrying the burden of having been the family caretaker too early. This exile carried grief for the childhood she never had and resentment toward her parents for the weight they placed on her.
• “The Artist” — a college-age part who had been exiled when Hoa chose the expected path (marriage, motherhood) over the desired path (painting, art, self-expression). This part carried yearning and mourning for a life unlived.

Couples Therapy:

• Hoa and Dũng began couples therapy in Month 3. The marriage had become a functional partnership devoid of emotional intimacy. Both were Vietnamese-American professionals who had inherited the cultural model of marriage-as-duty rather than marriage-as-connection. The therapy focused on: emotional communication (both struggled to express feelings directly), rebuilding physical and emotional intimacy, and renegotiating the marriage for its next phase — not as co-parents but as partners.
• This was culturally challenging. Vietnamese couples do not traditionally “go to therapy.” Dũng initially resisted. His willingness to attend, once he understood Hoa’s crisis, was itself a turning point.

Somatic Processing:

• Body-based processing of rage: breathwork, movement, vocalization. The instruction: “Anger lives in the body. It needs to move through the body, not just be talked about.”
• Yin yoga for the Liver and Kidney meridians: long-held hip openers (pigeon pose, dragon pose, butterfly) to release stored tension in the hips and pelvis — where anger and grief are somatically stored in Chinese medicine and somatic traditions.

Phase 3: Identity Reconstruction (Months 4-8) — Hummingbird Priority

Narrative Work: The central question: “Who is Hoa, apart from mother, wife, daughter, caretaker?”

This question was both liberating and terrifying. Hoa’s entire identity had been relational — defined by her roles, her functions, her service to others. Stripping those away revealed… what? The void she felt when her daughter left for college was the void of an unlived self.

• Journaling practice: “Write about the woman you were before you became a mother. What did she want? What did she dream? What did she love?”
• The painting returned. First tentatively — small watercolors at the kitchen table. Then larger. Then she enrolled in a weekend art class and came to the next therapy session glowing: “I forgot that I could make things. Not meals, not schedules, not arrangements — actual things. Beautiful things.”

Midlife Reframe: The cultural narrative Hoa had internalized: menopause = decline, aging = loss of value, midlife = the beginning of the end. The integrative reframe: perimenopause as initiation. In many indigenous traditions, menopause marks a woman’s transition from the mother archetype to the wise woman / crone archetype — not a diminishment but an elevation. The Vietnamese concept of “going from nuôi con (raising children) to nuôi mình (raising oneself)” was introduced — not from the culture directly (which does not frame it this way) but as an adaptation: the care and skill she brought to mothering, now directed inward.

Reading and Study:

• Christiane Northrup, The Wisdom of Menopause — the body-mind-spirit approach to the menopausal transition
• James Hollis, The Middle Passage: From Misery to Meaning in Midlife
• Sue Monk Kidd, When the Heart Waits — a contemplative approach to midlife transformation

Phase 4: Spiritual Emergence (Months 6-10) — Eagle Priority

Meditation Practice: The 3 AM expansion experience had planted a seed. When Hoa felt ready (Month 6), she was introduced to a simple sitting practice — not mindfulness-of-breath alone, but a more open awareness practice in which she was invited to rest in the awareness that was already present behind all the noise of her thoughts and emotions.

The instruction: “You have been the mother, the wife, the caretaker, the dutiful daughter. Behind all those roles, who is watching? That witness — that awareness — has been here your whole life, unchanged. Can you rest there, even for a moment?”

This practice was transformative. Within weeks, Hoa reported moments of the same spaciousness she had experienced at 3 AM — but without the terror, because now she had a framework for understanding it and a nervous system stable enough (from the hormonal, emotional, and soul-level work) to tolerate it.

Nature Contemplation:

• Weekly solo walks in nature — not as exercise, but as spiritual practice. The instruction: “Walk without destination. Listen to what the world is telling you. Let the trees be your teachers for an hour.”
• These walks became her primary spiritual practice — more resonant for her than formal seated meditation.

Integration of the 3 AM Experience:

• In therapy, the 3 AM experience was revisited. Instead of pathologizing it (as the ER and the PCP had implicitly done by treating the subsequent panic attack), it was honored as a genuine spiritual experience — a moment when the ego structure cracked and the larger Self was briefly visible. The panic was reframed: not as mental illness, but as the ego’s terror at its own transcendence. This reframe was profoundly healing.

