PCOS Doesn’t End at 30: What High-Functioning Women Need to Know in Midlife
Anna Harrelson • March 22, 2025
It’s not just about fertility. It’s about your metabolism, hormones, and long-term health—even in perimenopause and beyond.

"You can’t have PCOS anymore, you’re too old."
"You were just estrogen dominant."
"It was probably just your birth control messing with your cycle."
If you’ve heard any of these before, you’re not alone—but they’re not the full story. Polycystic Ovary Syndrome (PCOS)
is one of the most misunderstood and underdiagnosed hormonal conditions in women, especially as we move into midlife.
As a lifestyle medicine physician and menopause specialist, I see so many women in their 40s and 50s who were never properly diagnosed, or who were told their PCOS “resolved” after their twenties. But the truth is, PCOS is not just a reproductive disorder—it’s a lifelong metabolic and neuroendocrine condition that can shape how you experience perimenopause, menopause, and the decades beyond.
Let’s dive into what PCOS really looks like, why so many smart, high-functioning women have been missed or misdiagnosed, and how we can support your hormones, metabolism, and nervous system at midlife and beyond.
What Is PCOS, Really?
Polycystic Ovary Syndrome is a condition of hormonal imbalance, typically involving irregular or absent ovulation, higher levels of androgens (like testosterone or DHEA), and signs like acne, hirsutism, or hair thinning. It’s diagnosed using the Rotterdam criteria, which require two out of three of the following:
- Irregular cycles or lack of ovulation
- Elevated androgens (on labs or symptoms)
- Polycystic-appearing ovaries on ultrasound
But here’s the thing: you don’t need to look like a textbook case to have PCOS. And you don’t have to be overweight, either.
Many women I see had irregular periods in their teens or early 20s, were put on birth control to "regulate" them, and never thought about it again. But under the surface, they may still be dealing with insulin resistance, metabolic dysfunction, and the downstream effects of decades of low ovulatory progesterone.
PCOS in High-Functioning, Chronically Stressed Women
I want to name a pattern I see over and over again in my clinic: high-performing, deeply thoughtful, often anxious women with a history of:
- Childhood trauma or emotional neglect
- Chronic stress, perfectionism, or people-pleasing tendencies
- Neurodivergence or sensory sensitivity
- Head injuries or subtle brain trauma
- Long histories of surviving on willpower alone
These women may have had "normal" labs, been told their hormones were fine, and still feel awful—tired, inflamed, emotionally fragile, or completely burned out. Their PCOS may have never been diagnosed, or it may present now as midlife metabolic dysfunction, vasomotor instability, or nervous system dysregulation.
And because PCOS is so often framed as a fertility problem, it gets missed entirely after age 35.
PCOS Doesn’t Magically Go Away After Menopause
Yes, ovulation stops. But PCOS is not just about ovulation. Women with a history of PCOS:
- Often go through perimenopause with more erratic hormone fluctuations
- May retain higher levels of androgens than peers
- Often experience insulin resistance, stubborn weight gain, and mood swings
- Are at higher risk for type 2 diabetes, cardiovascular disease, fatty liver, and dementia
You may also experience a sudden onset of classic estrogen-deficiency symptoms after years of feeling "estrogen dominant": vaginal dryness, poor sleep, brain fog, hot flashes, or joint pain. This hormonal shift can feel disorienting—especially if you were previously told that you had too much estrogen or testosterone.
So Yes, You Might Still Need Hormones
One of the most common questions I get is:
"If I had PCOS or high estrogen before, why would I ever take hormones in menopause?"
Here’s why:
- PCOS doesn’t protect you from the effects of estrogen and progesterone deficiency
- You may still have low progesterone, especially if you had anovulatory cycles for years
- Testosterone levels decline sharply after menopause, even in women with a PCOS history
And importantly, many women who thrived on higher testosterone levels in their younger years may feel the effects of that decline even earlier—sometimes in late perimenopause rather than after menopause. This can look like a sudden drop in motivation, mental clarity, libido, or muscle tone. While your labs may still appear "in range," they may be low for you, based on where your body functioned best in your 20s or 30s. This is why a personalized approach matters—because it’s not just about numbers on a chart, but about how you feel in your body.
Hormone therapy can help with symptoms, muscle mass, cognition, and overall metabolic health
Of course, it has to be individualized. But fear of hormones due to your "PCOS past" should not be a reason to avoid evidence-based treatment that could dramatically improve your quality of life.
Where Do We Start?
I always begin with:
1. Lifestyle foundations:
- Balanced blood sugar (this is critical)
- Resistance training and muscle-building
- Nervous system regulation (because stress is metabolic)
- Sleep, circadian health, and gut support
2. Supportive supplements (individualized):
Inositol (myo + d-chiro), magnesium, omega-3s, sometimes berberine or NAC
3. Hormone support (when appropriate):
- Bioidentical progesterone for sleep, mood, and cycle regulation
- Estradiol and testosterone for quality of life and long-term disease prevention
- Vaginal estrogen for GSM, even in women with a PCOS history
Final Thoughts
If you have PCOS or suspect you might—even if no one ever told you that you did—you deserve midlife care that goes deeper. You deserve a plan that honors your past hormone story and supports the road ahead.
