Short Answer: Simply put, you don’t have to wait until menopause to consider HRT.
My Answer (with the usual maximum-verbosity):
Sometimes a story can explain what’s happening with your hormones better than a list of symptoms ever could.
So, let me introduce you to Megan.
Megan:
‘My period. Again.
I swear I just had it. And of course, here I am packing for my trip when Aunt Flo decides to kick down the bloody door again.
Two weeks. It has been TWO WEEKS.
What is going on?
Everything seems to be going to heck in a handbasket lately. Truth be told, I haven’t felt quite like myself for a while.
I’ve chalked it up to stress. Work. Too much on my plate. Politics. The general insanity of the world.
But maybe…
Maybe it’s me.
Am I going into menopause?
No. I’m only 41.
What is wrong with me?
Maybe it’s because I’m not sleeping. That’s it.
Except…why am I not sleeping?
Mercury in retrograde? Whatever that means, but at this point I’m willing to blame a planet.
Most nights I wake up and lie there for an hour, often longer, listening to the quiet while my brain decides 2:33 AM is the perfect time to doom-and-gloom every decision I’ve made since 2001.
And lately?
I’m as irritable as a priest in a brothel. And even just a look… don’t poke this bear. Bc it doesn’t take me long to start spewing venom.
This is not me. This is not my nature. I’ve never been…mean.
I can go from feeling normal to a pissed-off hornet’s nest faster than Dale Earnhardt Sr. on his final lap. Instead of stinging, I’m ready to go for the jugular.
My poor husband. Although he shouldn’t be chewing so loudly, blinking, snoring, singing, or asking me where his phone is…
My body. I feel as though four draft horses have drawn and quartered me, each taking slow, methodical pleasure in my suffering. Except there are no horses. No sweet Flicka.
Just shards of glass in my joints and muscles.
My doc says I’m fine and that it’s called ‘age.’ As though the slow betrayal of time should be politely accepted.
My body doesn’t even look like my own. I know it’s vain. But it’s not like I’m slipping out to Krispy Kreme after dark.
I do what a good girl does. I mind my diet, walk, and go to Pilates when I remember to sign up online. But in my defense, their booking system is designed for kids born with an iPhone in their quick-typing fingers.
But lately I have felt like my lights upstairs are flickering. Is it the lack of sleep? Fatigue? It's like my brain slipped off with my waistline, those nasty elopers!
What can I do? What is going on? Is it perimenopause?’
So, how do you know when to consider HRT in perimenopause?
Short answer: Your symptoms and lab work.
Long answer (hee hee): Let’s break down what I mean by symptoms and labs.
Symptoms:
In perimenopause, HRT is individualized based on the symptoms.
Some women like Megan are having a whole host of symptoms, and other women perhaps just a few.
HRT in peri comes down to HRT goals.
Goals: What are our goals in perimenopause?
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Longevity and Metabolic Health:
- Perimenopause is a great time, the best time (don’t wait), to look at both hormone balance and metabolic health. Don't wait until menopause, when some metabolic markers may have already started to change. This helps us identify changes early and support your long-term health now.
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Mood:
- I find that in perimenopause, women can get cranky.
- Patience can be short, and mood can be irritable (hence, Megan’s hornet nest and priest).
- When we get irritable and usually take it out (of course it’s always someone closest to us), it can make us sad, bc we know that it may not have been warranted.
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Inflammation:
- Joints hurt. Muscles hurt. Think frozen shoulder, an achy neck, or sore muscles for seemingly no reason. Maybe you even wake up in the middle of the night because your joints and muscles ache.
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Sleep:
- Waking in the middle of the night for hours
- Sometimes waking at night with angst, racing thoughts, or just being awake with nothing to do.
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Night Sweats:
- I often see night sweats in peri. But in peri, you don't get hot flashes during the day, more at night, especially toward the end of your cycle. Needless to say, not great for sleep (nor jammies, sheets…)
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Weight Gain:
- Your diet hasn’t changed. Your activity hasn’t changed. But ugh! The weight! It’s easier to gain, harder to lose, and it starts showing up in places it never used to, especially around the middle.
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Brain and Cognition:
- Brain fog, trouble concentrating, forgetting why you walked into a room, repeating yourself, or suddenly thinking, “Where is that word???”
- You haven’t suddenly lost your smarts. Your brain is in your head… It’s just hiding from you.
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Pesky Periods:
- Two periods in a month
- No period for two months
- Spotting for days or intermittently throughout the cycle
- Heavy period one month and light the next
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PMS, or in other words, intense PMS:
- The volume is way up: Mood changes, irritability, anxiety, low mood (doom and gloom), breast tenderness, bloating, headaches, water weight, puffy, super tired, carb/sugar cravings.
