Initiating HRT during perimenopause is a subject that needs more attention. This is because the current guidelines and traditional thinking about taking hormone replacement generally apply to women who have reached menopause – meaning they have gone 12 months without a menstrual period. However, many women experience distressing symptoms during perimenopause, which in some cases last years before menopause occurs. In addition, a number of negative health impacts caused by declining estrogen (such as bone loss and a rise in cholesterol) develop well before menopause.
Therefore, while it makes sense that initiating HRT during perimenopause is beneficial, there have not been many studies on this
to help guide women and their health care providers. In many cases women find themselves having significant symptoms during perimenopause but their health care providers don’t recommend hormones. Instead, they are advised to wait until menopause to receive HRT and are frequently treated with other measures which may or may not be very helpful.
Why is HRT during perimenopause problematic?
There are many reasons for this. One issue is that while menopause has a clear definition, i.e. going 12 months without a menstrual period, the onset of perimenopause may not be easily identified. Each woman has a varied and unique experience. While changes in the menstrual pattern are hallmark signs, these may be subtle or not even a factor if a woman has had a hysterectomy. Hot flashes, mood swings, sleep disturbance or cognitive changes generally develop but can wax and wane and vary in intensity. The fact that these symptoms are due to hormonal fluctuations is frequently not appreciated.
Even if recognized, the fluctuations in the hormone levels cause unpredictable symptoms. For some days or months the estrogen level may be normal and women feel “like their old selves.” Then the hormone levels go down and symptoms unexpectedly reappear. At times, sharp drops in estrogen occur and, in fact, it is these abrupt declines that bring on many symptoms such as sudden mood swings. Rapid changes in the estrogen level also trigger migraine headaches, another common problem women experience in perimenopause.
Taking an estrogen product during the low periods can help symptoms such as hot flashes and mood swings. However, adding estrogen to normal levels may cause other symptoms such as breast tenderness, nausea, vaginal bleeding or spotting. So, it is not simply a matter of taking a daily fixed dose of HRT, as is recommended after menopause. This is because the standard doses of HRT don’t suppress the signals from the brain that stimulate the ovaries to make hormones. Thus, the erratic fluctuations in the hormone levels that occur during perimenopause persist.
Another important point is that until the actual time of menopause a woman can get pregnant. So, for many perimenopausal women, contraception needs to be a consideration. Taking hormones in the form of HRT is not adequate to suppress ovulation and prevent pregnancy.
What are the options?
Contrary to what many health care providers realize, hormone therapy can be given during perimenopause. However, it needs to be tailored to each woman’s unique circumstances. Does the woman need contraception? Does she have a uterus? Is she having heavy bleeding or frequent spotting? Is she having hot flashes or other bothersome symptoms?
Once all this is assessed, then she can work with her health care provider to decide what option would work for her. These include the following:
Birth control pills
While it may seem surprising, many menopause experts recommend using low-dose birth control pills as a treatment option for women having issues during perimenopause. Almost all birth control pills contain a form of estrogen and a progesterone-like drug. So, birth control pills are effective in relieving symptoms related to the declining hormones, such hot flashes, sleep disturbance, mood swings and vaginal dryness. They also will prevent estrogen-deprived medical consequences such as thinning of the bones.
Birth control pills work by suppressing the brain’s production of the hormones that stimulate the ovaries to make estrogen and progesterone. Thus, the ovaries stop making these hormones. Since the pills contain fixed doses of hormones, the level of estrogen remains steady rather than fluctuating up and down. This further helps minimize many perimenopausal symptoms. Controlling and balancing the estrogen with a progesterone-like drug decreases heavy bleeding problems. In some cases the monthly menstrual cycles are even eliminated. In addition, birth control pills prevent ovulation. This fulfills the need for contraception if that is needed.
Although BCPs seem like the ideal solution, many women are leery of them. Contraceptive pills do not contain bioidentical hormones, like the ones we recommend for HRT. Most contain synthetic ethinyl estradiol and a synthetic progesterone-like product. These synthetic hormones are more likely to cause adverse effects compared to bioidentical hormones. A slight increase in the risk of heart disease (particularly in smokers) and breast cancer (with long-term therapy) has been reported with some forms of BCPs, particularly the higher dose formulations.
