Treating Perimenopause with Hormone Replacement Therapy (HRT)

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Hormone replacement therapy (HRT) offers benefits such as alleviating hot flashes, mood swings, and other symptoms associated with hormonal changes. As a result, HRT is considered a viable option for managing these symptoms in women over 50. But what about when those same symptoms are experienced by women under 50 who are still having menstrual periods and are in perimenopause? Does HRT benefit these younger women? What are the pros and cons of HRT for perimenopausal women? What challenges does HRT treatment pose for perimenopausal women under 50? In this article, we’ll look at important questions about HRT for younger women in perimenopause, and factors to consider when evaluating HRT treatment.

Perimenopause is the period when your body transitions towards menopause. This phase can start as early as the mid-30s but typically begins in the 40s. It is characterized by fluctuations in hormone levels, particularly estrogen and progesterone, leading to various symptoms such as:

• Irregular menstrual cycles 
• Hot flashes (also known as hot flushes)
• Night sweats
• Sleep disturbances
• Mood swings
• Vaginal dryness
• Decreased sex drive 

The perimenopausal period can vary in duration, lasting anywhere from a few months to years, and marks the gradual end of reproductive fertility. Typically, these symptoms improve and may resolve once menopause is reached. Menopause is defined as the point when it’s been a full 12 months since the last menstrual period, which in the U.S. occurs on average at age 51.

Hormone replacement therapy (HRT) has emerged as a popular and effective treatment option for managing perimenopausal and menopausal symptoms. 

HRT involves the administration of hormones, primarily estrogen and progesterone, to replace the ones the body no longer produces in sufficient quantities. The therapy aims to alleviate the symptoms associated with hormonal imbalances.

HRT can be administered in various forms, including:

• Tablets: Oral administration is a common method.
• Patches: These are applied to the skin and release hormones gradually.
• Gels, sprays, and creams: These are applied to the skin and absorbed into the bloodstream.
• Implants: Small pellets inserted under the skin release hormones over time.

There are different types of HRT, including: 

• Estrogen-only HRT: Used for women who have had a hysterectomy. It comes in forms such as pills, patches, gels, or creams.
• Combined HRT: Contains both estrogen and progesterone – whether bioidentical or conjugated/manufactured. Combination HRT is for women who still have their uterus to reduce the risk of endometrial cancer. It can be cyclical or continuous.
• Local estrogen: Low-dose estrogen in creams, rings, or tablets is used to treat vaginal and urinary symptoms.
• Bioidentical HRT: Derived from plant sources and chemically identical to the hormones produced by the human body, bioidentical HRT is available in standard manufactured formulations and custom-compounded formulations.

Guidelines and studies support the benefits of hormone replacement therapy (HRT) for younger women in perimenopause. According to the 2022 hormone therapy position statement of the North American Menopause Society (NAMS): 

“Hormone therapy remains the most effective treatment for vasomotor symptoms (VMS) and the genitourinary syndrome of menopause and has been shown to prevent bone loss and fracture. The risks of hormone therapy differ depending on the type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is used. Treatment should be individualized using the best available evidence to maximize benefits and minimize risks, with periodic reevaluation of the benefits and risks of continuing therapy.

For women aged younger than 60 years or who are within 10 years of menopause onset and have no contraindications, the benefit-risk ratio is favorable for treatment of bothersome VMS and prevention of bone loss.” 

One study demonstrated that healthy women taking combined HRT for 10 years immediately after menopause had a reduced risk of heart disease and death from heart disease. 

Additional analysis of the Women’s Health Initiative (WHI) trial data also showed that the use of HRT in younger women (50-59 years) or in early postmenopausal women (within 10 years of menopausal onset) had a beneficial effect on the cardiovascular system, reducing coronary diseases and all-cause mortality.

Symptom relief

Specifically, HRT has several benefits, but the primary one is its effectiveness in relieving perimenopausal symptoms. After starting HRT, women often experience significant improvements in:

• Hot flashes and night sweats: These symptoms often improve within a few weeks of starting HRT.
• Sleep problems: Improved sleep quality is a common benefit.
• Mood swings and anxiety: HRT can help stabilize mood and reduce anxiety levels.
• Vaginal dryness: Localized estrogen treatments can alleviate vaginal dryness and discomfort.
• Libido: Women sometimes experience an improved sex drive after starting HRT. 
• Sexual function: Vaginal dryness and discomfort during intercourse are common perimenopausal symptoms. HRT can improve vaginal lubrication and elasticity, enhancing sexual comfort and satisfaction.

Bone health and osteoporosis prevention

Osteoporosis, a condition characterized by weakened bones, is a significant concern for women after menopause due to the drop in estrogen levels. HRT helps maintain bone density and reduces the risk of fractures later in life.

