A couple months ago, I was driving to work, listening to the Huberman Lab podcast, and my ears perked up a little more than usual when I heard his guest, Dr. Peter Attia, rattle off a list of reasons why the Women’s Health Initiative study was a hot mess. A few weeks later, I heard Dr. Huberman interview Dr. Sara Gottfried, who offered a similar opinion of the Women’s Health Initiative, and shared her functional medicine approach to hormone therapy.
If you’re new to the topic, the Women’s Health Initiative was a landmark study that followed a huge group of women over the course of 15 years, investigating the effects of hormone replacement on outcomes like cardiovascular disease, bone density, and cancer in perimenopausal and postmenopausal women. The findings of the study, including things like an increased risk of breast cancer and cardiovascular events like strokes and heart attacks, caused a great deal of concern in the medical community. The study also received a huge amount of media attention, which amplified those concerns not only among physicians, but also among the general public. If you’re interested in why Dr. Attia and Dr. Gottfried both thought the study design and data interpretation were flawed, you should definitely listen to their full episodes here and here. But the takeaway is this: too many doctors and perimenopausal women have been terrified to use hormones for too long, and it might be time to rethink things. The New York Times agrees.
Should all women take hormones?
Does this mean hormone therapy is right for everyone? Absolutely not, and there are plenty of people for whom hormones are either contraindicated or ill-advised, so it’s a decision that needs to be made with your healthcare provider. In this post, I’ll share why I looked into hormone replacement therapy for myself, why I finally decided to give it a try, and what I’ve experienced so far. To be clear, this post does not constitute medical advice, or serve as my position statement on the issue. It’s just the story of a 49-year-old woman (with a medical degree) and her personal journey to navigate the turbulent waters of perimenopause.
What are the symptoms of perimenopause?
The symptoms of perimenopause, like the symptoms of premenstrual syndrome, are different for everyone. Common complaints include hot flashes, breast tenderness, cycle irregularities (shorter, longer, heavier, skipped), sleep disturbances, mood disturbances, anxiety, and diminished libido or painful intercourse. My symptoms were fairly manageable, but the lack of sleep and heightened anxiety were starting to wear me down. I could fall asleep, but woke at 2am most nights and my brain thought that was a good time to work out all the problems of the universe. I was also getting my period every 21 days, with extremely sore boobs for ten days of each cycle, and a debilitating dose of irritability and cramps when I started bleeding. I had learned to live with this pattern, as many of us do, but it wasn’t particularly fun for anyone in my house.
Where do I get hormone replacement therapy?
Start with the healthcare provider who does your pap smears. I spoke with my OB/GYN, whom I adore, and she definitely had a more traditional take on HRT than Sara Gottfried or Peter Attia. Her suggestion, which is standard practice in most places, was not to check levels, but to treat the symptoms, and start me on oral contraceptives, aka birth control pills consisting of progestin and ethinyl estradiol, synthetic versions of progesterone and estrogen. Because I spent plenty of years on the pill as a young women, and because the approach felt a little non-specific for my medically-trained, overanalyzing brain, I never picked up the prescription. Instead, I did a little more research.
What is bioidentical hormone therapy, aka BHRT?
Also known as bioequivalent hormone therapy, this approach uses hormones that are structurally identical to the hormones your body naturally produces, like estrogen, progesterone, DHEA, and testosterone. Conventional hormone replacement therapy uses different molecules, such as progestin and ethinyl estradiol. Is one better than the other? According to the current medical literature, there is no evidence to show that bioidentical hormone therapy is superior to conventional therapy. That said, it makes intuitive sense to me that using hormones my body is already manufacturing could have a better safety profile, even if we don’t have the data to support that theory yet.
What is the functional medicine approach to hormone therapy?
During the last 15 minutes of a webinar with Sara Gottfried, she suggested ifm.org as a resource for finding a functional medicine practitioner. The closest one to me was an OB/GYN a few hours away, but we did a virtual consultation, and quickly had a good rapport. She had a more specific plan, starting with bloodwork.
