A guide to hormone therapy for perimenopause

From vaginal dryness that can make sex hurt to hot flashes that seem to strike at the most awkward times, perimenopause — which is your transition to menopause (your final period) — can make itself known in a whole host of different ways. 

Menopause is a process that affects everyone who has periods. And just like periods, not everyone will deal with the same troublesome symptoms. But if you do, don’t worry — there are plenty of ways to improve what you’re experiencing and help you feel more like yourself. 

You might have heard of hormone therapy (HT, once known as hormone replacement therapy or HRT), which is one possible treatment option for symptoms of perimenopause. HT can relieve hot flashes, night sweats, and vaginal dryness for some people. It can also help with sleep problems, mood swings, and anxiety. And as a bonus, it can even promote healthy bones. 

But while hormone therapy works well for some people, it isn’t suited to everyone. Here, obstetrician and gynecologist Dr. Renita White of Georgia Obstetrics and Gynecology, US, shares everything there is to know about HT, including risks, benefits, and nonhormonal alternatives. But if you’re considering hormone therapy as an option or you have any other questions or worries around perimenopause, reach out to your doctor for advice.

Key takeaways

• Perimenopause is your transition through menopause. It covers the years leading up to menopause and the 12 months after, at which point you can be sure you’ve had your last ever period. It tends to start around your mid-40s, but everyone is different.
• For some people, perimenopause symptoms such as hot flashes, night sweats, and sleep problems can be difficult to live with. Other people may not notice them so much or at all.
• Hormone therapy used to be called hormone replacement therapy (HRT), but experts are now moving toward the medically accurate term hormone therapy because HT doesn’t intend to replace hormones to their original levels before menopause.
• It isn’t suited to everyone, but for many, hormone therapy can help to relieve tricky perimenopausal symptoms. 
• If you don’t want to (or can’t) take HT, there are plenty of nonhormonal treatment options to help you feel better in perimenopause. 
• Healthy lifestyle changes, including eating well, exercising, and looking after your mental well-being, can also make a big difference.

What is hormone therapy?

Hormone therapy is a treatment option for perimenopause and postmenopause symptoms. The terms perimenopause and menopause often get confused, but they’re actually two separate things. Perimenopause refers to the years leading up to menopause (your final period) and one year afterward — because you only know you’ve reached menopause when you’ve gone without a period for 12 months.

It doesn’t happen overnight. It can take between four and eight years for you to reach menopause — everyone’s different — but on average, the transition lasts about four years. 

During this time, your ovaries gradually lose the ability to produce the same amount of hormones as before. Not everyone feels it, but this shift in your hormone production can trigger a range of symptoms, including hot flashes, joint pain, and brain fog. 

Menopause is an expected process that anyone with a female reproductive system will go through, so it’s not that you’re abnormal or have an illness if you find you’re struggling. However, if symptoms do start to disrupt your life, HT is a treatment option that can help some people feel better. “Hormone therapy is a form of medication that [supplements] the hormones that are decreased in menopause,” explains Dr. White. 

Roughly 3 in 20 women aged 45 to 64 in England, UK use hormone therapy. It works by supplying the key sex hormones you might produce less of during perimenopause. “They generally include estrogen [and] progesterone,” says Dr. White. But it’s not something you can buy at your local drugstore. Not everyone is able to take it (more on that below). If you can use HT, you’ll need to find the right type for you with the help of your doctor. 

You can take HT in the form of:

• Pills
• Gel
• Cream
• Patches
• Spray
• Vaginal rings 

The type of HT you get will depend on your symptoms and health. For example, a health care professional might prescribe vaginal HT to you if vaginal dryness is the main perimenopause symptom you have. The best thing to do is book an initial chat with them. They can then talk you through your options based on your symptoms, medical history, and the type of HT you’d prefer to take.

Hormone therapy isn’t generally advised if you’re at risk or have a history of these conditions:

• Liver disease or blood clots: If you have a medical history of liver disease or blood clots, this may make the use of HT too risky. “It can increase the risk of blood clots to the deep vessels or lungs,” says Dr. White.
• Heart disease: “People with a higher baseline risk of cardiovascular disease or stroke may also not make ideal candidates,” says Dr. White. Your doctor will be able to tell you if you have a higher baseline risk.
• Ovarian or uterine cancer: People who have had ovarian or uterine cancers in the past are generally not offered hormone therapy in case it risks recurrence. 
• Breast cancer: People who have previously had breast cancer in the past are usually advised to avoid HT because some studies suggest that it could increase the risk of the cancer recurring. Other studies don’t show any increased risk, but your doctor may prefer to be on the safe side.
• Unexplained vaginal bleeding: If you’ve been bleeding abnormally and you don’t know the cause, hormone therapy wouldn’t be advised as a treatment option for you.

To learn more about perimenopause, you can visit Flo’s health library. And if you’re finding it hard to keep track of your symptoms, using a cycle-tracking app like Flo can help. In the app, you can log symptoms like brain fog and vaginal dryness alongside tracking your periods. Premium subscribers even get cycle and symptom reports each month to help you understand your body better. You can share these with a doctor to help explain what you’re experiencing.

The main benefits and risks of hormone therapy

Are you feeling confused about the benefits and risks of taking hormone therapy? There’s a whole lot of misinformation on the subject out there, so you’re not the only one. While many people who struggle with symptoms of perimenopause can use HT, keep in mind that it’s not for everyone. Some people can’t take HT for health reasons, while others simply don’t want to. You’ll need to work with your doctor to figure out if it’s right for you. In the meantime, here are some of the main benefits and risks.

