Let’s face it: hormones are critically important, often confusing to understand, and a common scapegoat, especially when in perimenopause and menopause. Have hot flashes? That’s hormones. Crying jags? Hormones. Hot flashes? Put on extra weight? It’s those darn hormones.

All 102+ signs and symptoms are one way or another, in many cases, related to hormones during perimenopause and menopause.

Just because hormones are potent players in countless numbers of processes and symptoms in our lives doesn’t mean we are victims or helpless against their influences, nor does it mean we should be afraid of them. The more we understand them, the better able we will be to manage their effects and benefit from their qualities.

Hormone homing

First, an important fact about hormones. When hormones are circulating throughout the body, they are “homing in” to find a place (receptor) to attach to so they can become activated and do their tasks. Every hormone has different numbers of receptors in different places in the body. Estrogen receptors, for example, are found in the reproductive tract and breast, but also in bone and the liver, colon, salivary glands, skin, brain, and more.

What is estrogen?

Estrogen is one of two sex hormones typically associated with individuals assigned female at birth (AFAB). (The other one is progesterone.) This includes transgender men, nonbinary people with vaginas, and cisgender women. Both estrogen and progesterone are major players in reproductive health and the development of secondary sex characteristics, pregnancy, menstruation, perimenopause, and menopause. AFAB individuals have the most estrogen, but all genders produce this hormone.

The three main types of estrogen are:

• Estrone (E1), the main form the body produces after menopause.
• Estradiol (E2), the most potent form of estrogen and the main one present in the body during reproductive years.
• Estriol (E3), the main form during pregnancy.

In addition to reproductive and sexual health, estrogen is also involved in maintaining cholesterol and blood sugar levels, bone and muscle mass, blood flow and circulation, skin hydration, collagen production, and brain function. Estrogen receptors throughout the body make it possible for the hormone to perform its necessary functions. Most of the estrogen in women is made in the ovaries, although the adrenal glands and body fat make it as well.

Estrogen deficiency, which is common in perimenopause and menopause, is associated with breast tenderness, hot flashes and night sweats, headaches, fatigue, insomnia, vaginal dryness, mood swings, depression, irregular periods, and weak or brittle bones. Consistently elevated estrogen can cause low libido, weight gain, irregular periods, endometriosis pain, fibroids, mood swings, headache, and polycystic ovarian syndrome. 

Read about role of progesterone in perimenopause and menopause

What is progesterone?

Progesterone is one half of the potent estrogen/progesterone team that works intimately together in a woman’s body. For example, progesterone thins the uterine lining while estrogen thickens it, and progesterone has a calming effect while estrogen is stimulating. Estrogen also actively promotes progesterone receptors throughout the body. As a team, estrogen and progesterone are essential for the healthy function of the cardiovascular system, bones, and brain.

Declining progesterone levels are associated with irregular menstrual periods, headache, mood swings, depression, insomnia, bloating, weight gain, and hot flashes. If progesterone levels are high, symptoms may include leg pain or discomfort, water retention, bloating, fatigue, weight fluctuations, and changes to sex drive.

Progestins are the synthetic form of progesterone. Progestins have different and even opposite effects compared with progesterone. For example, progesterone can reduce the risk of breast cancer while progestins may increase the risk. The bio-identical form of progesterone is called dydrogesterone.

What is testosterone?

The big T—testosterone—is not just for men. Women produce and need testosterone, yet it typically is not part of the conversation when hormones are discussed. Are you experiencing brain fog? Lack of motivation? Irritability and other mood issues? A muffin top that won’t go away despite eating right and exercising? Lost interest in the bedroom? These are signs and symptoms of low testosterone. 

Women’s testosterone levels begin to decline in their twenties and thirties, and so by the time perimenopause rolls around, the levels are quite low. While testosterone doesn’t play a big role in libido and other sexual issues prior to perimenopause and menopause, it does once women reach these stages of life, according to Brooke Faught, director of the Women’s Institute for Sexual Health. During an interview she gave at the Menopause Shift Summit, she noted that deficient or lack of testosterone can be involved just as much as estrogen in lack of sex drive, orgasmic dysfunction and vaginal dryness, which can be associated with recurring urinary tract infections, another symptom of menopause. Excess testosterone in women can cause unwanted facial hair, balding, mood swings, deepening of the voice, acne, and low libido.

Read about DHEA and menopause

What is DHEA?

Dehydroepiandrosterone (DHEA), which is sometimes referred to as the mother of all hormones, is the precursor of estrogens and androgens. It is produced by the adrenal glands, and levels peak at about age 25. Levels decline steadily as you age, reaching only about 10 to 20 percent of peak by age 70 to 80.

