Menopause hormone therapy (MHT) is one of the topics Iâm asked about most, and the conversation around it has changed dramatically over the years. For two decades after the 2002 Womenâs Health Initiative (WHI) study, women were told hormones were dangerous (which was largely a fault of media misinterpreting the design and results of the study). Now the pendulum has swung hard the other way, and if you believe everything you read on the internet youâd think every woman needs MHT, for life, or her health will fall apart.
The truth sits somewhere in the middle. MHT is a genuinely useful tool, and for many women it can be life-changing. But it isnât a cure-all, and it doesnât replace the lifestyle foundations that drive your health through midlife and beyond.
Thereâs so much to cover on this topic that Iâve split it into two parts. This week, weâll cover recognizing the signs, finding the right provider, testing, and what to expect when you start. In my next newsletter on November 2, weâll cover what MHT does (and doesnât do) for your body, the testosterone question, non-hormonal options, and how long to stay on it.
An important note before we dive in: MHT is often also referred to as HRT (hormone replacement therapy) or simply HT (hormone therapy). They all describe the same treatment, but most experts now prefer MHT, because the goal isnât to "replace" the hormones you previously had. Itâs to ease symptoms and protect your health through this stage of life.
Iâve also asked my friend Dr. Kiki Silver to weigh in on some of the practical, in-clinic questions, since I am not a medical doctor. Weâve known each other since 2014, when we both lived in the Bay Area. Dr. Silver is a UCSF-trained internal medicine physician who sees women for menopause care, optimal aging, and athlete-specific health concerns. Sheâs also an accomplished endurance athlete.
The Early Signs Are Easy to Miss
For active women, perimenopause often hides in plain sight. Fatigue, poor sleep, and slow recovery are easy to blame on a busy life or your training load.
One of the earliest signals can be a change in your cycle. âOne of the earliest symptoms can be a change in menstrual cycle length: it can be a shorter cycle, change in menstrual flow/quality of flow, and skipped cycles (long cycles followed by short cycles),â says Dr. Silver. âThis can be a challenging sign to identify if an active woman is taking the oral contraceptive pill, has a hormonal IUD (like the Mirena), and/or is struggling with LEA/REDs.â
Other signs worth noticing include:
- Fatigue that feels out of proportion to your total âlife loadâ: work, family, training, relationships
- Struggling to recover from workouts that used to feel routine
- Brain fog, irritability, or heightened anxiety
- Disrupted sleep
- Hot flashes or night sweats
- Vaginal dryness
- Stress fractures or other bone injuries
One notable caveat: low iron levels can mimic perimenopause almost perfectly. Brain fog, extreme fatigue, poor sleep, weight changes, low exercise tolerance, poor recovery, hair loss, and brittle nails can all come from low ferritin. Before you assume itâs hormones, get your iron checked (more on annual tests for perimenopausal women below).
When to See a Healthcare Provider
Any change is worth raising with your provider. It puts perimenopause on your radar and opens a conversation about other possible causes. But some symptoms shouldnât wait. âA definite must see/evaluate would be no menstrual cycle in more than three months in a formerly cycling female, vaginal dryness, hot flashes, significant cognitive or mood changes, and stress fractures,â says Dr. Silver.
Not every primary care doctor is up to date on menopause care, though, and neither is every OB-GYN. Questions worth asking include:
- Have you done specific training in menopause and hormone therapy?
- How many perimenopausal and menopausal women do you actively treat?
- How do you weigh the risks and benefits of MHT for someone with my history?
Online menopause clinics are everywhere on social media right now, and convenience comes with trade-offs. âWhile there may be an appeal with the ease of an online clinic, they often do not spend the time doing a thorough analysis and risk/benefit conversation, nor would they have all pertinent past medical and family history to take into account,â says Dr. Silver.
That said, some online services do this well. I would consider green flags to be:
- Clinicians with specific menopause training matched to menopause consults
- A full medical and family history taken before any prescription
- A real conversation about risks and benefits, not just a questionnaire
- Ongoing follow-up, with monitoring and dose adjustments built in
- Encouragement to keep up your regular screening, like mammograms
Red flags would be: a prescription after a five-minute form, one-size-fits-all âprotocols,â promises of weight loss or anti-aging, and testosterone or compounded hormones offered by default.
Is Hormone Testing Useful?
