Perimenopause &
Menopause Care

Care from a Menopause Society
Certified Practitioner

Menopause is a normal life stage, and you don’t have to just get through it

Menopause is the point when you have gone 12 months in a row without a period. In the US the average age is about 51. The symptoms that come with it can affect sleep, mood, work, relationships, and long-term health. Effective, safe treatments exist, and you deserve care from someone trained to provide them.

The stages

Perimenopause (the menopause transition) often starts in your 40s and can last several years. Hormone levels rise and fall unpredictably. Common signs:

• Changes in your cycle: periods that are closer together, further apart, heavier, or skipped

• Hot flashes and night sweats

• Trouble sleeping

• Mood changes, irritability, anxiety, or low mood

• Brain fog and trouble concentrating

• Joint aches and changes in sexual desire

You can still get pregnant during perimenopause, so birth control matters until we confirm menopause.

Menopause is confirmed after 12 months with no period. Menopause before 40 is called premature menopause, and before 45 is early menopause. Both deserve evaluation and usually treatment.

Postmenopause is everything after. Hot flashes often ease over time but can last 7 years or longer. Lower estrogen also affects bone, heart, and vaginal and urinary health over the long term.

Common symptoms we treat

• Hot flashes and night sweats (vasomotor symptoms)

• Sleep problems

• Mood changes

• Genitourinary syndrome of menopause (GSM): vaginal dryness, pain with sex, urinary urgency, and repeated urinary tract infections. GSM tends to get worse over time without treatment.

• Bone loss, which raises the risk of osteoporosis and fractures

Hormone therapy

Hormone therapy (HT) is the most effective treatment for hot flashes and night sweats. It also prevents bone loss and treats GSM.

• Estrogen relieves symptoms. It comes as a patch, gel, spray, or pill. Patches and gels have a lower risk of blood clots than pills.

• Progesterone is added if you have a uterus, to protect its lining. Using estrogen alone with a uterus raises the risk of uterine cancer.

• Low-dose vaginal estrogen treats GSM. Very little reaches the bloodstream, and most women can use it safely long term.

Other possible benefits, still being studied. Beyond hot flashes, bone protection, and GSM, research suggests estrogen and progesterone may help with other symptoms. The evidence for these is still developing, so they aren’t reasons on their own to start hormone therapy, but many patients notice a difference:

• Sleep: Estrogen can improve sleep by reducing night sweats. Micronized progesterone, taken at bedtime, has a calming effect and may help some people fall asleep and stay asleep.

• Mood and anxiety: Estrogen may help with low mood and depression that start during perimenopause, and some studies show benefit, especially with patches. Progesterone acts on calming receptors in the brain, which may ease anxiety for some people. Hormones don’t replace therapy or antidepressants when those are needed.

• Joint and muscle aches: In the Women’s Health Initiative, women taking estrogen reported less joint pain than those taking a placebo.

• Brain fog: Many women report clearer thinking once hot flashes and sleep improve. However, studies have not shown that hormone therapy improves memory or prevents dementia.

• Skin: Small studies suggest estrogen helps maintain skin collagen, thickness, and moisture.

• Heart and metabolic health: When started before age 60 or within 10 years of menopause, hormone therapy has been linked with lower rates of heart disease in some studies, and the WHI found fewer new cases of type 2 diabetes. Even so, hormone therapy is not recommended only to prevent heart disease or diabetes.

• Colorectal cancer: In the WHI, women taking combined estrogen and progestin had fewer colorectal cancers.

• Hot flashes without estrogen: For people who can’t take estrogen, progesterone alone reduced hot flashes in small studies.

We’ll talk through which of these matter most to you, and what the evidence shows for your situation.

Is hormone therapy safe? For most healthy women under 60, or within 10 years of their last period, the benefits of hormone therapy outweigh the risks. Risks depend on your age, health history, and the type, dose, and route of hormones. We review these with you:

• Breast cancer: Certain formulations of estrogen plus progestogen are linked to a small increase in risk after several years of use. Much of what people have heard comes from the Women’s Health Initiative (WHI), a large study published in 2002. It tested one specific combination: conjugated equine estrogen (Premarin) plus a synthetic progestin, medroxyprogesterone acetate (Provera), taken daily as a pill.

  What the WHI found, in plain numbers: Among 10,000 women taking that combination for one year, there were about 38 cases of breast cancer, compared with about 30 among women taking a placebo. That is about 8 extra cases per 10,000 women each year, or roughly 1 extra case per 1,000 women per year. In the same study, women without a uterus who took estrogen alone (Premarin) had about 7 fewer cases per 10,000 women per year than those taking a placebo.

