Should you start HRT, Hormone Replacement Therapy for Perimenopause or Menopause?
- Barbara Hoefener NP
- 17 hours ago
- 3 min read
Hormone Replacement
Barbara Hoefener NP 4/2026
Should you start Hormone Replacement Therapy? *How is your quality of life?
*There is grey area here...
Perimenopause = This is the period leading to menopause. This transitional phase before menopause typically lasts 4-8 years. Hormone levels fluctuate every hour and day, thus labs are not conclusive and not super helpful as there is “no baseline.”
SO…it is a clinical diagnosis, based on symptoms, age and quality of life.
Menopause = typical between 45-55 years of age, diagnosed by being without a period for 12 consecutive months.
Symptoms of Perimenopause
Irregular Periods: longer, shorter, heavier, lighter.
Cognitive changes: Brain fog, forgetfulness, fatigue
Physical changes: weight gain & new joint pain.
Sleep disruption: insomnia, disrupted sleep pattern, fatigue
Mood changes: irritable, anxious/ panic, depressed, mood swings
Vasomotor: Hot flashes, sweating, elevated heart rate.
Vaginal changes: vaginal dryness, discomfort during sex, lower libido
GI/Nausea/ stomach upset - worse in am because cortisol is high in am. low estrogen makes you more sensitive to cortisol.
Benefits of hormonal contraceptives.
Decreased risk of endometrial, ovarian, and colorectal cancer.
Improved bone mineral density in older women.
Induction of amenorrhea for lifestyle considerations.
Menstrual cycle regularity and premenstrual syndrome
Prevention of menstrual migraines.
Treatment of acne.
Treatment of leiomyoma.
Treatment of dysmenorrhea & menorrhagia.
Treatment of hirsutism.
·Treatment of Pelvic pain from endometriosis.
Hormone Therapy = helps to manage ongoing conditions and ease symptoms that happen with menopause & aging.
HRT is best if used when less than 60 years and/or within 10 years of onset of menopause.
You as a female have been making your own estrogen, progesterone, testosterone. It is now slowing.
The estrogen has been protecting against bone less (osteoporosis) and cardiovascular disease (heart & cholesterol). You are now exposed to bone, heart, artery issues, weight gain and symptoms listed.
Research showing long term hormone therapy can cause significant harm including:
Stroke, pulmonary embolism, gallbladder disease, breast cancer and heart disease risk.
**This is why you take the lowest dose possible for the shortest amount of time needed.
HRT Options:
Estrogen Stabilizes the endometrium and reduces spotting.
Progesterone - Helps sleep and night sweats. Provides contraception. Protective of the uterus from cancers including endometrial hyperplasia. Protective against osteoporosis.
Taking birth control with progesterone (most of yall have already) has helped to protect you already.
Oral progesterone is poor bc 1st pass, so take vaginally 100 then 150 then 200
Progesterone HT- reduces symptoms by about 56%
Combo Estrogen + Progesterone of course works more effectively.
Contraindication of Estrogen:
Risk for or History of: Breast cancer, DVT, blood clot or vein thromboembolism, stroke, CV disease, coronary artery disease, uncontrolled hypertension, liver disease, unexplained vaginal bleeding or adverse effect from medication including birth control.
Other helpful meds for:
Painful intercourse and vaginal dryness
DHEA- human made hormone dehydroepiandrosterone
Ospemifene-SERM- selective estrogen receptor modulator
Hot flashes:
Antidepressants, SSRI & SNRI
Gabapentin
Clonidine
Fezolinetant – blocks pathway in brain that manages body temperature. FDA approved for menopause.
HRT Meds:
* It may take 4-6 weeks to feel better, some quicker.
Of note: If you come off hormones, esp quickly, you can get rebound anxiety.
Labs
Yes, will order a “hormone” PLUS "yearly labs."
You will also get another set 4-6 weeks after starting and at dose changes.
Just hormones:
Estradiol - E2= Goal 50-100
Progesterone & Testosterone= if low libido or fatigue
FSH= to confirm menopause status. FSH up and estrogen down with menopause.
SHBG= sex hormone binding globulin- determine how much testosterone is bioavail.
DHEA= if taking
Prolactin- rule out pituitary gland issue that is disrupting cycle.
Yearly:
A1C
TSH, T4 – rule out thyroid gland issue that can mimic menopause symptoms.
CMP with liver & kidney
CBC & FE & Vit B & Vit D – especially with fatigue & headaches.
Lipids/ Cholesterol
**MORE READING. Also Youtube: kellycaspersonmd
Article 1:
80% women experience symptoms.
Half reporting daily symptoms that can last 7-10years.
Guidelines from menopause society and national institute health state benefit outweigh the risk in women <60years or within 10years of menopause onset, if no contraindications.
Table in photo below of risk (yellow) vs benefit (green). Participants were 50-79, most were postmenopausal.
Article 2:
WHY I AM STILL SKEPTICAL: https://www.aafp.org/pubs/afp/issues/2025/0700/editorials-menopausal-hormone-therapy.html
Symptomatic benefit to hot flashes and vaginal dryness
Serious harm: stroke, pulmonary embolism, gallbladder disease and breast cancer.
Resources:
AAFP.org, journals.lwww.com, Mayoclinic.org, Acog.org, http://pubmed.ncbi.nlm.nih.gov, endofound.org
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