The lab panel she ordered on day three of my short cycle was about $180 and included basic labs like a CBC and CMP, as well as levels of Vitamin D, DHEA, DHT, free testosterone, progesterone, estradiol, lipoprotein (a), apolipoprotein B, and homocysteine. I shared the results of a recent lipid panel with her, as well. Oof, that was a lot of medical words, but basically she wanted to make sure my bloodwork was normal, and get a baseline sense of my hormones and my cardiovascular risk. I also answered about a billion questions about my health, from diet to stress levels to an extensive family history. I was really impressed with how much homework she was doing before doling out the hormones. Cardiovascular risk factors, a family history of cancer, and blood glucose regulation matter when considering the potential risks and benefits of hormone therapy, so I was glad to know my doctor was trying to understand the whole picture of ME—something many conventional doctors neglect due to an unfortunate lack of time, training (trust me, I went to medical school), and resources.
When my labs came back, it turned out that I was estrogen-dominant, and my progesterone was almost non-existent. My DHEA and testosterone were both trending low, as was my Vitamin D level. My cardiovascular risk numbers looked awesome, and I had no signs of glucose dysregulation.
So, what did I do with all this information? Like a good scientist, I changed tons of things at the same time!! Here’s how we got started on my perimenopausal crusade:
- I started taking bioequivalent progesterone, 100mg every night. Since we’re hoping to lengthen my cycle a bit, I have been on it for a month straight now, but will likely take a few days off each month eventually. The prescription I have is for a vegan tablet (I don’t do gelatin), and came from a compounding pharmacy.
- I started DHEA, 25mg daily. (This is a fairly low dose.) At first, I took it in the morning, but then found I slept better when I took it with my progesterone at night. It suppresses cortisol, and can increase the gap between your bedtime cortisol and waking cortisol, which may help you feel more rested. DHEA is also used by your body to make estrogen and testosterone, and can be considered as an alternative to testosterone supplementation to support athletic performance and libido, although the data to support either is mixed.
- I started a Vitamin D supplement, specifically one that contains A, D, and K, three of the four fat soluble vitamins we need. Each capsule contains 5000 IU of Vitamin A, 5000 IU of Vitamin D3, and 500 mcg of Vitamin K2, and I take one about 4-5 times a week.
- No functional medicine doctor can get through a conversation without mentioning gut health, and we have a whole gut rehab thing going, which I think may require a separate blog post. In short, my gut is as leaky as my eyes when I watch This Is Us, so we’re actively working on the situation.
- To wash down my progesterone and DHEA, I take a little cocktail of magnesium chelate, glycine, N-acetylcysteine, and cranberry concentrate. It’s my nightcap, and it’s rather delicious.
Side note: my doctor prescribed all but the progesterone through Fullscript, a supplement website. While providers do get a little cut of anything I purchase there, the site offers discounted pricing on lots of supplements, subscriptions for anything you take regularly, and ships very quickly. I used my HSA card to purchase the supplements, so that helped a little, too!
Will hormone replacement therapy help me sleep?
I don’t know what you’ll notice with HRT, but I’ll tell you what I’m noticing: SLEEP. Both the quality and the quantity of my sleep have improved dramatically since I started hormones. It’s only been a month, but I can’t even tell you how good it feels to sleep again! Since I started medical school in 1997, my sleep has been irregular. Since I had kids in 2003 and 2007, my sleep has been interrupted. Since I started a business in 2012, my sleep has been laced with stress dreams. Since the world fell apart in 2020, my sleep has been fitful and woven through with an ever-present refrigerator hum of anxiety. And since I started perimenopause, whenever that happened, the anxiety hum has gotten louder and harder to manage, especially during those 2am worry sessions.
