Let’s be honest—perimenopause doesn’t get the conversation it deserves. For too long, women have been told to just “deal with it” or that their symptoms are “normal aging.” But here’s the thing: just because something is common doesn’t mean you have to suffer through it.
As an integrative medicine physician who’s been working with women through this transition for over 15 years, I want to share what I’ve learned about hormone replacement therapy (HRT), why the conversation is changing, and what you actually need to know to make informed decisions about your health.
First Things First: What Actually Is Perimenopause?
The word itself breaks down beautifully: peri (around) + men (month) + pause (stop). Perimenopause is that “around the pause” time—the transition period before menopause officially begins. While menopause is clinically defined as the point when a woman has gone 12 consecutive months without a period, it represents the beginning of a new hormonal phase that continues for the rest of a woman’s life. During this time, you might experience:
- Irregular or longer cycles
- Hot flashes that wake you up at night
- Brain fog (yes, that “where did I put my keys” moment)
- Vaginal dryness
- Mood changes
- Fatigue that no amount of coffee seems to fix
- Weight gain, especially around the midsection
- Changes in sexual function
- Sleep disturbances
Sound familiar? You’re not alone, and you don’t have to accept this as your new normal.
The HRT Conversation Has Changed—Here's Why
For years, hormone replacement therapy got a bad rap. In the early 2000s, the Women’s Health Initiative study scared everyone away from HRT. But here’s what many people don’t know: those studies were done on synthetic hormones, not the bioidentical hormones we use today.
This is a crucial distinction. The synthetic hormones studied—often derived from pregnant horse urine—carry increased risks of blood clots, cardiovascular disease, stroke, and liver toxicity. They’re metabolized differently in the body and don’t function the same way as the hormones your body naturally produced for decades.
Bioidentical vs. Synthetic: Why It Matters
Bioidentical hormones are the exact molecular replica of the hormones your body has been making your entire life. They work with your body, not against it. In my practice, I primarily prescribe bioidentical options because they offer a more favorable risk-benefit profile.
My preferred bioidentical options include:
- Estradiol patch – Easy to use (every 3.5 days), FDA-approved, and often covered by insurance
- Estrogel – A topical gel alternative
- Estring – A vaginal ring for genitourinary symptoms
- Bioidentical progesterone – Available in oral form (often covered by insurance) or compounded creams
Here in Austin, we’re fortunate to have exceptional compounding pharmacies that can create customized formulations tailored to your specific needs and sensitivities.
Why Consider HRT? The Benefits Go Beyond Symptom Relief
Hormone replacement therapy isn’t just about stopping hot flashes (though that alone can be life-changing). HRT is effective for:
- Vasomotor symptoms (hot flashes and night sweats)
- Genitourinary syndrome of menopause (vaginal dryness, recurrent UTIs, painful intercourse)
- Bone loss prevention (protecting against osteoporosis)
- Cognitive health (did you know we can lose IQ points during menopause?)
- Cardiovascular disease prevention
- Sleep quality (especially with progesterone)
Current research shows that hormone therapy tends to have the most favorable benefit-risk ratio for women who begin treatment before age 60 or within 10 years of menopause onset.
In practice, though, it’s never one-size-fits-all. I occasionally work with women later in life who are struggling with severe bone loss or cognitive decline, and together we carefully weigh the risks and benefits before deciding if HRT could still offer support.
The Progesterone Piece of the Puzzle
Here’s something critical: if you have a uterus and take estrogen, you must take progesterone to protect your uterine lining. No exceptions.
But progesterone isn’t just protective—it’s also calming to the nervous system and helps with sleep. In fact, there’s emerging research suggesting everyone should take progesterone (even if you don’t have a uterus) because of its calming effects and other potential effects that are still being studied.