  Today, we often use body-identical hormones, such as estradiol patches or gels with micronized progesterone. Observational studies suggest this combination may carry less breast cancer risk, though it hasn’t been tested in a trial as large as the WHI. For perspective, the added risk from combined hormone therapy is similar to the added risk from drinking two or more alcoholic drinks a day, and smaller than the added risk from obesity after menopause.

• Blood clots and stroke: Risk is higher with pills than with patches or gels, and higher when HT starts after age 60.

• Uterine cancer: Preventing it is why progesterone is added if you have a uterus.

There is no set age when you must stop. We reassess your plan with you every year.

Hormone therapy may not be right for you if you have had breast or uterine cancer, blood clots, stroke, heart attack, active liver disease, or unexplained vaginal bleeding. Effective non-hormonal options are available.

We prescribe FDA-approved, well-studied hormones, including body-identical estradiol and micronized progesterone.

Testosterone for women: what the evidence says

Testosterone gets a lot of attention on social media, often promoted for energy, weight loss, mood, or brain fog. Women do make testosterone, and it can help in the right situation, but the evidence is narrower than the hype.

Where it can help: Testosterone may improve distressing low sexual desire in postmenopausal women, called hypoactive sexual desire disorder (HSDD). This is supported by the Global Consensus Position Statement on the Use of Testosterone Therapy for Women, endorsed by The Menopause Society and other international societies.

Where the evidence doesn’t support it: Testosterone is not recommended for energy, mood, weight, bone health, or memory, because studies haven’t shown a clear benefit for these.

How we use it safely:

• We look for other causes of low desire first, such as sleep, stress, relationship factors, medications, and vaginal dryness or pain

• No testosterone product is FDA-approved for women in the US, so we use carefully dosed products made for women’s physiology

• We check your testosterone level before starting and during treatment to keep it in the normal range for women

• We watch for side effects such as acne or unwanted hair growth, and we reassess after about 6 months: if it isn’t helping, we stop

• We don’t recommend testosterone pellets, because the dose can’t be adjusted once placed and levels can rise too high

Do I need my hormone levels tested?

Many people expect a blood test to “check their hormones” or confirm menopause. For most women over 45, testing isn’t needed and doesn’t change the plan. During perimenopause, estrogen and FSH levels can swing widely from day to day, and even hour to hour, so a single result can look normal one week and “menopausal” the next. Perimenopause and menopause are diagnosed by your age, symptoms, and changes in your cycle.

When hormone testing can be helpful:

• Symptoms before age 40, or periods that stop early, to check for premature ovarian insufficiency. This needs a full workup and specific treatment.

• Symptoms between 40 and 45, when the picture is less clear.

• When your cycle can’t be tracked, for example after a hysterectomy or endometrial ablation, though results still need careful interpretation.

• Ruling out other causes of symptoms like fatigue, missed periods, or heavy bleeding. This may include thyroid testing, a pregnancy test, prolactin, or a blood count and iron levels.

• Testosterone therapy, where we check levels before starting and during treatment to keep them in the normal range for women.

• Rarely, during estrogen therapy, if symptoms continue despite usual doses and we want to check how well it’s being absorbed.

When testing isn’t helpful:

• Routine estrogen, progesterone, or FSH levels to “confirm” menopause in women over 45 with typical symptoms

• Repeated hormone panels to adjust your dose. We adjust hormone therapy based on how you feel and your symptoms, not on a target number

• Saliva, urine, or “hormone balancing” panels. These haven’t been shown to accurately guide treatment

• Progesterone levels to dose progesterone

Unnecessary testing can add cost, cause worry, and lead to treatment decisions based on numbers that don’t reflect how you feel. Instead, we focus on labs that protect your long-term health, such as cholesterol, blood sugar (A1c), and others based on your history, along with bone density scans and mammograms when they’re due.

Non-hormonal options

• Newer non-hormone medications that target the brain’s temperature control center (fezolinetant, elinzanetant)

• Certain antidepressants (SSRIs and SNRIs) at low doses

• Gabapentin, which can help especially with night sweats and sleep

• Cognitive behavioral therapy (CBT) and clinical hypnosis, both shown to reduce how much hot flashes bother you

• Vaginal moisturizers and lubricants for dryness

Bladder leaks and pelvic floor weakness: Lower estrogen and aging can weaken the pelvic floor. Along with vaginal estrogen and pelvic floor exercises, we offer the EMSELLA chair, an FDA-cleared, non-invasive treatment for urinary incontinence that you sit on fully clothed.

Beyond symptoms: your long-term health

Midlife is a key time to protect your future health. Your visits can include blood pressure, cholesterol, and blood sugar; a bone health assessment; cancer screening; and support with sleep, nutrition, strength training, and weight changes in midlife.