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Timeline & Progress

Month 1

• Began progesterone, supplements, dietary changes, acupuncture
• Night sweats reduced approximately 40% within first week of progesterone
• Sleep improved dramatically — falling asleep within 20 minutes instead of 2 hours
• Panic attacks: still occurring but less frequent (1-2/week instead of 2-3)
• Rage episodes: unchanged (the hormonal support reduced the intensity but the emotional content required its own work)

Month 2

• Hot flashes reduced to 3-4/day (from 8-12)
• Sleep: waking once at night instead of 2-3 times; returning to sleep within 20 minutes
• Began IFS therapy — initial sessions with the Manager part
• Panic attacks: 1/week
• Began couples therapy consultation (Dũng agreed to attend after Hoa expressed the depth of her crisis)

Month 3

• Repeat labs: Fasting insulin 10.8 (down from 14.2), hs-CRP 1.8 (down from 3.1), Vitamin D 36 ng/mL
• Energy significantly improved — “I feel like a human being again”
• IFS: accessed the rage Firefighter. Two intensely emotional sessions. Hoa expressed anger in session for the first time — toward her parents, toward the cultural expectations, toward her husband.
• Couples therapy began — first session was awkward and surface-level. By the third session, Hoa said things to Dũng she had never said in 23 years of marriage.

Month 4-5

• Hot flashes: 1-2/day, manageable
• Panic attacks: rare (1-2/month), less intense, resolvable with breathing techniques
• IFS exile work: the Parentified Child was unburdened. Hoa grieved the childhood she never had — the freedom, the play, the right to be a child rather than a caretaker. This grief was immense and necessary.
• Marriage: emotional intimacy increasing. First genuine conversation about their sexual relationship in years. Both vulnerable, both scared, both willing.
• Began painting again — small pieces, private, but deeply satisfying

Month 6

• Repeat DUTCH: cortisol rhythm normalizing (CAR 44%, evening cortisol declining). Progesterone metabolites improved with supplementation. DHEA-S 148 mcg/dL (rising with DHEA supplementation, 10mg morning).
• The Artist exile was approached in IFS. Hoa wept when she realized how long this part of her had been silenced. “I abandoned her. The part of me that makes beauty — I locked her in a room for twenty years because there was ‘no time.’”
• Began meditation practice — initially 10 minutes, increasing to 20 by month’s end
• Described the process as: “I’m not just feeling better. I’m becoming someone new. Or maybe I’m becoming who I always was.”

Month 7-8

• Hot flashes: rare (1-2/week, mild)
• Sleep: consolidated 7-8 hours most nights without medication
• Panic attacks: none in 6 weeks
• Rage: transformed from explosive outbursts to clear, firm communication. “I still feel the fire. But now I can use it to speak my truth instead of burning down the house.”
• Weight: lost 8 of the 12 pounds without dieting — cortisol normalization + insulin sensitivity improvement + reduced stress eating
• Marriage: described as “a work in progress but with a pulse — we’re actually growing together instead of just coexisting”
• Enrolled in a community art class — painting watercolors of Vietnamese landscapes from her parents’ stories

Month 10 (Final Assessment)

• Labs: TSH 2.2 (improved), Free T3 2.9 (improved), TPO antibodies 32 (declining), HOMA-IR 2.1 (near-normal), hs-CRP 0.9 (normalized), Homocysteine 8.2 (improved), Lipid panel normalizing (Total cholesterol 198, LDL 118, HDL 56, Triglycerides 120)
• DEXA: T-score -1.1 (slight improvement with progesterone, vitamin D, K2, weight-bearing exercise)
• Hot flashes: rare and mild
• Sleep: healthy and restorative
• Mood: stable with full emotional range — capable of anger, joy, grief, and peace without being overwhelmed by any
• Relationship with children: more authentic. “I’m not performing motherhood anymore. I’m actually being their mother — a real person, not a saint.”
• Relationship with husband: renewed. Physical intimacy returned. Emotional intimacy deepening.
• Painting: now a regular practice. Had shown her work at the community art class exhibition. Was considering teaching art to Vietnamese immigrant children.
• Meditation: daily practice, 20 minutes. Described moments of “being at home in the universe” that no longer frightened her.
• Her summary: “I thought perimenopause was something happening to me. Now I understand it was something happening for me. It burned down the life I’d built so I could build the one I actually wanted.”

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Key Turning Points

Turning Point 1: Progesterone at Bedtime (Month 1)

The single most impactful initial intervention. By restoring GABA-A receptor activity, progesterone addressed the insomnia, reduced the anxiety, and dampened the hot flashes — all within the first week. This is the Serpent lesson: biochemistry matters. When progesterone plummets and the nervous system loses its primary calming neuromodulator, no amount of therapy or meditation can compensate. The physical foundation must be addressed.

Turning Point 2: The Rage Sessions in IFS (Month 3)

When Hoa allowed herself to feel and express the rage she had suppressed for decades — in a safe, contained therapeutic space — the panic attacks virtually stopped. The panic had been the body’s alarm system signaling that overwhelming emotion was breaking through. Once the emotion had a channel — speech, expression, tears — the alarm was no longer needed. This is the Jaguar lesson: emotions do not disappear when suppressed. They go underground and emerge as symptoms.

