Perimenopause is the natural transition before menopause, caused by a decline in the number of eggs in the ovaries. This leads to fluctuating/declining hormones—mainly estrogen, progesterone, and (eventually) testosterone—which can cause a wide range of symptoms.

It typically begins in the mid-40s, but can start earlier or later, lasting from a few months to over 10 years. Symptoms vary greatly and may include irregular periods, skipped periods, hot flashes, night sweats, joint pain, mood changes, brain fog, poor sleep, hair thinning, low libido, headaches, fatigue, weight gain, and more. Some experience few symptoms, while others have severe symptoms disrupting their health, career, relationships, and quality of life greatly.

Menopause is defined as 12 months without a period. This definition can be confusing when women don’t have periods due to birth control, hysterectomy (with ovaries still intact), uterine ablation, or other reasons. The average age of menopause in the U.S. is 52, but this varies significantly. After12 months have passed without a period, a woman is considered postmenopausal—any bleeding after this time should be discussed with your medical practitioner.

If both ovaries are removed during a hysterectomy, this is considered surgical menopause. This sudden hormone drop can lead to more intense symptoms.

These terms both refer to hormones that are given to replace the bodies hormones after they have decreased (e.g. hysterectomy, premature ovarian insufficiency, perimenopause, menopause). Bioidentical HT or HRT is NOT a form of birth control. If you are in perimenopause it is possible to get pregnant while using these methods. Make sure you know if the hormones you are on can prevent pregnancy or not.

If you have a uterus, you will need both estrogen and progesterone. If you have had a hysterectomy you can take estrogen alone and progesterone is optional (many find it helps symptoms, especially sleep, anxiety, and irritability). Testosterone may be indicated for women with low sexual desire, though this concern is complex and may be due to many factors.

This is dependent on your symptoms and health history. Many women start hormone therapy as soon as they start to have signs of perimenopause/ menopause or immediately following hysterectomy (especially if the ovaries are removed).

Studies show that women benefit most from starting hormone therapy younger (during the perimenopause/ menopause transition) rather than later (10-20+ years) after menopause, when the benefits decrease and certain forms of HT may have more risks than benefit.

Symptom relief (hot flashes, sleep, brain fog, mood swings, libido, etc) and reduced risk of multiple chronic diseases, such as: genitourinary syndrome of menopause, osteoporosis, cardiovascular disease, diabetes, collagen and muscle loss, and more.

Oral estrogen can increase your risk of blood clots and gallstones, but transdermal (patch, gel, spray, ring, vaginal) does not. Hormone therapy reduces your risk of cardiovascular disease if started early (<10y since menopause), but may increase your risk if started >20y after menopause. Risk of breast cancer is very low and has not been seen with studies using bioidentical estrogen and progesterone products.

The safest form of hormone therapy is transdermal estradiol and micronized progesterone, though other forms of hormone therapy may be still be used depending on your individual health risks, side effects, goals, and preferred formulation.

Estrogen may cause breast pain, vaginal bleeding, headaches, bloating, and nausea. Progesterone may cause dizziness, sedation, nausea, bloating, and sometimes depression. These can often be mitigated with time, dose, or formulation changes.

This is dependent on individual preference, health risks, and symptoms. If you start hormones around menopause and continue them, there may be more benefits than risks in continuing indefinitely. For others, there may be more risks than benefits. It is individualized.

Contraindications are hormone sensitive cancer (e.g. breast, ovarian), unexplained or abnormal vaginal bleeding (evaluate before starting), advanced liver disease, recent history of heart attack or stroke, or current/certain blood clots.

Even if you have had one of these conditions, there are several considerations that go into determining if you are a candidate or not. Most women are candidates for some type of hormone therapy and all women, regardless of history, deserve an individualized menopause treatment plan as there are many hormonal and non-hormonal options.

Both bioidentical and synthetic forms of FDA-approved hormone therapy are readily available through most pharmacies.

Estrogen: pill, patch, spray, gel, or vaginal

Progesterone: pill, patch, IUD

Testosterone: gel, injection

Selective estrogen modulators (SERMs): typically a pill

Compounding pharmacies are unregulated and do not use FDA approved products. Compounded medications are not covered by insurance so are typically more expensive. That being said, sometimes compounding pharmacies are useful if the formulation/product is not available through your regular pharmacy. Common reasons to use a compounding pharmacy would be allergies, ease of dosing (ex: combined estrogen/testosterone cream), or preference for a product not commercially available.

100% of women who have low estrogen will experience increased pH of the genitourinary system. Though reported symptoms may vary, this shift can eventually cause skin changes (thinning skin, narrowing of the vagina, reabsorption of the labia minora, etc), dryness, tearing/bleeding, pain with intercourse or pap smear, recurrent infections (UTIs, yeast, or bacterial vaginosis), as well as urinary symptoms (frequency, incontinence, prolapse). GSM is preventable with treatment.

First-line treatment is low dose vaginal estrogen. This is extremely safe and almost never needs to be stopped. Systemic estrogen, like a pill or patch, treats GSM about 60% of the time, however many women will also need vaginal estrogen (cream, tablet, ring) to adequately control symptoms. Other treatments like vaginal DHEA or ospemiphene (daily oral pill) are also available. Lubrication and vaginal moisturizers can help with some symptoms, but do not treat this condition.

Low libido is complicated and can be due to hormones, psychosocial factors, lifestyle, health, medications, and much more. Medications that can be used include: hormone therapy (estrogen & testosterone) and specific medications that can increase libido are flibanserine (Addyi), bremelanotide (Vylessi), bupropion (Wellbutrin), and buspirone (Buspar).

Evidenced-based options include: fezolinetant (Veozah, FDA approved), SSRIs/SNRIs (some anti-depressants), gabapentin, and oxybutynin. Cognitive behavioral therapy and hypnosis have also been shown to be helpful.

Being up to date on recommended cancer screenings is always important, and it’s important to discuss family history with your clinicians. If there is a very strong cancer history in the family, genetic testing may be appropriate. However, it is important to know that family history alone should never exclude someone from being offered hormone therapy if they want to try it. Family history is one of several considerations, but many women who have a family history of breast cancer or other cancers are still candidates for hormone therapy.

The recommended treatment options are very individualized for this group of people. It depends on the type of cancer, the date of diagnosis, treatments, and an individualized discussion around benefits and risks for that person. All women deserve an informed discussion about the perimenopause/menopause treatment options (hormonal and non-hormonal) available to them. These discussions should be done with a menopause expert, who can help guide women to the right treatment options for them, while in collaboration with their oncologist.