Written by
Stacy Miller
If perimenopausal symptoms are interfering with your daily life, you may be considering hormonal treatment to help provide relief. While many women believe hot flashes, mood swings, vaginal dryness, fatigue, night sweats, and similar symptoms only occur during menopause, you may also experience them a few years before this major life change. Hormonal replacement therapy, or HRT for perimenopause, can provide relief, but it’s not a one-size-fits-all solution. In this article, we’ll explain what HRT is, how it works for perimenopause, and the side effects and risks to be aware of.
Throughout your menstrual cycle, you experience normal hormonal fluctuations that are responsible for proper bodily functions like ovulation and menstruation. However, once you enter perimenopause, your hormone fluctuations change.
As ovaries become less responsive to brain triggers, the pituitary gland releases extra follicle-stimulating hormone or FSH. The role of FSH is to stimulate the ovaries to recruit follicles at the beginning of the ovarian cycle and to help to release the egg in the middle. Excess FSH does not cause symptoms, so you may not even notice when it starts to rise.
During early perimenopause, this initial rise in FSH is helpful for stimulation. However, as you progress further, your ovaries become less and less responsive. Because of this, estrogen levels can fluctuate dramatically, becoming both higher and lower than before. Progesterone levels also tend to decline. Around one to two years before your final period, both estrogen and progesterone levels drop and remain low for the rest of your life. This is the time when women commonly start experiencing hot flashes, night sweats, sleep disturbances, and vaginal dryness. Earlier on, your first symptoms might include mood changes, forgetfulness, and difficulty concentrating.
Hormone replacement therapy, or HRT, is a perimenopausal treatment that involves reintroducing hormones that the body is either not producing sufficient quantities of or no longer producing at all. Taking HRT before menopause can offer symptom relief and make the transition more manageable.
Women who are not yet in menopause but are experiencing symptoms often ask, “Can you start HRT in perimenopause?” The answer is yes, for many, taking HRT during perimenopause is highly effective and offers many benefits. Let’s explore its impact on some of the most common symptoms below.
Hot flashes are caused by declining estrogen levels, a key hormone used for body temperature regulation. HRT provides estradiol, helping to stabilize the body’s temperature control system, leading to a reduction in hot flashes.
Hormonal fluctuations during perimenopause can lead to sleep difficulties while also causing fatigue. Some women with sleep disturbances benefit from taking estrogen HRT with micronised progesterone.
Perimenopause and HRT treatments often go hand in hand for its ability to help women feel like themselves again. Mood swings can feel like they wreak havoc on your life, making everyday interactions difficult. Hormone replacement therapy can help stabilize both mood and emotions. It can help reduce other emotional fluctuations like depression, anxiety, and irritability that are commonly experienced with hormonal shifts connected to perimenopause.
It’s no surprise that dropping estrogen levels also play a part in increased vaginal dryness during perimenopause. Estrogen is essential in maintaining vaginal tissue and natural lubrication production, which is why it’s common to experience vaginal atrophy and dryness as these levels decline. Local forms of HRT can help by reducing dryness and discomfort, restoring vaginal lubrication, and thickening vaginal walls.
One of the most serious side effects of perimenopause and menopause is bone loss, putting you at an increased risk of osteoporosis. Estrogen works to suppress osteoclast activity, cells that work to break down your bone tissue, and stimulate osteoblasts, which build new bone. Without enough of this hormone, your bones have inadequate protection against deterioration and insufficient resources to replenish bone density. HRT gives your body the boost it needs to maintain its bone strength and density, slowing down the speed of bone loss.
Some women may experience headaches and migraines during perimenopause due to hormonal changes. The introduction of estrogen in HRT treatments may help reduce the severity and frequency of this symptom.
While HRT can be effective for treating perimenopausal symptoms, it’s important to discuss possible side effects. As with any treatment plan, always discuss the benefits and risks with your doctor beforehand.
Depending on the dose, you may experience nausea when taking HRT. The type of medication you take can also play a role, with oral tablets often causing stomach upset.
Mood changes, like increased anxiety or agitation and irritability, can occur when starting HRT. However, many women’s mood stabilizes after two to three months.
While rare, oral HRT can increase your chances of developing blood clots, especially when taken orally. Women at a higher risk for blood clots, including those over the age of 40, who have had previous blood clots, have a clotting disorder, are obese, smoke, and have prolonged periods of inactivity, may consider taking transdermal HRT instead of oral.