When HRT May Not Be Right for You
It’s important to acknowledge that HRT isn’t for everyone. Contraindications (based primarily on synthetic hormone data) include:
- History of deep vein thrombosis (DVT) or pulmonary embolism
- Those with known or suspected hormonally-sensitive cancers (like breast or endometrial cancer)
- End-stage liver disease
- Unexplained vaginal bleeding
Important note: Even with a history of breast cancer, vaginal estrogen may still be an option. Many OB-GYNs and oncologists now prescribe vaginal estrogen because it’s minimally absorbed systemically and uses only bioidentical hormones.
Beyond Hormones: Preparing Your Body for This Transition
HRT can be incredibly helpful, but it’s not the only tool in the toolbox. In my practice, we take a whole-person approach to perimenopause. Here’s what I recommend to all my patients:
Lifestyle Foundations
- Lift weights – Building lean muscle mass is crucial for metabolic health and bone density
- Increase protein intake – Your protein needs increase during this transition
- Prioritize fiber – Helps with blood sugar regulation, hormone metabolism, and elimination
- Optimize your circadian rhythm – Get outside for natural vitamin D and regulate your sleep-wake cycle
- Actually rest – Not “doing 10 things while lying down” rest, but true, restorative rest
- Set boundaries – Learn to say no and prioritize self-care (this is huge)
- Reduce alcohol – Your tolerance changes, and alcohol can worsen symptoms
Alternative and Complementary Approaches
Not everyone wants or needs HRT, and that’s okay. Other options include:
- Acupuncture – Excellent for calming the nervous system and managing hot flashes
- Herbal support – Black cohosh, kava, maca, and valerian can help with various symptoms
- Sustained-release melatonin – Particularly helpful for sleep (we’re even using it in breast cancer treatment at higher doses)
- Cooling technologies – Mattress toppers and other cooling mechanisms
- Apollo Neuro bracelet – A vagus nerve stimulator that can help with hot flashes
- Other medications – Options like venlafaxine or gabapentin when HRT isn’t suitable
The Spiritual Lesson of Perimenopause
Here’s something I’ve observed over 15 years of practice: there are cultures without even a word for menopause. In these communities, this transition is simply seen as moving into the role of wise woman, elder, and council member.
The difference? These cultures don’t live in our productivity-obsessed society. They’re part of interconnected communities with shared support systems and lower chronic stress.
While we can’t completely change our society, we can learn from this wisdom. Perimenopause is asking you to pause and take inventory: What do I want for the second half of my life? How do I want to live? What boundaries do I need to set?
This isn’t just about managing symptoms—it’s about transitioning into a new phase of life with intention, support, and yes, if you choose, the help of bioidentical hormones.
The Bottom Line: It's All About Individualization
If there’s one thing I want you to take away from this, it’s this: hormones are complex, and one size does not fit all.
Every woman I see in my practice is different. Some start needing support in their early 40s. Others sail through with minimal symptoms. Some need full HRT, others just progesterone, and some do beautifully with lifestyle changes and herbal support alone.
The key is finding a practitioner who will:
- Listen to your symptoms and concerns
- Consider your individual risk factors
- Work collaboratively with you (not dictate a one-size-fits-all approach)
- Adjust treatment as your needs change
- Look at your whole health picture, not just hormone levels
At West Holistic Medicine, this is exactly what we do. We offer the full spectrum of support—from bioidentical HRT to acupuncture, from lifestyle counseling to herbal medicine. We’re here to help you navigate this transition in a way that honors your individual body, history, and goals.
Ready to take the next step?
If you’re struggling with perimenopausal symptoms or wondering if HRT might be right for you, I invite you to schedule a consultation. We’ll take time to understand your unique situation, review your health history, and create a personalized treatment plan that makes sense for you.
Remember: You don’t have to suffer through this transition. With the right support and treatment approach, you can feel like yourself again—or perhaps even better than before.
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Or give our office a call at 512-814-0148, and we’ll be happy to help!
Medical Disclaimer: This blog post is for educational purposes only and does not constitute medical advice. The information provided should not replace consultation with a qualified healthcare provider. Treatment decisions should be individualized based on your personal health history, risk factors, and goals.