Muscle strength

HRT can also help maintain muscle strength, which tends to decline during perimenopause and menopause. This benefit, combined with regular exercise, can help women stay more active and healthy.

Cardiovascular health

Some studies suggest that HRT initiated around the time of perimenopause can have a protective effect on cardiovascular health. Estrogen has been shown to benefit cholesterol levels and blood vessel function.

Mental health and mood

Hormonal fluctuations during perimenopause can contribute to mood swings, anxiety, and depression. HRT can stabilize these fluctuations, improving mental health and quality of life.

While HRT offers significant benefits, it is not without risks, even for women under 50. This is why the decision to start HRT should be made in consultation with a healthcare provider who can consider your individual health profile and risk factors.

The risk factors include the following:

Breast cancer risk

Some studies suggest a slight increase in the risk of breast cancer with long-term HRT use. This risk appears to be more associated with combined estrogen-progestin therapy rather than estrogen-only therapy. In addition, this risk seems to be relatively small for women under 50 or within 10 years of menopause onset.

Estrogen-only HRT, typically prescribed for women who have had a hysterectomy, also carries a lower risk. Some studies also suggest that bioidentical HRT, particularly transdermal estradiol and micronized progesterone, may carry a lower risk of breast cancer compared to conjugated estrogens and synthetic progestins. However, more long-term studies are needed to confirm these findings.

Risk of blood clots

Oral HRT has a slightly increased risk of blood clots, particularly with oral estrogen-progestin therapy. However, this risk is significantly lower with transdermal methods such as patches, gels, sprays, and creams, as estrogen is absorbed through the skin rather than the digestive system.

Risk of stroke and cardiovascular disease

The Women’s Health Initiative (WHI) study initially raised concerns about increased risks of heart disease and stroke with HRT. However, subsequent analyses found that HRT initiated closer to menopause (within 10 years or under age 60) does not increase these risks and may even provide cardiovascular benefits. Transdermal forms of HRT carry almost no increased risk of stroke.

Risk of endometrial cancer 

For women with a uterus, the use of estrogen-only HRT increases the risk of endometrial cancer. Adding progesterone (combined HRT) helps mitigate this risk, but the balance of hormones must be carefully managed.

Individual risk factors

Women with specific risk factors, such as a personal or family history of breast cancer, cardiovascular disease, or blood clotting disorders, may have higher risks with HRT and require careful evaluation.

Other risks

Other potential side effects of HRT include the possibility of weight gain, bloating, mood changes, and an increased risk of gallbladder disease.

If you’re a woman in your 40s experiencing bothersome perimenopausal symptoms, you can consider starting HRT when symptoms start interfering with your quality of life. It is not necessary to wait until symptoms become severe, menopause is reached, or you’re over age 50. Early intervention can provide significant relief and improve your quality of life.

For women experiencing premature menopause before age 40 or early menopause before age 45, HRT is particularly important. It helps protect against osteoporosis and other health issues associated with low estrogen levels. Women in this situation are usually advised to continue HRT until the average age of natural menopause at around age 51.

The American College of Obstetricians and Gynecologists (ACOG) provides comprehensive guidelines on the use of HRT for perimenopausal and menopausal women, including women under the age of 48. These guidelines include the following recommendations:

Risk assessment: ACOG advises healthcare providers to conduct a thorough risk assessment before initiating HRT. This includes evaluating the patient’s risk for cardiovascular disease, breast cancer, and osteoporosis.

Individualized treatment: ACOG emphasizes the importance of individualized treatment, considering the patient’s symptoms, health history, and personal preferences. The decision to start HRT should be made after a thorough discussion of the benefits and risks.

Type of hormone therapy: Systemic estrogen therapy (ET), with or without a progestin, is the most effective treatment for vasomotor symptoms (hot flashes, night sweats) in perimenopausal women. Estrogen-only therapy is suitable for women who have undergone a hysterectomy. For women with a uterus, a progestin should be added to the estrogen therapy to protect against endometrial cancer. This is called estrogen-progestin therapy (EPT). 

Dosage, timing, and duration: ACOG recommends that HRT be started close to the onset of menopausal symptoms to maximize benefits and minimize risks. The lowest effective dose should be used, and the duration of therapy should be individualized but focused on the shortest duration needed to manage symptoms. Low-dose and ultra-low-dose estrogen may improve vasomotor symptoms in some women and have a better side effect profile. However, typical doses are generally more effective.

Monitoring and follow-up: Regular follow-up appointments are essential to monitor the effectiveness of HRT, manage any side effects, and reassess the continued need for therapy.

