Hormonal Replacement Therapy (HRT) involves supplementing the body with estrogen and often progesterone to alleviate the symptoms of perimenopause and menopause caused by declining hormone levels.

Menopause is defined as the cessation of a menstrual cycle. This event is timed as the absence of a menstrual period for one complete calendar year. When menopause is established it means the ovarian reserve is empty and no eggs are left to ovulate. The ovaries have stopped producing estrogen and progesterone in a monthly cycle. 

Perimenopause is the decade or so leading up to menopause. This can begin anytime after 35 years of age. This is a period of hormonal change that mirrors the arch of puberty. It typically lasts about 10 years, with the average age of menopause being 52 years old in the USA.

Common Symptoms: Some mid-life symptoms are widely recognized as classically perimenopause and reflect fluctuating estrogen levels that are in decline. These include:

• Hot flashes and night sweats

• Irregular menstrual periods (longer, shorter, heavier, or lighter)

• Mood changes (irritability, anxiety, depression)

• Sleep disturbances (insomnia)

• Vaginal dryness and discomfort during intercourse

• Difficulty concentrating or "brain fog"

• Increased premenstrual syndrome (PMS) symptoms

• Weight gain, especially around the abdomen

• Changes in libido (sex drive)

Other Symptoms: Other symptoms of mid-life are related to estrogen decline but are not widely recognized as such in mainstream medicine:

• Headaches or migraines

• Joint and muscle aches (arthralgia) such as frozen shoulder or an increased frequency injuries

• Increased urinary urgency or frequency

• Recurring UTIs and vaginal yeast infections

Honestly everyone with a uterus in midlife. Estrogen and progesterone are not simply "reproductive" hormones; they are foundational systemic hormones that mediate health across the entire body, from the brain and bones to the cardiovascular system. During the perimenopausal and menopausal transition, the natural decline of these hormones leads to a loss of their protective and regulatory effects. Replacing these hormones through HRT aims to mitigate the adverse long-term effects of this depletion, offering significant physiologic benefits for virtually everyone born with a uterus and ovaries, regardless of their immediate symptom severity:

Though current research demonstrates that HRT when done with the correct formulation of bioidentical hormones and administered topically - we are emerging from an era when research with design flaws dictated and directed hormone replacement in perimenopause. A controversial study called the Women's Health Initiative (WHI) study findings in the early 2000s. The following risks were found to be associated with HRT, however the study itself had design flaws discussed below. 

The primary concerns historically linked to HRT include:

• Increased Risk of Blood Clots (VTE): This includes Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE).

• Increased Risk of Stroke: For oral estrogen formulations, there is a small, but notable, increase in the risk of ischemic stroke.

• Increased Risk of Breast Cancer: The WHI found a small increased risk of invasive breast cancer in women taking combined estrogen-progestin therapy for five or more years.

• Increased Risk of Gallbladder Disease: Oral HRT can increase the risk of requiring gallbladder surgery.

Choosing to forgo Hormone Replacement Therapy (HRT) means accepting the natural, systemic, and accelerated loss of the protective effects of estrogen and progesterone across major organ systems. This decision, while personal, carries significant long-term health consequences that extend far beyond simply managing hot flashes.

Missing the "Window of Opportunity"

The most critical concept in modern hormone therapy is the "Timing Hypothesis," also known as the "Window of Opportunity." This refers to the period during which HRT offers its maximal health benefits while carrying the lowest risks. This window is generally defined as:

• A growing body of evidence suggests replenishing hormones when they first start to decline significantly in your early 40s has markedly beneficial long term impacts on your health span, most significantly bone health and cardiovascular health

• Initiating HRT within 10 years of the Final Menstrual Period (FMP, or the onset of menopause).

• Initiating HRT before the age of 60.

When estrogen is introduced early, it acts preventively to keep the cardiovascular system and bones healthy. Once the body has gone without estrogen for an extended period—often decades, as was the case with many participants in the WHI study—irreversible changes (e.g., significant atherosclerotic plaque buildup or major bone density loss) may have already occurred. At this point, initiating HRT can paradoxically increase risks (like blood clots) without providing the same level of long-term cardiovascular and bone protection.

Conventional/Synthetic Hormones: These are pharmaceutical hormones that are chemically similar to, but not identical to, the hormones naturally produced by the human body (e.g., conjugated equine estrogens (CEE) or synthetic progestins). I do not prescribe these hormones in my practice

Bioidentical Hormones (BHRT): These hormones are chemically and molecularly identical to the hormones naturally produced by the human body. They are synthesized and then compounded or manufactured to match the exact molecular structure of human estradiol, progesterone, and testosterone. The benefit often cited for BHRT is that, because the body recognizes the hormones structurally, they may have fewer side effects or be metabolized differently.

HRT is typically administered in two main patterns:

• Phasic (Sequential Combined or Cyclical): This regimen mimics the natural pre-menopausal cycle more closely. Estrogen is taken daily, but progesterone is added for a specific number of days each month (e.g., 12 to 14 days). This pattern results in a predictable, withdrawal bleed similar to a period once the progesterone is stopped each month. It is often preferred by those early in perimenopause who want to maintain a menstrual cycle or those who experience side effects on continuous progesterone.

• Static (Continuous Combined or Continuous Estrogen): This regimen involves taking the same dose of estrogen daily. If the person has a uterus, progesterone is also taken daily continuously. This pattern aims to minimize cyclical bleeding, and for most, it leads to no bleeding at all after the initial adjustment phase.