Similar to blood clots, oral HRT has a higher risk of ischemic stroke. Women with a medical history of high blood pressure, blood clots, diabetes, atrial fibrillation, heart disease, and high cholesterol should speak with their doctor before requesting oral HRT.
HRT introduces artificial progesterone, known as progestin, into the body, which can put you at a higher risk of developing breast cancer. Estrogen alone is also shown to contribute to uterine cancer development. Women with risk factors for cancer, including a family history, early menstruation, obesity, dense breast tissue, and those who have had cancer in the past, may be more susceptible to this rare side effect.
There are four main types of HRT and six common delivery methods.
Estrogen-only HRT
Estrogen-only HRT is used on women who have had a hysterectomy. It’s not recommended for women with a uterus since the high estrogen levels increase the risk of developing endometrial cancer.
Combined HRT (progestin and estrogen)
Combined HRT is used on women with a uterus, since the progestin protects the uterine lining from the estrogen. Combined HRT can also be with micronised progesterone that for some holds less side effects and is better tolerated.
Tibolone
Tibolone contains synthetic hormones with androgenic, progestogenic, and estrogenic activity. It’s often used to treat perimenopause symptoms and may help prevent the development of osteoporosis. It can be prescribed for postmenopausal women, meaning who had their final menstrual period more than 12 months ago.
Testosterone HRT
Sometimes estrogen therapy is ineffective for low sex drive and testosterone is prescribed for that purpose.
Oral
Oral HRT is convenient and easy to take, but it can lead to more serious side effects like blood clots, stroke, liver issues, and cancer.
Transdermal patches
Transdermal HRT offers steady and consistent hormone delivery, without the higher risk of blood clots with oral HRT, however it still increases the risk of developing breast cancer.
Topical gels and sprays
Topical gels and sprays are easily applied to the skin but may cause skin reactions. Additional drawbacks include inconsistent absorption, along with the possibility of transferring to others.
Vaginal rings
A vaginal estrogen is inserted into the vagina, releasing a steady flow of estradiol. Although it’s used to treat vaginal dryness, it can cause irritation, changes in discharge, spotting and headaches.
If you’re not sure about taking HRT to treat your perimenopause symptoms, there are alternative strategies you can try.
Since perimenopause is caused by hormonal fluctuations, incorporating lifestyle changes that promote hormone balance can be effective. Exercising regularly, practicing proper sleep hygiene, managing stress, eating a nutrient-dense diet, and using vaginal lubricants can help you control symptoms.
One common question women ask is whether to use HRT or the pill for perimenopause symptoms. Both options are used during perimenopause, but they have different purposes.
Birth control pills are not prescribed to manage perimenopause symptoms, however if you have started taking pills long before potential start of perimenopause and feel great, you can continue taking them up to the age 50, if you are taking combined pills, and up to the age 55, if you’re taking progestin-only pills.
Some women may find symptom relief in herbal remedies like red clover, St. John’s Wort, ginseng, angelica, black cohosh, and evening primrose. It’s important to speak to your doctor before taking any alternative supplements, since some may interfere with other medications and the safety may not be fully established.
Using a hormone tracking app is one of the best ways to get deeper insights into your perimenopause symptoms. Hormona is the leading hormone tracker, revolutionizing women’s health. With Hormona, you can input symptoms and monitor your menstrual cycle for personalized insights into your hormonal health. Hormone tracking will help guide your HRT decisions, making it easier to choose a treatment plan that works best for you.
Although it’s not a weight loss solution, taking HRT can help address some of the underlying factors for perimenopause weight gain, like increased appetite, and poor sleep.
Most women begin taking HRT for perimenopause between the ages of 45 and 55, but it can be taken early for premature menopause symptoms.
Whether or not your HRT is covered depends on your insurance provider. Most insurance plans will cover at least some of the treatment cost if it’s deemed medically necessary and prescribed by a doctor.
After a Women’s Health Initiative study was released, some people stopped using HRT out of fear. However, it is still recommended by most healthcare professionals as a safe and effective treatment for perimenopause, with 5% of postmenopausal women in the US and 25 to 33% of symptomatic perimenopausal women in Europe taking HRT.
When deciding between HRT vs birth control pills perimenopause symptoms respond well to both. For women up to 50 years old, who started combined birth control, and up to 55 years old, who started progestin-only pills for contraceptive purposes and respond well, birth control pills are a good alternative to HRT.
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Dr Singh is the Medical Director of the Indiana Sleep Center. His research and clinical practice focuses on the myriad of sleep.
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