Struggling with Perimenopause? HRT is Safe and Effective

Perimenopause and menopause are often referred to as “the change of life” and for good reason. This stage in a woman’s life can profoundly affect her quality of life and long-term health. Yes, that might sound a little dramatic, but it’s the reality of the situation.  

My female patients talk to me regularly about sleepless nights and hot flashes, which can be detrimental to their health. Insomnia is tied to a long list of conditions and hot flashes are linked to heart disease. There’s also the gradual weakening of bones leading to osteoporosis and hormonal shifts that can cause mood swings, weight gain and additional challenges that extend far beyond temporary discomfort. The health effects of perimenopause/menopause can be broken down into two categories – immediate symptoms and long-term consequences.

Typical Symptoms

These symptoms can disrupt a woman’s daily routine.

• Weight gain – is usually rapid and most noticeable at the onset of perimenopause, the very beginning of the process of menopause. It’s very frustrating for women because the weight gain often isn’t caused by lifestyle changes; in fact, many women report the same dietary habits, caloric consumption and exercise routine. Of course, weight gain is part of the natural aging process, but studies attribute menopausal weight gain to metabolic changes caused by a decrease in estrogen and progesterone. As a result, women experience decreased muscle mass, particularly in their midsection, causing fewer calories to be burned and fat to accumulate. Disordered sleep, another perimenopause-related issue, also contributes to weight gain.  
• Disordered sleep - leaves many women exhausted and struggling to function. The fluctuations in estrogen and progesterone can cause night sweats that cause women to awaken and not be able to fall back asleep. Postmenopausal women are two to three times more likely to have sleep apnea compared with premenopausal women.  
• Hot flashes – are caused by a drop in estrogen and can interrupt work and social activities.  
• Vaginal dryness and sexual dysfunction – are additional issues caused by low estrogen, and it’s known for straining relationships and diminishing self-confidence.  
• Mood changes and irritability – usually occur during perimenopause (as opposed to post-menopausal). Disordered sleep is considered the primary culprit of irritability.  

Long-term Health Consequences

Many of these symptoms are related to low estrogen levels, and if a woman goes untreated, there’s a greater risk she will develop: 

• Cardiovascular disease – declining estrogen levels affect heart health.  
• Osteoporosis – lower estrogen levels take their toll on bone density, increasing the risk of a fracture.  
• Cognitive impairments - years of disordered sleep can affect memory and cognitive skills and cause brain fog.  
• Urinary incontinence – less estrogen causes tissues to lose elasticity and support.
• Higher mortality risk – lower estrogen levels are associated with an overall decline in health.  

Perimenopause/Menopause Treatments

To alleviate the discomfort, doctors often suggest lifestyle changes, which may help women with milder symptoms, but are of limited value to women with moderate to severe symptoms. A specific antidepressant has been found to help control hot flashes and night sweats, but a recent study linked antidepressant usage to sudden cardiac arrest. And of course, many women try nutritional supplements, but studies have shown that they may not be a better alternative.    

Fortunately, there is a treatment that’s effective for easing moderate to severe symptoms and lowering the risk of developing chronic conditions. It’s hormonal replacement therapy (or HRT). Yet, despite its availability, many women avoid it because of widespread misconceptions that stem from previous, poorly conducted research. However, when used appropriately, HRT is safe and effective for alleviating perimenopausal/menopausal symptoms and helps mitigate serious health problems.  

Modern Take on HRT  

Modern HRT blends natural estrogen and progesterone, replacing the waning estrogen and progesterone produced by the ovaries and other organs. It’s not just estrogen-only therapy; it has been found to raise the risk of cancer. And it’s usually given to women during their 40s when they’re going through perimenopause, but can be prescribed within 10 years of menopause or before age 60. It factors in safety guidelines that focus on individual risk assessment, risk factors such as age, family history, personal medical history and symptom severity. Benefits include:

• Immediate relief from hot flashes and night sweats, mood swings, depression, disordered sleep, sexual function issues.  
• Long-term protection of bone, heart, brain and urogenital health, cognitive function.

HRT got a bad rap because a large-scale study conducted in the 1990s linked it to breast cancer, heart disease, blood clots and stroke. However, the study was prematurely stopped and considered flawed because it only used synthetic conjugate equine estrogens in women in their 60s who didn’t have a uterus and had been in menopause for about 10 years. Media coverage amplified these concerns, creating a stigma that has persisted for decades.

Since modern HRT became available, the landscape of HRT recommendations has shifted dramatically. The North American Menopause Society's 2022 statement emphasizes individualized risk-benefit assessment rather than broad restrictions. It’s not a one-size-fits-all approach. The idea is to develop a personalized plan to manage a woman’s symptoms based on her needs, preferences and risk factors. Four leading medical societies now recommend HRT for menopausal symptoms, marking a transition away from blanket restrictions toward personalized care and a more nuanced understanding of HRT's role in women's health.

The approach dovetails well with MDVIP’s model, which involves partnering with patients to help them achieve many of their health goals. I begin by offering the MDVIP Wellness Program, a comprehensive battery of advanced screenings and tests that are not covered by insurance. The program helps me assess your individual risk factors, rule out underlying medical causes, and develop a personalized plan that's safe and effective for your situation. This wellness plan can include HRT if you meet the criteria.  

If you’re struggling with moderate to severe perimenopausal symptoms but have a history of breast, ovarian or uterine cancer, blood clots, heart disease, stroke, high blood pressure or liver disease, I may switch gears and instead, focus on lifestyle changes you can make to help ease symptoms. For example, you can:

• Alleviate hot flashes and night sweats by cutting back on caffeine, alcohol and spicy foods, wearing loose clothes and exercising.  
• Help keep your bones strong by taking supplements like calcium and vitamin D.
• Control stress by meditating and using cognitive behavioral therapy.
• Ease hormonal shifts that can cause many symptoms, including fatigue, hot flashes, mood changes and sleep issues by quitting smoking.

Most importantly, if you’re going through menopause, work with your primary care physician. They can set up your treatment plan, advise you of important lifestyle changes you should make and refer you to specialists, if needed. If you don’t have a primary care physician, consider joining an MDVIP-affiliated practice. MDVIP-affiliated physicians have more time to help you in your pursuit of a healthier lifestyle. Find a physician near you and begin your partnership in health »