• Hormonal Birth Control: Hormonal Birth Control (HBC), while containing estrogen and progestin, is not Hormone Replacement Therapy (HRT). It is often erroneously prescribed as a substitute for HRT by providers who are not up-to-date on best practices for midlife hormone stewardship. Hormonal Birth Control provides a steady state of both synthetic estrogen and synthetic progestin, typically in an oral format. This delivery method and hormone profile are not optimal for midlife hormonal replenishment for several reasons:

  • Synthetic Hormones: HBC uses high-dose synthetic hormones that are chemically different from the bioidentical hormones (estradiol and micronized progesterone) that are preferred and safer for HRT.

  • Oral Delivery and Risk Profile: The oral route of administration, typical for HBC, requires hormones to pass through the liver (first-pass metabolism). This process increases the production of clotting factors, which elevates the risk of venous thromboembolism (VTE) and stroke—risks that modern, transdermal (patch, gel, cream) HRT protocols are specifically designed to avoid.

  • Dosing and Goal: HBC is dosed to suppress ovulation and prevent pregnancy, requiring significantly higher and non-physiologic levels of hormones than the lower, symptom-relieving, and health-protective doses used in HRT. The goal of HRT is replenishment to near pre-menopausal levels, not suppression.

  • People often feel immediately worse taking OCPs - not only do they have less benefits but they are often accompanied by more side effects

The short answer is because you are over 35 years old and have noticed the physiologic effects of lowering hormone levels manifest in your body. People often choose to initiate Hormone Replacement Therapy (HRT) primarily to alleviate the disruptive and uncomfortable symptoms associated with perimenopause and menopause. These symptoms can significantly impact quality of life and include:

• Vasomotor Symptoms: Hot flashes and night sweats.

• Genitourinary Symptoms: Vaginal dryness, painful intercourse (dyspareunia), and increased risk of urinary tract infections (UTIs) and urgency.

• Sleep Disturbances: Insomnia and poor sleep quality.

• Mood and Cognitive Changes: Mood swings, irritability, anxiety, depression, and "brain fog" or difficulty concentrating.

Beyond symptom relief, HRT is also initiated for its long-term health benefits, particularly:

• Bone Health: HRT is highly effective in preventing osteoporosis and reducing the risk of bone fractures by preserving bone mineral density.

• Cardiovascular Health: When started near the onset of menopause (within 10 years or before age 60), estrogen therapy may be protective against coronary artery disease in some women.

Labwork alone will not reveal exact serum levels that direct your choice to initiate HRT. However there are some hormonal markers that can reveal levels at which we know bone density is vulnerable to decline, and the health of your vascular system is at risk. Therefore it can reveal a layer of understanding at where you are on your journey, along with ruling out other issues like hypothyroidism which can present with similar symptoms as perimenopause. 

Central to everyone's midlife health—whether or not they choose HRT—are comprehensive strategies focusing on the foundations of well-being:

• Lifestyle Modifications: This includes personalized guidance on nutrition, targeted exercise, stress management techniques, and optimizing sleep hygiene. These changes can dramatically mitigate many common perimenopausal symptoms.

• Vitamin and Mineral Supplementation: We use sophisticated lab work to identify specific nutrient deficiencies that may be exacerbating symptoms (such as iron, Vitamin D, magnesium, and B-vitamins) and create a tailored repletion plan.

• Herbal Strategies:Herbal medicine and specific botanical agents (like Black Cohosh, Ashwagandha, or Maca) can be highly effective in managing vasomotor symptoms (hot flashes), mood changes, and sleep disturbances by supporting the body's natural processes.

I respect and support the choice to omit HRT entirely, focusing instead on an integrative, supportive care model that helps the body adapt gracefully to its changing hormonal landscape. This approach is rooted in providing you with the tools and knowledge to feel your best without pharmaceutical intervention.

Yes. Perimenopause is a time when unplanned pregnancies can catch people off guard. Cycles become less regular in the decade leading up to menopause, leading to less predictable ovulation. Therefore, the fertility awareness method becomes a less reliable form of birth control. Another factor contributing towards unplanned pregnancy in perimenopause is that people assume they are less fertile - which is true; there will be more anovulatory cycles coupled with eggs that are less likely to establish into healthy pregnancies. However, there are also some healthy eggs on the proverbial shelf with the ability to implant and evolve into healthy pregnancies. As a clinician, I have managed care of more unplanned pregnancies for people in their 40s than people in their 20s. I like to point out to my families graduating from homebirth care upon completing their family, that you can spend a decade or two learning your cycle and how to predict ovulation when trying to conceive and also as a method of contraception. When you enter your 40s, your ovaries have learned you, and they are standing armed with their remaining eggs ready to shoot their shot. So yes, you need to think carefully and comprehensively about birth control in your perimenopausal years.

Possibly the most comprehensive labwork you have ever done in your life! We will unturn every leaf. We’ll look at your hormone levels on day 21 of your cycle to track where your estradiol, estrone, progesterone, testosterone, and DHEA-sulfate land. This will not provide a conclusive answer about where you are on your journey to menopause - but it will pinpoint where your serum levels are and direct choice and dosage of HRT.

Hormone cycles are unique to the individual. The same way puberty is a decade long period of time that universally occurs, but unfolds on an individual timeline. Though there are numeric values of serum levels that we know are protective of bone density and cardiovascular health, we don’t know what levels your body mediated estrogen for across your lifespan. What this looks like in labwork is a wide variation in how much estrogen and progesterone have been manufactured and physiologically active by each individual. Therefore, we can’t use your serum values to direct the exact moment HRT is indicated - your symptoms and preferences will direct therapeutic avenues.

Yes

Yes

• PAP screening for cervical cancer

• Mammogram referral

• Colonoscopy referral