Non-hormonal alternatives: For women who cannot or prefer not to take HRT, ACOG suggests considering non-hormonal treatments (such as SSRI antidepressants) and lifestyle modifications to manage perimenopausal symptoms.

Many barriers get in the way of women seeking help for perimenopause in their 40s. These include:

• A failure to understand that symptoms usually associated with “menopause” can actually start early in perimenopause
• A lack of knowledge about the various symptoms of perimenopause and how long they can last
• Mistakenly assuming the perimenopausal symptoms are due to another health issue
• Normalization of perimenopausal symptoms (i.e., “Of course you’re tired, you are a working mother!”) 
• Limited opportunities to talk to their provider about their symptoms
• The incorrect perception that the risks of HRT always outweigh the benefits
• The misguided idea that HRT is “unnatural” or “medication” rather than hormone replacement that restores hormonal balance. 
• Embarrassment and reluctance to acknowledge that one is in perimenopause
• Some women decline HRT due to concerns about risks like breast cancer, a “just get on with it” attitude, apprehension about taking medication, or fears that periods and severe symptoms will return when stopping HRT.
• Cultural or family expectations around menopause and its symptoms. (i.e., “I didn’t need any treatment during menopause, my daughters won’t either!”) 

There is resistance to prescribing HRT for women under 50 among some medical professionals. Here are some of the most common points of resistance. 

Fallout from the Women’s Health Initiative (WHI) 

The WHI study reported increased risks of breast cancer, heart disease, and stroke associated with HRT. However, this study primarily involved older women (average age 63.2) who were more than a decade past menopause, not newly menopausal women or those under 50.

The media played a significant role in amplifying these findings, leading to widespread fear and confusion about the safety of HRT. This resulted in many women abandoning HRT and a generation of doctors who were hesitant to prescribe it.

The WHI study’s design and participant demographics also led to conclusions that did not apply to younger, perimenopausal women. Subsequent reanalyses and newer studies have shown that HRT can be beneficial for women under 60 or within 10 years of menopause onset, reducing risks of heart disease and mortality.

Despite these newer findings, the initial fear and misinterpretation have had a lasting impact, causing ongoing resistance to prescribing HRT to younger women.

Medical and regulatory caution

Following the WHI study, medical professionals and regulatory bodies adopted strict guidelines and cautious approaches, further limiting the use of HRT. This cautious stance persists despite newer evidence supporting the benefits of HRT for younger women.

Lack of definitive tests

There are no definitive tests that enable healthcare providers to diagnose perimenopause or menopause officially. In some cases, “normal” follicle-stimulating hormone (FSH) or luteinizing hormone (LH) levels may lead a provider to mistakenly rule out that a woman is in perimenopause. 

Downplaying of symptoms 

Some doctors don’t consider perimenopausal symptoms severe enough to warrant treatment and view menopause as “a natural process” rather than as a transition that sometimes warrants medical intervention. 

Lack of awareness and education

Many doctors lack knowledge about HRT, its benefits, risks, and appropriate use, leading to a lack of confidence in prescribing it. 

In addition, there is a need for better education and awareness among healthcare providers about the benefits and risks of HRT for younger perimenopausal women. Misconceptions and outdated information continue to influence decision-making.

Preference for non-hormonal treatments

Due to concerns about the perceived risks of HRT, some healthcare providers prefer to recommend non-hormonal treatments for managing perimenopausal symptoms. These include: 

• Lifestyle changes: Regular exercise, a healthy diet, and stress management can help alleviate symptoms.
• Non-hormonal medications: Certain antidepressants and other medications can help manage hot flashes and mood swings.
• Complementary therapies: While not all are scientifically proven, some women find relief with herbal remedies, supplements, and acupuncture.

For more information on natural and non-hormonal treatments for perimenopause and menopause, read Natural Treatments for Perimenopause and Menopause.

A note from Paloma

It’s important to note that the benefits of HRT for symptom relief, enhanced mental well-being, better sexual function, and prevention of osteoporosis are generally considered to outweigh the risks for most healthy perimenopausal women under 50 or within 10 years of menopause onset. Individual risk factors such as breast cancer, cardiovascular issues, and endometrial cancer must be considered for younger women deciding to take HRT.

If you’re a woman under 50 experiencing perimenopausal symptoms, we recommend a thorough discussion with your healthcare provider about the benefits and risks of HRT for you. Open conversation can help you make informed decisions. Whether you opt for HRT or explore other treatment options, the goal is to manage your symptoms effectively and maintain a high quality of life during this transitional phase.

At Paloma Health, our healthcare providers recognize that each woman’s experience with perimenopause is unique. When you are a Paloma member, your perimenopause and menopause care will be carefully tailored to meet your specific needs and health profile and help you enjoy the best possible health at every stage of life.

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