Understanding Menopause Hormone Therapy: A Guide for Women in Perimenopause

What is Menopause Hormone Therapy (MHT)?

Menopause Hormone Therapy (MHT) is a hormone treatment option to help manage symptoms of perimenopause and menopause. This therapy involves taking medications that contain hormones, primarily estrogen and progesterone. During perimenopause, women experience fluctuating hormone levels, which can lead to a variety of symptoms such as hot flashes, night sweats, and mood changes. MHT aims to balance these hormone levels, thus providing relief to women navigating this transitional phase of life.

If you're in your late 30’s, 40’s or 50’s and noticing some unwelcome body changes, you’re not alone.

Perimenopause can start as early as your late 30s. During this time, your hormone levels (specifically estrogen and progesterone) begin to fluctuate WILDLY. It’s not a smooth curve. Some days your levels of estrogen might be sky high, and other days they may plummet. These dramatic fluctuations can lead to a wide range of symptoms, which are different for each woman. They could include hot flashes, night sweats, anxiety, fatigue, vaginal dryness, and changes in your menstrual cycle.

This is when many women start to wonder: should I be thinking about hormone therapy?

And the answer is YES, this is actually the ideal time to start the conversation about hormone therapy, even if you don’t end up taking them yet.

Knowing what is happening with your hormones, so you can make educated decisions about which one(s) to replace, is key.

Here are some things to consider:

Estrogen (in the form of estradiol) is the main hormone used to treat perimenopausal symptoms like hot flashes, night sweats, vaginal dryness, and sleep disruptions. If you're noticing these symptoms, estrogen therapy might be the foundation of your treatment.

I often encourage women to discuss with their doctor using a patch version (transdermal estradiol) rather than a pill, because it decreases the risk of blood clots compared to taking oral estrogen (a pill). It is still available from a regular pharmacy, and can go through insurance, so you don’t need a fancy compounded cream for this.

It can take weeks to several months for things to fully normalize, but you might notice relief from hot flashes even within the first week.

Equally as important as estrogen, however, is progesterone.

First of all, if you still have a uterus, and you’re using estrogen, you’ll always need progesterone. That’s because estrogen on its own can cause the lining of the uterus to thicken, which increases the risk of endometrial cancer over time.

Progesterone will offset that effect and protects the uterus. So having a uterus + taking estrogen = you need progesterone in some form.

Progesterone itself has many benefits, especially in early perimenopause, when periods might actually be heavier more frequent than usual (they tend to become lighter and more spotty over time, as estrogen declines). In early perimenopause, many women are actually “estrogen-dominant” meaning they have relatively high estrogen compared to their progesterone levels. Estrogen dominance can be pretty miserable: it can lead to anxiety, difficulty sleeping, breast tenderness, and heavy or irregular periods. If these symptoms predominate, adding progesterone alone (even if you’re not taking estrogen yet!) can help.

I always recommend women take progesterone at nighttime since it can help with sleep. My “favorite” form of progesterone is micronized progesterone (in pill form), which is a bioidentical form of progesterone. It is still covered by insurance and can be dispensed at a regular pharmacy as well.

The reason I tend to prefer the bioidentical progesterone is that it has fewer side effects than synthetic progestins, and tends to help with calmness and mood a bit more. It is chemically identical to the form of progesterone that your body naturally makes, helping smooth out your hormone levels as they naturally decline during perimenopause.

Still, remember that hormone therapy isn’t one-size-fits-all. There are different forms if you don’t tolerate one form, and they all can be helpful in some instances. To be honest, though we can make an educated guess as to what the best dose/delivery method might be for any one patient, it does sometimes take trial and error, and might take a few months or more to get the dose exactly “right.”

But the most important thing to remember is that you don’t have to suffer with menopause symptoms for years without any support. If your symptoms are disrupting your life and health, perimenopause is the time to start exploring your options, not just waiting until periods stop altogether. A knowledgeable healthcare provider can help you decide whether estrogen, progesterone, or both are right for you. If you’re having difficulty finding one, I often recommend MIDI health, as they accept many forms of commercial insurance and they have decent providers who are trained to prescribe bioidentical options when appropriate.

Hope this helps and as always, feel free to reach out if you need anything.

Cheering for you,

Nicole