On the positive side, however, beside decreasing perimenopausal symptoms and preventing bone loss, taking BCPs can help prevent migraine headaches and have been shown to decrease the risk of ovarian and uterine cancer.
One recent development with respect to BCPs is the introduction of a new product that contains estetrol, a hormone produced by the fetal liver. The brand name for this pill is Nextstellis. Since estetrol is a bioidentical estrogen, it may be that it is safer than the synthetic estrogen in other BCPs.
Regardless, the bottom line is that low-dose BCPs taken for a limited number of years during the perimenopause is generally very safe for most healthy women and likely provides more benefits than risks.
Standard HRT regimens
The term HRT is used to designate the hormone regimens used to treat women once they reach menopause. HRT regimens contain some form of estrogen with or without a progesterone-like drug. Estradiol and micronized progesterone, which are identical to the hormones made by the ovaries, are the ideal choices.
The doses in HRT regimens are lower than what the body had been making prior to menopause. They are also much less potent
than the hormones in BCPs. HRT regimens do not provide contraception.
Simply taking HRT in perimenopause is tricky because the doses used in HRT are not adequate to suppress ovulation nor do they prevent the ovary from making its own hormones. So as noted above, taking HRT during the perimenopausal transition can periodically cause higher than desirable levels of estrogen leading to negative side effects.
The ideal solution would be to add extra HRT when the hormone levels are low. The problem is that women can’t predict when this will occur and would end up “chasing” the symptoms rather than preventing them. However, as women get closer to menopause, where the hormone levels remain consistently in the lower ranges, daily HRT can prove beneficial.
Some women find that taking a daily dose of progesterone without an estrogen helps mitigate some of the perimenopausal symptoms, particularly sleep problems. However sometimes adding progesterone alone can lead to unexpected menstrual spotting or bleeding.
Using a progestogen containing IUD plus estradiol
There are several IUDs on the market that contain a synthetic progesterone-like drug. These are not approved specifically to treat perimenopausal or menopausal symptoms but are approved for birth control and to control heavy bleeding. So in cases where a woman is having heavy bleeding and having hot flashes, one option is to have an IUD inserted (which would control the bleeding) and take a low dose of estradiol (to control the hot flashes). The IUD also provides contraception and can remain in place for up to eight years.
What about vaginal hormones?
So far, I have addressed options for women troubled by hot flashes, abnormal menses, and other systemic symptoms. But in some women, it is only vaginal dryness and discomfort that is problematic. In this situation there are many products available that are designed to specifically treat these symptoms. These contain ultra-low doses of estrogen and are inserted into the vagina in the form of a suppository, gel or ring. Negligible amounts of estrogen get into the blood stream while using these products and so they are extremely safe. These can be started at any point during perimenopause without causing adverse effects. They are not potent enough to relieve symptoms such as hot flashes or help prevent bone loss.
What about testosterone?
A woman’s testosterone level peaks in her mid 30’s and then gradually declines during the rest of her life. So unlike estrogen and progesterone which fall significantly during the perimenopause transition, testosterone does not change very much. There is very little research on the role of testosterone treatment during perimenopause. Some women find that low-dose testosterone helps libido, and some menopause experts endorse a trial for women with these complaints. Currently here are no FDA approved testosterone preparations for women. For a more detailed discussion of testosterone use see my blog on this subject.
The bottom line
Perimenopause is a multi-year transition period where a woman’s hormone levels go through an erratic descent. This decline in estrogen causes many symptoms and promotes bone loss as well as other negative changes that can impact a woman’s future health. There are very few studies to guide women and their health care providers to deal with the hormone changes that occur during this phase of life.
Importantly it is critical to realize that every woman’s situation is unique, and an individualized approach is necessary. Many women do benefit from hormone treatment, but it may require working closely with a health care provider who is willing and able to create a treatment plan.
The final part of this series on perimenopause will address other pharmaceutical measures that are available to treat issues that arise in perimenopause. In some cases hormone treatment is neither feasible nor desirable; so it is helpful to be aware of some of the non-hormonal treatments that are commonly utilized.
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