A couple of months ago, while commuting to work, I tuned into the Huberman Lab podcast. My interest piqued when I listened to his guest, Dr. Peter Attia, discuss the numerous shortcomings of the Women’s Health Initiative study. Shortly after, I caught Dr. Huberman interviewing Dr. Sara Gottfried, who echoed similar critiques of the Women’s Health Initiative and shared her insights on a functional medicine approach to hormone therapy.

For those unfamiliar with the topic, the Women’s Health Initiative was a groundbreaking study that tracked a substantial cohort of women for 15 years to examine the impacts of hormone replacement on critical health outcomes such as cardiovascular disease, bone density, and cancer among perimenopausal and postmenopausal women. The study’s revelations, which included increased risks for breast cancer and cardiovascular incidents like strokes and heart attacks, sparked significant concern within the medical community. Additionally, the extensive media coverage amplified these worries, influencing both healthcare providers and the general public. If you’re curious about the specific flaws pointed out by Dr. Attia and Dr. Gottfried regarding the study’s design and data interpretation, I encourage you to listen to their full episodes here and here. The essential takeaway is that many doctors and perimenopausal women have been overly cautious about using hormones, and it may be time for a reevaluation of this approach. The New York Times supports this idea.

Is Hormone Therapy Suitable for All Women?

Does this imply that hormone therapy is appropriate for every woman? Certainly not. There are numerous individuals for whom hormone therapy is contraindicated or not advisable, so it is crucial to make this decision in consultation with your healthcare provider. In this post, I will share my personal exploration of hormone replacement therapy, detailing why I chose to pursue it and the experiences I’ve had thus far. To clarify, this post does not serve as medical advice or a definitive stance on the matter. It simply recounts the journey of a 49-year-old woman (who also happens to have a medical degree) as she navigates the complex landscape of perimenopause.

Understanding the Symptoms of Perimenopause

The symptoms associated with perimenopause can vary widely from person to person, much like those experienced during premenstrual syndrome. Commonly reported symptoms include hot flashes, breast tenderness, irregular menstrual cycles (shorter, longer, heavier, or skipped), sleep disturbances, mood swings, heightened anxiety, and a decrease in libido or painful intercourse. Although my symptoms were generally manageable, the persistent lack of sleep and increasing anxiety began to take a toll on my well-being. I often found myself able to fall asleep, only to wake at 2 AM with my mind racing, contemplating all of life’s challenges. Additionally, my menstrual cycle was occurring every 21 days, accompanied by severe breast tenderness for ten days, followed by significant irritability and cramps upon the arrival of my period. While I had learned to cope with this routine, it was less than enjoyable for my family and me.

How to Access Hormone Replacement Therapy

The first step is to consult with your healthcare provider, particularly one who performs your routine pap smears. I reached out to my beloved OB/GYN, who offered a more traditional perspective on hormone replacement therapy than what I had gleaned from Sara Gottfried or Peter Attia. Her recommendation, which is common practice in many locations, was to address the symptoms directly without checking hormone levels and to initiate treatment using oral contraceptives (birth control pills containing progestin and ethinyl estradiol, which are synthetic forms of progesterone and estrogen). Given my previous experience taking the pill during my younger years, I found this approach a bit too generic for my medically-trained, analytical mind, so I opted not to fill the prescription and decided to conduct further research.

Exploring Bioidentical Hormone Therapy (BHRT)

Also referred to as bioequivalent hormone therapy, this method utilizes hormones that are structurally identical to those naturally produced by the body, including estrogen, progesterone, DHEA, and testosterone. In contrast, conventional hormone replacement therapy employs different molecules, such as progestin and ethinyl estradiol. Is one method superior to the other? Current medical literature does not provide evidence that bioidentical hormone therapy is more effective than conventional methods. However, intuitively, using hormones that my body already produces seems to suggest a potentially better safety profile, even if supporting data is still lacking.

Understanding the Functional Medicine Approach to Hormone Therapy

During a recent webinar with Sara Gottfried, she recommended visiting ifm.org to find a functional medicine practitioner. The closest one to me happened to be an OB/GYN located a few hours away, but we arranged a virtual consultation and quickly established a strong rapport. She proposed a more tailored plan, beginning with bloodwork.