Since I started progesterone and DHEA, it feels like each little cell in my body gets in bed, blows out a wee candle, and tucks itself in for the night. When I wake up, I feel rested, but not groggy. And that 4pm energy slump is now the exception instead of the rule. Like I said, I changed a lot of things at once, so this is in no way a perfect experiment. But I do have some data to show that it’s not all in my head! The screenshots below are from my Whoop, the little data gathering sensor I wear on my wrist every day.
Here’s an average month of sleep before I started hormones:
And here’s what things look like since I started taking hormones and my nightly magnesium potion:
I like this trend, and I hope it continues!
Does hormone therapy help anxiety?
I don’t have data to support this yet. (Whoop just introduced a “stress monitor” feature, so maybe I’ll have data soon.) Subjectively, I’d say my anxiety is slightly improved since starting hormones. For the record, I meditate and exercise 5-6 times a week, so I’m actively engaged in stress management, and my anxiety has never been crippling or required medication of any kind. But, while my reasons for worrying have not changed, the internal volume at which I do my worrying seems to have decreased by a notch or two. I’ll take it, and I’m hoping this trend continues as well.
Does hormone therapy help with sex drive?
The right cocktail of hormones can definitely increase sex drive, also known as libido. As for me, I don’t know yet. My sex drive is decent. I mean, sometimes I have to do what I call “getting over the hump to hump,” meaning that it takes a bit of conscious energy on my part to get things going, but once the engine is started, sex is awesome! That said, I want to make sure our sex life stays energized as we get older, so I’m taking DHEA to support both libido and athletic recovery. DHEA is an androgen hormone that we make in our bodies naturally, and serves as a precursor for both estrogen and testosterone, so it’s like taking the long road to an increased libido. But for some reason, I didn’t feel ready to start testosterone yet, and I definitely wasn't interested in testosterone pellets, a method that allows no nuance or adjustments as your body reacts to the therapy. After a month of DHEA, I haven’t noticed much of a change in libido specifically, so I’ll keep working on it with my doctor. Side note: my husband is watching me type this paragraph, and he wants you to know he’s holding up his end of the bargain.
Does hormone therapy have side effects?
Everything has side effects, or at least the potential for side effects. With the first month of this progesterone + DHEA regimen, which I started on the first day of my cycle, I experienced about 14 days of low-grade bleeding and my boobs were substantially less sore. When I got my period again, it came a bit later, and cramping was minimal. Other than those “side effects,” I have had none—hallelujah! I imagine that could change if I increased the dose or added estrogen, but for now, I’m not experiencing any unpleasantness whatsoever.
Keep in mind that adverse consequences of hormone therapy are not considered side effects. These would include things like blood clots (not likely with progesterone-only therapy) or the development of breast cancer or endometrial cancer, and are the main reasons an individual risk assessment is necessary before starting HRT. Luckily, I was a good candidate, with no personal or family history of blood clots or hormone-related cancers.
How long should I stay on hormone replacement therapy?
Again, this question gets answered on a case-by-case basis. I’m still menstruating monthly, and HRT won’t change when my body goes through menopause. Fun fact: menopause is a one day event—the day when you have not had a period for one year. Some women stay on for six months, others for ten years—the idea of hormone therapy is to smooth the sharp edges of your transition to a post-menopausal state, making it a much less bumpy ride. The good news is that you’re in control of the decision making here; if you start HRT and find that it doesn’t help or isn’t for you, you can stop it, or work with your provider to change your regimen to get the results you want.
So, are you saying I should start hormone therapy?
I’ll say it again, extra loud for the folks in the back: THIS IS NOT MEDICAL ADVICE, OR ME TELLING YOU THAT YOU SHOULD START HORMONE THERAPY. It’s a very personal decision that must be made in collaboration with a licensed medical professional. But it was a confusing landscape for me, even with a medical degree and ten years of practice under my belt. That’s why I wrote this post—in case it’s helpful to hear someone else’s specific story as you write your own. Send me a message on Instagram if you have any questions—happy to answer them if I can!
With love and happy hormone levels,