Other Considerations:
Make sure you are not looking through a narrow lens and pointing an accusatory finger at hormones. There may be other reasons, considerations, or conditions to rule out first:
- Thyroid
- Iron: Ferritin, iron deficiency/anemia
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Adrenals
- POTS
- DHEA
- Pregnenolone
- Cortisol
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Metabolic health
- Insulin resistance/high insulin
- Hyperglycemia
- Hypoglycemia
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Vitamin/nutrient deficiencies
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Sleep disorders
- Medication effects
- Stress/life circumstances
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Gynecologic issues (which can be part of hormone imbalance)
- Fibroids
- Adenomyosis
- Endometriosis
Labwork:
I am going to keep this to blood work bc most women have access to this.
Not all practitioners use labs to evaluate HRT in peri. And that’s part of the art of medicine: different practitioners may approach the same woman differently.
Personally, I like having lab values in perimenopause. In my clinical practice, labs can show which hormones we may want to consider supporting.
What Blood Work Should I Get Testing In Perimenopause?
Blood testing is just a “snapshot” in time. While it can provide useful information, I like to pair it with symptoms and test at a specific time in your cycle. I prefer testing during the luteal phase because we can see what’s happening with estrogen and also get an idea of how much (or not) progesterone you’re producing.
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Estradiol
- I prefer an estradiol level rather than a total estrogen level. Total estrogen combines different estrogens, making it less useful when I’m specifically trying to evaluate estradiol.
- Estradiol can fluctuate up and down like a roller coaster in peri
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Progesterone:
- Progesterone rises after you ovulate, so testing before ovulation isn’t very helpful if you’re trying to evaluate progesterone production.
- In perimenopause, progesterone can be lower, ovulation may not occur during some cycles, or progesterone production may not be sustained as long after ovulation. This is where intense PMS can really take hold, anywhere from a few days to 2 weeks before your cycle.
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Sometimes even testing around day 14 can be too early, especially for women with longer or irregular cycles.
- Ideally, I like to test around day 19-21.
- But in perimenopause, cycles can be all over the place, and sometimes perfect timing simply isn’t possible. Or you have had a hysterectomy and do not have a period. In that case, I would rather have the blood work than no information at all. This is also where looking at LH and the rest of the hormone picture can provide additional context.
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FSH (Follicle-Stimulating Hormone) and LH (Luteinizing Hormone):
- FSH and LH are signals from the pituitary (your brain) that monitor and oversee ovarian function for estrogen and progesterone.
- When the ovaries produce less estrogen and progesterone, FSH and LH rise.
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In a very crude, broad sense, you can think of FSH as giving us more context about estradiol, while LH can give us more context about progesterone.
- For example, higher FSH can sometimes accompany declining or less consistent estradiol production, though that's not always the case in perimenopause.
- LH can help us understand where you may be in the ovulatory process, which can help us better interpret a progesterone result.
- It’s not quite that simple physiologically, but it’s an easy way to think about FSH and LH when looking at your labs.
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Testosterone
- Total testosterone: Shows the overall amount of testosterone in your blood.
- Free testosterone: Gives us an idea of how much testosterone is available for your body to use.
- SHBG: SHBG binds testosterone. A higher SHBG can mean less testosterone is available to your tissues, even when total testosterone looks fine.
- DHEA-S: DHEA is an adrenal androgen that can be converted downstream into testosterone (and estrogens), so I like looking at it as part of the overall androgen picture.
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Other labs I like to consider:
- Thyroid: TSH, Free T4, Free T3
- Iron and blood counts: CBC (complete blood count), ferritin + iron studies
- Metabolic health: CMP (comprehensive metabolic panel), fasting glucose, fasting insulin, hemoglobin A1c, lipid panel
- Nutrients: Vitamin D, B12
- DHEA-S
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Cortisol
- Serum (blood): Gives us a snapshot of your cortisol level, so this is often where I start.
- Salivary cortisol throughout the day: Can provide more information about your diurnal cortisol pattern and how cortisol changes from morning to evening.
Feel familiar?
If you see yourself reflected in Megan’s story and the symptoms above, welcome to the wonderful world of perimenopause. You don’t have to suffer or wait till your periods have completely stopped to get relief and answers.
Perimenopause is a transition, and your hormones can be anything but predictable during it. That’s why I like looking at the whole picture: your symptoms, your cycles, your health history, your goals, and, yes, your lab work.
So, should you consider HRT in perimenopause? You certainly can. The bigger question is what HRT should look like for you.
But what does HRT actually look like in perimenopause? In the full paid article, I walk you through the different approaches to progesterone, estradiol, testosterone, and rhythmic dosing, including how I would approach HRT for Megan, and my clinical reasoning.
Continue reading the full paid article →
