Perimenopause dismissed her fatigue, but celiac disease was the cause

Natalie Crawford was 39 when fatigue was brushed off as perimenopause, but the real cause was celiac disease. Crawford, a double board-certified obstetrician-gynecologist and reproductive endocrinology and infertility physician, co-founder of Fora Fertility in Austin, Texas, said the mislabeling delayed the diagnosis of a condition that can damage the small intestine and show up far from the gut.

That distinction matters because menopause guidance does not support guessing. Mayo Clinic says perimenopause can begin as early as the 30s, though many women notice changes in their 40s, and there is no single test or symptom that definitively proves it has started. Clinicians are supposed to look at age, menstrual history, symptoms and other possible causes, not assume every new complaint is hormonal. In practice, ACOG says evaluation may include pelvic exams, blood tests and ultrasound, with clinicians also ruling out thyroid disorder, hyperprolactinemia, fibroids, adenomyosis, infection and other causes when symptoms warrant.

Celiac disease is one of the diagnoses that can hide in plain sight. PubMed and NIDDK describe it as an immune reaction to gluten that damages the small intestine, and it can present with fatigue, anemia, weight loss, skin rashes and osteoporosis instead of obvious digestive symptoms. Testing usually starts with celiac-specific antibody blood work, often tTG-IgA or EMA, and is typically confirmed with a small-intestinal biopsy. A review cited in the research notes that fewer than 5% of cases are diagnosed in many regions, which helps explain why women can spend months or years being told something vaguer is to blame.

The overlap is especially risky in midlife, when perimenopause symptoms themselves can be nonspecific. The Menopause Society says brain fog is common during the transition and that dementia at midlife is very rare, but fatigue, sleep trouble and mood changes can still point somewhere else. In a recent Flo-based international survey of women aged 35 and older, fatigue and physical and mental exhaustion were each reported by 83% of respondents. Irritability followed at 80%, depressive mood at 77%, sleep problems and digestive issues at 76% each, and anxiety at 75%.

That is the diagnostic trap Crawford’s story exposes. Perimenopause can be real and disruptive, but it should not end the evaluation when symptoms are new, severe or atypical. Fatigue with weight loss, anemia, skin changes, digestive symptoms or other red flags deserves a broader workup before anyone settles on hormones alone.