Menopausal Hormone Therapy

What is perimenopause?

Perimenopause is having menopause symptoms before going through menopause.

What is menopause?

Menopause happens once the ovaries are no longer making estrogen or progesterone. This can happen spontaneously or surgically when the ovaries are removed.

When is menopause?

Menopause is when you have gone 12 consecutive months without a period.

When is perimenopause?

Perimenopause typically occurs 12-14 years before menopause. Menopause typically occurs between the ages of 51-53 in the U.S. This means Perimenopause can start as early as your late 30s.

How do you diagnosis perimenopause?

Perimenopause is diagnosed based on clinical symptoms. The reason is because hormone levels can fluctuate during pre- and perimenopause. Because the hormones are erratic rather than rhythmic, we can develop symptoms of menopause. Management of this is to give hormone replacement therapy. The goal of HRT during perimenopause is to help regulate the hormones rather than replacing the hormones since the hormones are typically still present during this time.

Should I get labs?

Yes and no. While it is good to have baseline labs, the labs will not tell you whether or not you are in perimenopause or menopause. The reason for this is because they can be normal and you still are in perimenopause. This is why we use symptoms to diagnose perimenopause.

How do you treat perimenopause?

First line treatment for perimenopause is hormone therapy. However, not everyone is a candidate for hormone therapy therefore it is important to discuss with your clinician. There are non-hormonal medications and supplements that may help with symptoms.

How do I know if I am in menopause?

Once you have gone 12 months in a row without a menstrual cycle (period) then you can consider yourself in menopause.

For women that have had a hysterectomy (removal of the uterus), this is more difficult to determine since menstruation has already stopped. In this case, we use symptoms together with labs to determine if someone is menopausal.

What are the risks of Hormone Replacement Therapy (HRT)?

Hormone replacement therapy utilizes estrogen, progesterone, and testosterone. Like all medications, these medications also carry risks and benefits. Estrogen and progesterone may increase the risk of breast and ovarian cancer. Not because they cause cancer but because the hormones can cause the cancer cells to rapidly multiply (think of it as feeding the cancer). Obviously, we do not want that to happen so it is important to disclose cancer history to your clinician.

Another risk is blood clots. Estrogen and some progesterones can increase the risks of the blood thickening in the vessels which increases the risk of developing a blood clot (vascular thrombosis). If the blood clot breaks apart and travels to your heart and lungs this is called a pulmonary embolism and is a life-threatening emergency. If the clot breaks apart and travels to the brain then this is a stroke and is a life-threatening emergency. If you feel like this is happening then please call 911 receive emergent care and be taken to the hospital.

The overall risk of developing a deep vein thrombosis (DVT), pulmonary embolism (PE), and stroke are rare with oral estrogen and even less so with transdermal estrogen. Transdermal (absorbed through the skin) estrogen is safer than oral estrogen.

Common side effects of hormone therapy are headaches, nausea, breast tenderness, bloating/cramping, breakthrough bleeding, vaginal spotting, to name a few.

What are the benefits of HRT?

So, you’re asking yourself, “Why on Earth would I ever want to try hormone therapy?”. Well, because there are benefits to HRT. One benefit is that your can have a relief of symptoms, which is a great feeling. Also, we know that when hormone therapy is started within 10 years after the onset of menopause or before the age of 60, it can be protective of the heart and bones in our body. We know the sooner we start HRT, the more protection it provides.

What HRT methods are available?

The gold-standard method for HRT in those that can use it is transdermal methods. This is available in a patch or gel. It is bioidentical and plant derived. It uses a synthetic version of the 17-beta estradiol that naturally occurs in our body. This is the same for the progesterone that is available in pill form.

Testosterone can come in pill, cream, and pellet form. Rare risks are masculinization (hair growth, voice change, clitoromegaly), changes to lipids. Common side effects are acne, headaches, GI side effects. I recommend the cream because it is compounded and can be made in lower doses that provide benefits. However, this is NOT FDA approved and will not be covered by insurance companies.

This information is general advice and not to be considered direct medical advice. You should talk with your provider about your situation as this can vary from person to person.