Benefits of HT

If you’re finding the effects of perimenopause difficult to live with, you might benefit from hormone therapy, explains Dr. White. “Not every person is a candidate,” she says. “But if you fall into this category, it may be worthwhile to discuss hormone therapy as an option.”

The most obvious benefit of HT is relief from tricky perimenopause symptoms, but you’ll only be prescribed this treatment for certain ones. “Replacing estrogen can improve symptoms of hot flashes, night sweats, [and] vaginal dryness,” says Dr. White.

In fact, one study that followed over 3,000 perimenopausal and postmenopausal women found that the group’s symptoms, particularly hot flashes, improved by 75% after taking HT for at least three months. 

HT can also play a key role behind the scenes, too. “Estrogen is important for preventing bone mineral loss,” adds Dr. White.

Risks of HT

Like most medical treatments, HT can come with risks, but these depend on your age, health history, and the different types of hormone therapy that can be prescribed. Some of the risks include vaginal bleeding, heart disease, blood clots, and cancer, but these are by no means guarantees. The best thing to do is to speak to your doctor for more information about the risks and which ones may apply to you based on your personal health.

Fortunately, if you decide hormone therapy isn’t for you, it’s not the only treatment for perimenopause. We’ll talk more about nonhormonal alternatives as you read on.

The most common side effects of hormone therapy

Some of you might experience side effects while your body gets used to HT. This is expected, and they usually improve over time. But of course, it’s a balance, and if the side effects ever feel worse than your original perimenopause symptoms, it’s worth a chat with your doctor about whether you want to change your dosage or type of HT. Some hormone therapy side effects can include: 

• Spotting: The most common side effect is spotting or light bleeding. “The increased estrogen may cause the uterine lining to increase slightly — enough to cause spotting,” explains Dr. White. 
• Headaches: Some people get headaches from HT. If this sounds like you, talk to your doctor about adjusting your dosage or experimenting with different forms of estrogen.
• Breast tenderness: If your breasts start to feel sore, it could be linked to HT, according to Dr. White. “Similar to premenstrual syndrome (PMS), the elevated progesterone levels from the hormone therapy cause these symptoms,” she says. 
• Bloating: If you find yourself feeling more bloated than usual around your belly, it could be caused by fluid retention as a result of HT. 

If three months have gone by and your symptoms don’t improve, check in with your doctor. Finding the right form of HT can take some trial and error. It might be that the amount of HT you’re on is too high for your body to process properly. Remember that medical treatment is always a balance of risk versus reward, and in all cases, your doctor will take a close look at your medical history to figure out whether HT would be a safe fit for you. 

Some hormone therapy alternatives

HT is often hailed as a cure-all for tricky perimenopause symptoms. But, some people don’t want to take hormones, while others aren’t advised to based on their previous medical history. For these people, it’s useful to know that hormone therapy isn’t the only route to feeling better. There are a number of nonhormonal treatment options for perimenopause symptoms.

You might consider:

• Antidepressants: Did you know they’re not just beneficial for mental health conditions? Doctors can prescribe these for hot flashes. “Selective serotonin reuptake inhibitors (SSRIs) are a class of antidepressant that has been shown to decrease hot flashes, sweats, and mood changes,” says Dr. White. “They may also improve sleep disturbances.”
• Selective estrogen receptor modulators (SERMS): These can change the amount of estrogen in your body by working on the estrogen receptors. “It can improve menopause symptoms without actually giving you hormones back,” says Dr. White. 
• Gabapentin: Doctors may prescribe this anti-seizure medication for hot flashes. “Some nerve medications, like gabapentin, can improve symptoms,” says Dr. White.
• Clonidine: This low-dose high blood pressure medicine has been linked with improvement in symptoms, according to Dr. White.
• Vaginal creams and lubes: They could be an answer for easing painful sex and reducing unwanted friction.
• Hormonal contraceptive pills: Birth control can be used as a two-for-one to help perimenopause symptoms and to avoid pregnancy. The pill can help to stabilize hormone levels, which is what helps to ease your body’s reaction to perimenopause. In the same way as HT won’t be recommended for everyone based on medical history, neither will hormonal birth control, but it can be a helpful treatment option for some — especially if you’re already taking it.  
• NK3 receptor antagonists: These newer medications can help people with moderate to severe hot flashes. The newest one on the market is fezolinetant. “This nonhormonal medication blocks chemicals in the brain that impact how we regulate temperature,  improving hot flashes and sweats,” says Dr. White.

Lots of herbal remedies claim to be effective too, but their safety is unknown. More generally, healthy lifestyle changes, including eating well, exercising, and looking after your mental well-being, may be enough to help you navigate this life stage. For some people, losing weight may also be suggested as another way to help ease hot flashes and night sweats. But because a healthy weight looks very different on different people, it’s best to speak to your doctor before trying to tackle this yourself.

As always, talk with your doctor before considering any form of treatment. They can offer advice to help you decide which option might work for you.

Hormone therapy: Is it right for you?

HT is widely considered to be an effective treatment option for certain symptoms of perimenopause. “If you are struggling with hot flashes, night sweats, or vaginal dryness, you may benefit from hormone therapy,” says Dr. White. She adds that some people may also notice an improvement in “mood disturbances, insomnia, joint aches, or concentration issues,” but it’s important to note that doctors wouldn’t prescribe hormone therapy for these symptoms unless you were experiencing hot flashes, vaginal dryness, or night sweats, too. 

As we now know, hormone therapy isn’t for everyone, so if you’re thinking about taking it, it’s important to understand the risks as well as the benefits. “If you are struggling with menopausal symptoms and want to know your options or review the safety of hormone therapy, work with your gynecologist to determine what may be right for you,” advises Dr. White.