Perimenopause is diagnosed mainly from your symptoms and cycle pattern, not a blood test. Estrogen and progesterone can swing wildly from week to week, so a single result is a snapshot, not a verdict. Testing estradiol, LH (luteinizing hormone), FSH (follicle-stimulating hormone), and testosterone can help in some cases: if your cycle is masked by hormonal contraception, LEA (low energy availabilty), REDs (Relative Energy Deficiency in Sport), or if symptoms start earlier than expected.
The Tests That Matter More: Your Baseline
Arguably more useful than hormone levels are the tests that show where your health is heading. The goal is to catch anything trending the wrong way while thereâs still time to change course. Hereâs a healthspan checklist; these are tests worth considering each year in perimenopause:
- CBC (complete blood count), plus ferritin and iron
- Comprehensive metabolic panel
- Lipid panel, plus Lp(a) (once in adulthood if you havenât had it)
- HbA1c and/or fasting glucose
- Vitamin D
- TSH (thyroid)
- hs-CRP
- Blood pressure
- DEXA scan for bone density and body composition
- Mammogram, every one to two years from age 40
An important note on iron: Standard labs flag ferritin as ânormalâ at 15 ng/mL or above, a bar set to avoid anemia, not to support training. However, the American Society of Hematology (ASH) recently released new guidelines raising that threshold to 30 ng/mL in non-athletes. We aim for at least 50 ng/mL in female athletes, and ideally 100 ng/mL for endurance athletes. If youâre under 30 ng/mL, raise it with your doctor rather than waiting for your hemoglobin to drop.
MHT Options
If you do decide MHT is the best course of action for you, the next key decision is how estrogen gets into your body. For most women, transdermal estradiol (a patch, gel, or spray) is the preferred starting point. Because itâs absorbed through the skin, it bypasses the liver on its first pass and doesnât raise clotting risk the way oral estrogen can. Youâll also need a progestogen to protect the uterine lining (unless youâve had a hysterectomy). Oral micronized progesterone is the usual choice.
Some early side effects are common and often settle within a few weeks: breast tenderness, bloating, headaches, spotting or irregular bleeding. Progesterone can make you drowsy, which is why itâs usually taken at bedtime, and some women find it lowers their mood. Talk to your provider if bleeding is heavy or persists beyond the first few months, or if you develop new or severe migraines. Seek urgent care for calf pain or swelling, chest pain, shortness of breath, or sudden vision changes.
What to Expect Once You Start
For women dealing with hot flashes, poor sleep, vaginal dryness, brain fog, or joint aches, improvement often comes within a few weeks. Sometimes itâs faster. Some fine-tuning is normal, and doses are usually dialed in within the first two to three months. If you start during perimenopause, your dose may change again over the following years as your own ovarian function slows.
And if hormones werenât the main driver of your symptoms, MHT wonât fix everything. As Dr. Silver puts it, âMHT can help but likely wonât be the panacea.â Thatâs when sleep, training load, fueling, and stress need to be looked at too.
Who Shouldnât Take MHT
MHT generally isnât recommended if you have or have had breast cancer or another hormone-sensitive cancer, a history of blood clots, stroke, or heart attack, active liver disease, or unexplained vaginal bleeding. Starting it more than 10 years after menopause, or after age 60, calls for a more detailed conversation about risks and benefits.
The 2002 WHI study still colors how some providers talk about risk. But the women in that trial were older (average age 63), and they used older oral formulations. Later analyses showed that for healthy women who start within about 10 years of menopause or before 60, the benefits generally outweigh the risks.
Coming Up in Part Two
In part two, Iâll get into what the research actually shows MHT does (and doesnât do) for muscle, bone, body composition, metabolic health, and mood. Iâll also cover testosterone, non-hormonal options worth taking seriously, and how long to stay on MHT.
If you want to go deeper in the meantime, Menopause 2.0 walks you through the science and the practical levers for this stage of life. Itâs my most impactful course, and thousands of women have completed it. Up until this Friday (October 23), itâs on sale for 40% offâand you can also buy it as a gift for someone else. Simply select âsend as a giftâ at checkout.
Until next time,
Please note: This newsletter is for education only and isnât individual medical advice. Please talk to a healthcare provider whoâs knowledgeable about menopause before starting, changing, or stopping any treatment.
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