At Wondercreek Health, I don’t just treat numbers on a lab report. I listen to your lived experience, your history, your intuition. PCOS is real. Your symptoms are real. And there is help.
WonderCreek Health Blog

You’re not crazy. You’re not lazy. And no, you’re not just "getting older." If you’re dragging through your days, feeling foggy, heavy, or worn out—but your labs are "normal"—you’re not alone. One of the most overlooked causes I find in my practice is suboptimal ferritin levels. Let’s break it down—with science, a little wit, and a whole lot of hope. Your Body: A High-Performance Machine Imagine your body like a beautifully engineered, high-performance car. Hormones are your spark plugs. Micronutrients are your engine oil. Proteins are your gears and pulleys. Without the right balance of all these building blocks, the engine sputters. It doesn’t matter how good the outside looks—if you're low on fuel or missing key fluids, you’re not getting out of the driveway. And iron —stored as ferritin—is a huge part of that fuel system. What Is Ferritin, and Why Should You Care? Ferritin is your body's iron storage protein. It’s like your gas tank. Not your current speed, not your miles per gallon—your actual reserve of fuel. Iron is essential for carrying oxygen to every cell in your body. It's crucial for energy production (ATP) in your mitochondria. It supports your thyroid, neurotransmitter function, hair growth, immune system, and even mood. If you’re low on ferritin, you might still show " normal " hemoglobin or hematocrit—so traditional screening won’t catch it until you’re running on fumes. Symptoms of suboptimal ferritin can include: Fatigue and poor exercise tolerance Brain fog or poor concentration Mood swings or low mood Headaches Hair shedding Shortness of breath with minimal exertion Restless legs or poor sleep Sound familiar? But My Labs Say I'm Normal... Here's the kicker: most lab ranges are designed to flag anemia — not optimal function. You could have a ferritin of 12 and be told " everything looks fine " — but feel absolutely awful. For most women, especially those who are still menstruating or recently stopped, ferritin levels under 40–60 ng/mL can cause symptoms . Many functional and integrative medicine specialists aim for 70–100+ ng/mL to support optimal energy, cognition, and hair health. Low-normal is not optimal. When your engine light is blinking, topping off the tank halfway doesn’t cut it. Why You Might Be Low Menstruation: Every period can deplete iron stores, especially if cycles were heavy. Pregnancy and postpartum: Even years later, many women never rebuild their iron stores. Gut health issues: Poor absorption due to low stomach acid, celiac disease, or IBS. Dietary patterns: Plant-based diets can be low in easily absorbed heme iron. Chronic inflammation: Inflammatory signals can "hide" your iron from circulation. Food First, But Realistic Yes, food matters. Red meat, poultry, seafood, lentils, spinach, and pumpkin seeds all contribute iron. But rebuilding storage? That’s a bigger lift. Think of dietary iron like filling up your gas tank 10–15% at a time. Helpful, but slow if you're starting on empty. Sometimes you need a boost. That’s where targeted supplementation can help—whether it’s gentle oral iron (like iron bisglycinate) or occasional intravenous iron if needed. And by the way, ever wonder why "senior" vitamins have no iron? Because postmenopausal women typically don’t lose blood monthly. We don’t want too much iron. But we also can’t function with too little. Balance is everything. Final Thoughts If you’re feeling run down, foggy, achy, or unlike yourself—it’s not "all in your head." Your body is whispering (or screaming) for better support. And sometimes the missing piece isn’t fancy. It’s basic, foundational, and fixable. Ferritin matters. Iron matters. You matter. At Wondercreek Health, I believe in digging deeper, connecting the dots, and helping you rebuild the strong, steady foundation your body deserves. Because you weren’t designed to run on empty. Iron-Rich Foods to Boost Your Levels Beef, lamb, liver (heme iron is best absorbed) Dark poultry (chicken thighs, turkey) Shellfish (clams, oysters, mussels) Lentils and chickpeas Spinach and swiss chard Pumpkin seeds and cashews Fortified cereals and oatmeal Tofu and tempeh Tip: Pair iron-rich foods with vitamin C (like bell peppers, oranges, or strawberries) to boost absorption! Ferritin Target Chart Ferritin Level What It Means <15 ng/mL Severe deficiency 15–40 ng/mL Low stores (symptoms likely) 40–60 ng/mL Borderline (may still have symptoms) 70–100+ ng/mL Optimal for energy, cognition, hair health Individual needs vary—always interpret ferritin in the context of your full health picture! When to Suspect Low Iron Feeling tired despite good sleep Exercise feels harder than it used to Brain fog or poor memory Unexplained hair thinning Pale skin or brittle nails Frequent headaches Restless legs or poor sleep Shortness of breath climbing stairs If you’re nodding along to several of these, it’s worth a closer look at your ferritin levels.