The lab panel she ordered on the third day of my short cycle cost about $180 and included fundamental tests like a CBC and CMP, alongside assessments for Vitamin D, DHEA, DHT, free testosterone, progesterone, estradiol, lipoprotein (a), apolipoprotein B, and homocysteine levels. I also provided her with results from a recent lipid panel. While that might sound overwhelming, her objective was to ensure my bloodwork was normal and to establish a baseline understanding of my hormone levels and cardiovascular risk. Furthermore, I underwent an extensive health questionnaire, covering everything from my diet and stress levels to a detailed family medical history. I was genuinely impressed with the thoroughness of her approach before prescribing hormones. Factors such as cardiovascular risks, family history of cancer, and glucose regulation are crucial when weighing the risks and benefits of hormone therapy, and I appreciated that my doctor aimed to understand the complete picture of my health—something many conventional practitioners may overlook due to time constraints, lack of training (believe me, I went through medical school), and limited resources.

Upon receiving my lab results, I discovered that I was estrogen-dominant, with minimal levels of progesterone. Additionally, my DHEA and testosterone levels were both trending low, as was my Vitamin D. However, my cardiovascular risk numbers appeared excellent, and there were no indications of glucose dysregulation.

So, what actions did I take with this information? In true scientific fashion, I implemented numerous changes simultaneously! Here’s how I embarked on my journey through perimenopause:

• I began taking bioidentical progesterone, starting with 100mg every night. Since we aim to extend my menstrual cycle, I’ve been on it continuously for a month, though I plan to take occasional breaks each month in the future. The prescription I received is for a vegan tablet (I avoid gelatin) from a compounding pharmacy.
• I also started DHEA at a daily dose of 25mg, which is relatively low. Initially, I took it in the morning but found that my sleep improved when I took it at night alongside my progesterone. DHEA helps suppress cortisol levels and can widen the gap between bedtime cortisol and waking cortisol, potentially leading to better rest. Additionally, DHEA is a precursor for estrogen and testosterone, serving as an alternative to testosterone supplementation for enhancing athletic performance and libido, although research on its effectiveness is mixed.
• I incorporated a Vitamin D supplement that also includes Vitamins A and K, three essential fat-soluble vitamins. Each capsule contains 5000 IU of Vitamin A, 5000 IU of Vitamin D3, and 500 mcg of Vitamin K2, and I take one capsule about 4-5 times each week.
• No discussion of functional medicine is complete without a mention of gut health. We are currently undertaking a gut rehabilitation plan, which could easily warrant its own blog post. To summarize, my gut health is as compromised as my emotional state when watching This Is Us, and we are actively addressing these concerns.
• To complement my progesterone and DHEA, I’ve been enjoying a blend of magnesium chelate, glycine, N-acetylcysteine, and cranberry concentrate. It serves as my delightful nightcap.

As a side note, my doctor prescribed all except the progesterone through Fullscript, a platform for supplements. While providers receive a minor commission from purchases made, Fullscript offers competitive pricing on various supplements, subscription options for regular purchases, and prompt delivery. I utilized my HSA card for these supplements, which helped with the costs!

Can Hormone Replacement Therapy Improve Sleep Quality?

While I can’t predict your experience with HRT, I can share my observations: SLEEP. Both the quality and quantity of my sleep have seen remarkable improvements since I started hormone therapy. Although it’s only been a month, I cannot express how revitalizing it feels to enjoy restful sleep again! My sleep has been irregular since I began medical school in 1997. Post-children in 2003 and 2007, it became even more fragmented. Starting a business in 2012 introduced a layer of stress dreams, and the chaos of 2020 further disrupted my sleep, exacerbated by a constant undercurrent of anxiety. As I transitioned into perimenopause, this anxiety only intensified, particularly during those 2 AM worry episodes.