Turning Point 3: Painting (Month 6)

The return to art was not a hobby. It was a soul retrieval. In Villoldo’s framework, soul loss occurs when a vital part of the self is severed through trauma, neglect, or cultural conformity. Hoa’s artist-self had been severed when she chose the expected life over the desired one. Its return brought vitality, color, and meaning that no supplement or therapy session could provide. This is the Hummingbird lesson: the soul must be fed its native food.

Turning Point 4: The Reframe of the 3 AM Experience (Month 6)

When the expansion experience was reframed from “something terrifying that preceded a panic attack” to “a spiritual opening that your ego was not yet ready to integrate,” Hoa’s relationship with her own consciousness changed. She stopped fearing the dissolution and began welcoming the spaciousness. This is the Eagle lesson: the dissolution of identity that perimenopause catalyzes can be the gateway to a deeper, more expansive sense of self.

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Where Single-Direction Treatment Failed

Serpent alone (hormones and supplements): Progesterone and supplements would have reduced symptoms — hot flashes, insomnia, anxiety. But without addressing the decades of suppressed rage, the empty-nest identity crisis, and the spiritual awakening in process, Hoa would have been comfortable but still lost. The hormones would have managed the transition without catalyzing the transformation it offered.

Jaguar alone (therapy without hormonal support): Therapy in the context of severe progesterone deficiency, disrupted cortisol rhythm, and profound sleep deprivation would have been marginally effective at best. A brain deprived of sleep and GABA activity cannot do deep emotional work. The nervous system must be stabilized before it can be explored.

Hummingbird alone (midlife workshops and journaling): Identity work without the biochemical stabilization or the emotional processing would have been intellectual and disconnected. Hoa could not access her soul’s questions while her body was in hormonal crisis and her emotional system was in civil war.

Eagle alone (meditation retreats): Meditation in an unstable nervous system can be destabilizing — as Hoa’s 3 AM experience demonstrated. The expansion was real, but without the container of physical stability, emotional processing, and soul-level understanding, it manifested as terror rather than liberation.

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Lessons & Principles

1. Perimenopause is not a disease to be managed — it is a developmental transition to be supported. The conventional approach (SSRIs, anxiolytics) manages symptoms while suppressing the transformation. The integrative approach addresses the biochemistry while honoring the developmental process.

2. Progesterone is the forgotten hormone of women’s mental health. Its decline in perimenopause directly causes anxiety, insomnia, irritability, and panic through GABA-A receptor withdrawal. Bioidentical progesterone at bedtime is often the single most impactful intervention.

3. Midlife rage in women is not pathology — it is revelation. The anger that emerges in perimenopause is often decades of suppressed truth finally reaching the surface. It requires expression and metabolization, not suppression.

4. The empty nest is an identity crisis as much as an emotional event. For women whose identity was organized around motherhood, the children’s departure creates an existential vacuum that demands soul-level work — not just grief counseling.

5. Vietnamese cultural expectations for women can be both strength and prison. The values of devotion, sacrifice, and family commitment are genuine and beautiful. When they become totalizing — when a woman cannot exist outside her roles — they become pathogenic. Healing requires honoring the culture while claiming the self.

6. Spiritual experiences during life transitions deserve to be honored, not pathologized. The expansion, dissolution, and oceanic experiences that can accompany perimenopause, grief, and other major life transitions may be spiritual emergences — not symptoms of mental illness.

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References

• Bommer, S., Klein, P., & Suter, A. (2011). First time proof of sage’s tolerability and efficacy in menopausal women with hot flushes. Advances in Therapy, 28(6), 490-500.
• Borrelli, F., & Ernst, E. (2008). Black cohosh (Cimicifuga racemosa) for menopausal symptoms: A systematic review of its efficacy. Pharmacological Research, 58(1), 8-14.
• Chiu, H. Y., et al. (2015). Effects of acupuncture on menopause-related symptoms and quality of life in women in natural menopause: A meta-analysis of randomized controlled trials. Menopause, 22(2), 234-244.
• Dalessandri, K. M., et al. (2004). Pilot study: Effect of 3,3’-diindolylmethane supplements on urinary hormone metabolites in postmenopausal women with a history of early-stage breast cancer. Nutrition and Cancer, 50(2), 161-167.
• Grof, S., & Grof, C. (1989). Spiritual Emergency: When Personal Transformation Becomes a Crisis. Tarcher/Putnam.
• Hollis, J. (1993). The Middle Passage: From Misery to Meaning in Midlife. Inner City Books.
• Northrup, C. (2012). The Wisdom of Menopause: Creating Physical and Emotional Health During the Change. Bantam.
• Prior, J. C. (2018). Progesterone for the prevention and treatment of osteoporosis in women. Climacteric, 21(4), 366-374.
• Schwartz, R. C. (2021). No Bad Parts: Healing Trauma and Restoring Wholeness with the Internal Family Systems Model. Sounds True.
• Villoldo, A. (2000). Shaman, Healer, Sage: How to Heal Yourself and Others with the Energy Medicine of the Americas. Harmony Books.