This post is for all you forty and fifty-somethings who are looking for some kind of clarity around hormone replacement therapy (HRT) or menopausal hormone therapy.

You want to know if HRT is safe and which type to choose. And you want to know if hormone treatment is actually going to help with the sleep disturbance and mood changes and crazy periods that you’re experiencing now (but really didn’t expect to see for a few more years).

Perimenopause or “second puberty” is the two to twelve years before menopause and can be the time of strongest symptoms.

Here’s what you need to know.

You’ll need progesterone before you need estrogen

The earliest symptoms of perimenopause (heavy periods, insomnia, and anxiety) are the result of losing progesterone, not estrogen. They typically occur while we’re still having periods but are making the natural progression to having more anovulatory cycles, rather than real periods.

👉 Tip: An anovulatory cycle is a cycle in which ovulation did not occur and progesterone was not made.

We lose progesterone during perimenopause but can have up to three times more estrogen than we did before.

High, fluctuating estrogen contributes to the symptoms of anxiety, migraines, and histamine or mast cell activation. (Symptoms that are sometimes referred to as “estrogen dominance.”)

Taking estrogen as the pill or hormone replacement is not the best treatment during this time.

Progesterone is a better option.

Progesterone alone can relieve symptoms and lighten periods

Micronized progesterone or “body-identical” progesterone can relieve the mood and sleep symptoms of perimenopause including anxiety, insomnia, hot flushes, and reduced ability to cope with stress.

Progesterone is calming because it converts to the neurosteroid allopregnanolone (ALLO) which acts on GABA receptors in the brain.

The advantage of taking progesterone rather than estrogen is that progesterone can be stopped anytime without inducing a withdrawal syndrome of hot flushes. Stopping estrogen is harder to do.

Progesterone can also make periods lighter and is a viable alternative to progestin drugs such as the pill and the hormonal IUD.

The big difference between progestins and progesterone is that progestins are usually bad for mood and can cause hair loss.

Progesterone, on the other hand, is usually good for both mood and hair. Progesterone is also good for bones, cardiovascular system, and may help to prevent breast cancer.

👉 Tip: Progesterone stimulates metabolic rate so can also help to prevent menopausal weight gain.

For more information about the benefits of progesterone, read the Progesterone Therapy section of Prof Jerilynn Prior’s CeMCOR site. Prof Prior has also published several papers about the benefits of using progesterone-alone for the hot flushes of menopause and perimenopause.

You may eventually need estrogen

The later symptoms of perimenopause (hot flushes, vaginal dryness, weight gain, and depression) are the result of losing estrogen. They typically coincide with the final disappearance of periods.

At this stage, some estrogen can be helpful, but only in combination with progesterone! My advice is to start with progesterone and if it doesn’t relieve all the symptoms, look to body-identical transdermal estradiol.

👉 Tip: You also need progesterone, even if you don’t have a uterus. Why? Because natural progesterone protects breasts and is good for mood.

The good news about estrogen is that it’s a lot safer than we thought. The book Estrogen Matters by Dr Avrum Bluming makes a strong case for the safety of estrogen.

What you need to know about estrogen

According to the latest research, there are three ways to safely take estrogen:

When it comes to cardiovascular health, transdermal (through the skin) delivery of estrogen is safer than taking a pill.

Use it together with natural progesterone rather than a progestin.

Commence it at the onset of menopause (when periods stop) rather than later in life. There’s some evidence that starting estrogen later could be a risk for cardiovascular disease.

The study that scared everyone (the 2001 WHI study) had the flaw that the average age of the participants was 63 and arguably too old to have safely commenced estrogen therapy. Conclusions from that study cannot be applied to younger women.

Use the term “body-identical” when speaking with your doctor

The truth about bioidentical hormones

I’ve seen a few articles lambasting “bioidentical hormones.” What most experts are critical of is “compounded” or “individualized” hormone formulas, which is probably a fair criticism.

No experts are critical of the assertion that estradiol and progesterone are better and safer when they are “identical to the body’s own hormones.” Because that is just a fact.

Both the term bioidentical and body-identical can be used to describe hormones that are “identical to the body’s own hormones.” They mean the same thing.

Bioidentical was the term for compounded hormones during all the decades when compounding was the only way to access estradiol and progesterone “identical to the body’s own hormones.”

Body-identical is now the preferred term for all the modern estradiol and progesterone formulations that are “identical to the body’s own hormones.”

Your doctor probably prefers that you take an approved body-identical medication and not one that has been formulated individually by a compounding chemist. She has concerns about the potential quality of compounded formulations and does not agree that hormone formulas can be “individualized” based on blood, saliva, or urine tests.

I agree with the last point. There is really no way to “tailor” the dose of hormones based on testing. The best strategy is to start with progesterone on its own, and then if you still have symptoms, speak to your doctor about adding low-dose transdermal estradiol.

After that, if you still have symptoms, consider switching to a higher-dose estrogen (but continue the progesterone).

Summary

Hopefully, that has clarified a few things. You may still be wondering if you need hormones at all or if you could just get by with supplements and lifestyle?

Put it this way: Herbal medicines and supplements (especially magnesium) can be very helpful. Read Rescue prescription for perimenopause. Other helpful strategies include:

• reducing histamine foods
• quitting all alcohol
• exercising regularly.

If, after doing all that, you still have symptoms, I think it’s reasonable to take body-identical hormones, at least for a few years. They’re a better and safer treatment than the pill or antidepressants.