Ask a Doc: Hormone Replacement Therapy and Perimenopause Explained

How do I know if I'm in perimenopause and is it too early to start hormone replacement therapy?

Kelly Wiersema, MD: Perimenopause is the transition leading up to menopause. It can start several years before periods completely stop. Perimenopause is a clinical diagnosis, which means we diagnose it based on your symptoms. Hormone levels fluctuate significantly in this time frame, so there is no blood test that can tell us if someone is in perimenopause or not. Women often start to notice changes in their periods. They could be closer together, further apart, heavier, or lighter. Women may start to notice symptoms like hot flashes, night sweats, sleep problems, mood changes, or brain fog.

You do not have to wait until your periods stop completely to talk with your doctor about hormone therapy. If your symptoms are affecting your daily life, ask your doctor about treatment options.

What symptoms can hormone replacement therapy help with during perimenopause?

Kelly Wiersema, MD: Hormone therapy is the most effective treatment for hot flashes and night sweats. It can often help with sleep as well, especially if hot flashes or night sweats are waking you up. Some women will notice improvement in mood, joint aches, or overall sense of well-being. Estrogen can be very helpful for vaginal dryness, discomfort with intercourse, and some urinary symptoms.

Is hormone replacement therapy safe and what are the real risks I should know about?

Kelly Wiersema, MD: For most women who are younger than 60 or within about 10 years of menopause, the benefits of hormone therapy generally outweigh the risks. The risks associated with hormone therapy can vary based on your age, health history, which type of hormones you take, the dose and route of hormone therapy.

For some women with certain medical conditions (hormone-sensitive cancers, a history of some types of blood clots, stroke, or heart attack), hormone therapy may not be a good option.

Every patient is different and individual risks and benefits should be discussed with your provider.

What's the difference between hormone replacement therapy and birth control pills during perimenopause?

Kelly Wiersema, MD: Birth control pills usually contain higher doses of hormones than hormone replacement therapy. They also often use different types of hormones. Birth control pills help prevent pregnancy and can help manage heavy or irregular periods during perimenopause. Hormone replacement therapy uses lower doses of hormones to treat symptoms, but it does not prevent pregnancy.

For some women, another option is a hormonal IUD to prevent pregnancy or help control bleeding, along with estrogen to help manage menopause symptoms.

Can hormone replacement therapy help with weight gain and brain fog during perimenopause?

Kelly Wiersema, MD: Perimenopause and menopause are associated with changes in metabolism and body composition, including a tendency to carry more fat around the midsection. Hormone therapy may have some favorable effects on body composition but generally has not been shown to specifically help women lose weight.

Brain fog is very common during perimenopause. Women may have trouble concentrating, finding the right words or remembering things. Hormone therapy is not recommended specifically to treat brain fog or prevent dementia. However, some women notice clearer thinking once other menopause symptoms are under better control.

How long can I stay on hormone replacement therapy and how do I know when it's time to stop?

Kelly Wiersema, MD: There is no specific age or number of years when a woman must stop hormone therapy. We generally take an individualized approach with each patient. If hormone therapy continues to provide meaningful benefits and a woman’s overall health and risk factors remain appropriate, it is reasonable to continue. I generally recommend discussing yearly with your provider to see if hormone therapy continues to make sense for you.

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