Since commencing progesterone and DHEA, it feels as though each cell in my body is settling down for the night, extinguishing a tiny candle, and comfortably tucking itself in. I wake up feeling refreshed without any grogginess, and that dreaded 4 PM energy slump has become the exception rather than the norm. Admittedly, I made several lifestyle changes simultaneously, so this is not a controlled experiment. Nonetheless, I have some data suggesting that this improvement is not merely psychological. The screenshots below are from my Whoop, the wearable sensor I track daily.

Here’s a look at my average sleep patterns for a month before starting hormone therapy:

And here’s a comparison of my sleep patterns since beginning hormone therapy and my nightly magnesium regimen:

I am optimistic about this positive trend and hope it continues!

Can Hormone Therapy Alleviate Anxiety Symptoms?

At this stage, I lack concrete data to confirm this. (Whoop has recently added a “stress monitor” feature, so perhaps I’ll have data soon.) Subjectively, I perceive a slight improvement in my anxiety levels since beginning hormone therapy. For the record, I meditate and maintain an exercise routine 5-6 times weekly, actively managing my stress levels. My anxiety has never been debilitating or necessitated medication. While my reasons for worry remain unchanged, the internal volume at which I experience these concerns seems to have decreased slightly. I view this as a positive development and hope to see further improvements.

Can Hormone Therapy Enhance Libido?

The right combination of hormones can certainly boost libido, or sexual desire. Personally, I am still assessing this aspect. My sex drive is decent; however, sometimes I find it takes a bit of effort to initiate intimacy, which I refer to as “getting over the hump to hump.” Once I get started, the experience is fantastic! To maintain an active sex life as I age, I’m taking DHEA to support my libido and athletic recovery. DHEA is a naturally occurring androgen hormone in our bodies, serving as a precursor to both estrogen and testosterone, making it a long-term strategy for increasing libido. However, I haven’t yet felt ready to explore testosterone options, nor am I interested in testosterone pellets, which provide a rigid approach without room for adjustments as my body responds to the therapy. After a month of DHEA, I haven’t observed significant changes in my libido yet, but I plan to continue discussing this with my doctor. A fun fact: my husband is watching me as I write this, and he wants you to know he’s fully supportive!

What Are the Potential Side Effects of Hormone Therapy?

As with any treatment, there are potential side effects associated with hormone therapy. During the first month of my progesterone and DHEA regimen, which I initiated on the first day of my cycle, I experienced approximately 14 days of light bleeding, and my breast tenderness significantly decreased. Upon my next period, it arrived slightly later than usual, and the cramping was minimal. Besides these minor side effects, I have experienced no adverse reactions—thank goodness! I do anticipate that side effects could arise if I increase the dosage or add estrogen, but for the moment, I am enjoying a lack of unpleasant symptoms.

It’s crucial to differentiate between side effects and serious risks associated with hormone therapy. Adverse effects like blood clots (which are unlikely with progesterone-only therapy) or the development of breast or endometrial cancer necessitate an individualized risk assessment before starting HRT. Fortunately, I was considered a good candidate, with no personal or family history of blood clots or hormone-related cancers.

How Long Should One Continue Hormone Replacement Therapy?

This question is best addressed on an individual basis. Since I am still experiencing monthly menstruation, HRT will not alter the timing of my transition into menopause. Interestingly, menopause is technically a single-day event—the day when you have gone an entire year without a period. Women may remain on HRT for six months, ten years, or longer; the goal of hormone therapy is to smooth the transition into a post-menopausal state, making the experience less challenging. The good news is that you have control over this decision; if you begin HRT and find that it does not meet your needs or is unsuitable for you, you can discontinue it or collaborate with your healthcare provider to adjust your regimen for better outcomes.

Should I Consider Starting Hormone Therapy?

Let me reiterate this point clearly for everyone: THIS IS NOT MEDICAL ADVICE, NOR AM I SUGGESTING YOU SHOULD START HORMONE THERAPY. This is an intensely personal choice that must be made in partnership with a qualified medical professional. Even as a healthcare provider with a medical degree and a decade of practice experience, I found this journey to be confusing. That’s why I chose to share my story—hoping it may resonate with others as they navigate their unique paths. If you have any questions, feel free to reach out to me on Instagram; I’m happy to help if I can!

Wishing you love and balanced hormone levels,