Let’s start with this: there is nothing shameful or trivial about wanting a healthy sex life. If you're in your 30s, 40s, 50s, or beyond and wondering where your libido went, why sex feels different (or uncomfortable), or why no one ever warned you about vaginal dryness, you’re not alone. And you’re not imagining it. At Wondercreek Health, I talk to people every week who feel confused, dismissed, or ashamed about the sexual changes happening in their bodies. Many are thriving in every other area of life—careers, caregiving, health—but when it comes to intimacy, they feel stuck or unseen. So let’s say this together: sexual health is part of whole-person health. And pleasure is not optional . It’s a reflection of nervous system safety, hormonal balance, connection, and self-awareness. It belongs to you. What Happens to Sexual Health in Midlife and Beyond? Hormonal shifts during perimenopause and menopause can affect every part of your sexual experience. But so can chronic stress, birth control, antidepressants, trauma, and the weight of daily responsibilities. This is never just one thing. Common symptoms include: Vaginal dryness, burning, or itching (genitourinary syndrome of menopause, or GSM) Pain with sex (dyspareunia) Loss of libido or arousal Less intense or harder-to-reach orgasms Urinary urgency or UTIs Pelvic floor tension or dysfunction These changes aren’t "just in your head" and they’re not a moral failure. They reflect real shifts in tissue, blood flow, hormones, and brain chemistry. Sex Isn’t Just for Someone Else’s Benefit Let’s say the quiet part out loud: many of us were raised to believe that sex was about someone else's pleasure. That we should be desirable, responsive, available—regardless of how we felt. That conditioning runs deep. But sex isn’t about performance. It’s about connection, intimacy, and pleasure—for you. Pleasure is your birthright. Intimacy can be tender, playful, spiritual, or wild— but it should never feel like pressure. Your desire may look different than someone else's, and that’s okay. This is true whether your partner is male, female, nonbinary, or you're navigating intimacy solo. There is no one-size-fits-all experience. Why Your Desire Might Feel "Off" Sexual changes can happen at any age. Oral contraceptives (OCPs) can suppress libido by lowering free testosterone. SSRIs and other antidepressants are well known to impact arousal and orgasm. Perimenopause often starts in the mid-30s, long before you notice hot flashes. Chronic stress and the mental load of caregiving, multitasking, and decision fatigue can leave no room for desire. Because here’s the reality: desire doesn’t live in your genitals. It starts in your brain . And when your brain is overloaded with to-dos, responsibilities, or unspoken resentment, it’s nearly impossible to shift into a space of curiosity, connection, and arousal. Unwinding the mind can be hard. For some of us, it means learning to use tools like mindfulness, breathwork, somatic practices, therapy, or just having space and time away from the demands of the world. Creating room for desire isn’t selfish. It’s a form of self-trust and reclamation. The Good News: This Is Treatable Sexual health doesn’t have to decline just because estrogen does. There are safe, effective, empowering ways to reconnect with your body and reclaim your pleasure. 1. Local vaginal estrogen (or DHEA or testosterone): Restores tissue health, lubrication, and blood flow Improves comfort, arousal, and pelvic health Safe for most people, even those with a history of breast cancer (with appropriate guidance) 2. Systemic hormone therapy: Can improve libido, mood, sleep, and confidence Testosterone therapy (when indicated) can support arousal and orgasm 3. Pelvic floor physical therapy: Addresses pain, tension, and coordination issues Supports better sensation and comfort 4. Nervous system regulation: Practices like breathwork, somatic therapy, or trauma-informed care help shift from "fight or flight" into connection When the nervous system feels safe, desire can return 5. Sex therapy or coaching: Helps explore personal blocks, relationship dynamics, and pleasure mapping Let’s Talk About Desire You might notice you don’t feel spontaneous desire anymore— but that doesn’t mean you’re broken . For many people, responsive desire (desire that follows arousal) becomes the norm in midlife. And it’s perfectly valid. Touch, connection, and intimacy may need more warming up. But your ability to experience pleasure is still intact—and it can grow deeper, richer, and more grounded as you reconnect with your body on your own terms. Final Thoughts You don’t need to be fixed. You deserve to be heard. You deserve to feel good in your body. Sexual health is not about keeping up with anyone else’s timeline or expectations. It’s about reclaiming what intimacy and connection mean to you in this season of life. At Wondercreek Health, I’m here to help you connect the dots, reduce shame, and support you with science-backed, judgment-free options that honor your experience. Because this is not the end of your sexual story. It might just be the beginning of the most powerful chapter yet.