what is perimenopause?

Perimenopause is the (looooooong) ramp up to full menopause. It typically starts in a person’s 40s, but can start even earlier (especially for women of color), and can last for years. It brings with it all sorts of fun symptoms brought on by declining estrogen levels, such as irregular periods, hot flashes, brain fog, anxiety, irritability, heart palpitations, joint pain, frozen shoulder, and dry eyes, among others. There are good lists of possible symptoms here and here.

what is menopause?

The standard definition states that you enter menopause when it’s been a year since your last period. This is a useless definition for many whose periods have already stopped due to a variety of reasons (including birth control), or who are thrust into medical menopause through a surgical procedure, but here we are. Effectively menopause means your ovaries have finally closed up shop, and your body is no longer producing estrogen. Bonus: no more investing in menstrual cups and pads. Drawback: zero estrogen means our rates of disease jump to match, or surpass, men with things like cardiovascular disease, osteoporosis, Alzheimer’s, and dementia.

what is hormone replacement therapy (HRT)?

HRT (also known as MHT or Menopausal Hormone Therapy) is an umbrella term for the various hormones prescribed to replace the declining/absent levels during peri/menopause. Most options are now body-identical, but there are also synthetic options. The dosage is far lower than that of the birth control pill (which are also synthetic hormones).

Current guidance from experts says you can start HRT up to ten years after your last period (starting after that can potentially cause issues, as your body’s estrogen receptors have been shut down for too long). And most experts also recommend staying on HRT for life, not just until your symptoms have subsided, to receive all the health benefits and protections. The vast majority of women are eligible to take HRT, even those with a history of breast cancer (Dr. Avrum Bluming, co-author of Estrogen Matters, explains it quite simply in talks such as this).

The health benefits of HRT include:

• Prevention of symptoms such as hot flashes, which can in themselves be quite detrimental and cause long-term cardiovascular damage

• Protection against heart disease

• Protection against cognitive decline, including dementia and Alzheimer’s

• Protection against osteoporosis (hip fractures are a leading cause of death in women)

• Reduction of recurrent UTIs

The Rx cocktail consists of:

• Estrogen (specifically estradiol) – The primary hormone, taken in the form of a patch, gel, or pill (and separately as a vaginal cream). Many specialists prefer the transdermal forms (patch or gel) as they pose no threat of blood clots or stroke because they don’t have to be processed by the liver. The patch looks like a small round bandaid, applied to your abdomen or thigh, and gets swapped out twice a week; the gel typically comes in a pre-measured pump dispenser and gets rubbed into your skin (for example, on your inner arm). Some women at low risk of blood clots prefer the convenience of a daily pill.

  The bonus vaginal estrogen (in cream or slow-release insert form) directly treats the vaginal canal and surrounding areas to tackle dry and atrophying tissue which can lead to painful sex and recurring UTIs (which have also been linked to increased dementia risk).

• Progesterone (progestin) – If the patient still has their uterus, progesterone is paired with estrogen to prevent potential uterine cancer (since estrogen builds up the uterine lining). It’s taken in the form of pills (do NOT buy progesterone gels or creams, as progesterone molecules are too big to be absorbed through the skin). Alternatively, IUDs can provide localized protection (a great option for women who are progesterone intolerant).

• Testosterone – Not just for men! Testosterone is getting a lot of recent traction as an important potential addition to the HRT regimen, especially for help with libido, energy, and brain fog. Must be prescribed off-license, as there is currently no FDA regulated formulation for women, which means it’s legal but not covered by insurance. Yet.

what was the women’s health initiative (WHI)?

Launched in 1991, the WHI was one of the largest health studies ever commissioned by the U.S. government, and studied a variety of health issues in postmenopausal women. (Data analysis from the study is still ongoing.) In 2002, an un-vetted statement was released to press stating that the WHI had noted a slight increase in breast cancer rates among recipients of Hormone Replacement Therapy (HRT), and all HRT studies were halted immediately, which caused quite a media frenzy and panic in women everywhere. Prescriptions for HRT came to a screeching halt. A few specialists took it upon themselves to continue researching the issue, which eventually led to the exposure of the substantial flaws of the original WHI study (i.e., the majority of participants were already post-menopausal, and many had comorbidities such as excessive weight or diabetes, which contribute to higher cancer risk), and the current reevaluation of HRT. To quote a recent National Library of Medicine article, “Unfortunately, the surge in HRT use and its consolidation was abruptly stopped by the publication of the WHI trial, which was inadequately designed, evaluated, and reported. The damage done was huge, basically leaving many symptomatic women without an effective treatment, even if the epidemiological data were not strong enough to document a clear harm to women’s health.”

For an in-depth explanation, check out Estrogen Matters by Avrum Bluming, M.D., and Carol Tavris, PhD. For an abbreviated explanation, check out this New York Times Magazine piece by Susan Dominus.

what is the menoposse?

Do they call themselves this? They do! Comprised of many of the aforementioned specialists who have taken it upon themselves to further research and education in the field of menopause, they amplify each other’s work, making sure the rest of us benefit. You can find a not-comprehensive list of them in our Recommendations section.  

how do i find a specialist?

Most doctors and other medical practitioners receive little-to-no instruction on menopause during medical school. And by “little” we mean a one-hour lecture for gynecological students. But all is not lost! There are many practitioners who have taken it upon themselves to become educated on the topic. Your doctor might be one of them, but if not, and you need an alternate option, here are some ways to find them:

• The North American Menopause Society has a very useful database of menopause specialists if you, you know, live in North America. There are similar organizations elsewhere, such as the European Menopause and Andropause Society and the British Menopause Society. Trans and nonbinary individuals experiencing symptoms can find providers who specialize in LGBTQ+ care at sites like GLMA and WPATH.

• If there aren’t any practitioners in your area, there are now several online options offering specialized menopause telehealth care. This article has a roundup of some of the bigger ones in the U.S., which often take insurance.