DHEA supplements are available over the counter, but they are often synthetic so discuss their use with your doctor before using them. Supplements have been shown to lower levels of good cholesterol and raise levels of estrogen and testosterone in some women.

Among women in perimenopause, some take DHEA supplements for relief from vaginal dryness, lack of libido, and poor skin tone. According to a recent overview of DHEA use among pre-menopausal and menopausal women, study findings are mixed. While some research indicates it can relieve hot flashes, preserve the immune system, increase muscle mass, and reduce bone loss, other findings have not found definitive effects on the cardiovascular system, insulin sensitivity, adrenal insufficiency, and cognition.

Perimenopause and Menopause Testing for Hormone Levels

One of the more popular perimenopause and menopause tests available for identifying hormone levels is the DUTCH (Dried Urine Test for Comprehensive Hormones). It is used to measure total hormones and how the body is metabolizing them and helps assess hormone imbalance throughout the reproductive years up through postmenopause. This information is critical for evaluating the risk of developing breast cancer and other hormone-related health issues. Several forms of the DUTCH test are available, with some providing more detailed information than others.

The DUTCH test can measure hormones as well as their metabolites, which provides clinicians and patients with comprehensive information of hormone production and how the body processes and detoxifies/breaks them down into metabolites. It also can help monitor the levels of hormones used in hormone replacement therapy.

In addition to the DUTCH test, doctors may order a thyroid function test to determine thyroid levels or a blood test to measure follicle-stimulating hormone and estrogen levels. Women who are considering conventional (vs bio-identical) hormone replacement therapy may ask their doctors about testing for genetic polymorphisms associated with the risk of using estrogen therapy.

Sara Gottfried, MD, integrative physician and hormone expert, also suggests testing for various cardiovascular risk factors, as heart disease is a significant issue among menopausal women. Among the markers she tests are hemoglobin A1C (three month average of blood sugar), lipid panel, and C-reactive protein, which indicates inflammation. Levels of sex hormone binding globulin (SHBG) is a biomarker of cardio-metabolic risk, and the ratio of testosterone to estradiol is another cardiovascular risk tool.

Hormone replacement therapy

Some women think about turning to hormone replacement therapy to help them manage or get relief from a number of signs and symptoms typically associated with perimenopause and menopause. Some of them include hot flashes and night sweats, chronic insomnia, hair loss, urinary problems, vaginal itching, low sex drive, bone loss, memory problems, and risk of heart disease.

There are two main types of hormone therapy: conventional hormone replacement therapy (HRT), which uses synthetic hormones; and bio-identical hormone therapy (BHRT), in which the hormones used look, act, and break down the way the body is familiar with. That means, for example, if you take bio-identical estradiol, your body will treat it exactly like estradiol your body used to make. Bio-identical hormones are made from plant extracts that are structurally indistinguishable from those produced by the human body. Typically, BHRT includes estradiol, estriol, progesterone, testosterone, and DHEA. Doctors can custom formulate BHRT based on a woman’s test results.

Before any woman goes on hormone therapy, several things need to occur. One is thorough testing of hormone levels so everyone has a clear idea of what the levels are. Genetic testing as well as the DUTCH test are good places to start. It’s also essential to have a detailed discussion with a healthcare provider about symptoms and their frequency, intensity, and impact on daily living, as well as an understanding of any underlying health conditions. Women also should be fully informed about the known side effects and consequences of taking hormone replacement therapy.

A compounding pharmacy can formulate a dose of bio-identical hormones for your specific needs, as determined by your physician. For example, if you are experiencing low sex drive, lack of vaginal lubrication, and urinary tract infections, this may indicate low estrogen and testosterone, since there are many receptors for both of these hormones in the pelvic region.

Regardless of which type of hormone replacement therapy you ultimately decide to take, routine testing of hormone levels and activity is recommended. OB/GYN hormone specialist Dr. LaKeischa McMillan, who prescribes bio-identical hormones to her patients, suggests quarterly testing of serum and then the DUTCH test once or twice a year or less often, depending on the individual woman. 

Brief Guide to Hormone Therapy

- Conventional estrogen-only therapy, can be seen here.

- Bio-identical estrogen, which is available as Vivelle Dot, Estrogel, Elestrin, Evamist, Vagifem, Estring, FemRing, and Minivelle.

- Conventional progesterone is prescribed as progestins, which are available as Prometrium (micronized progesterone) and Provera (medroxyprogesterone acetate).

- Bio-identical progesterone, which is also called oral micronized progesterone. It is available as Prometrium®, Utrogestan®, Teva®, Famenita®.

- Conventional combinations of estrogen and progestins, which can be seen here.

- Testosterone replacement for women is primarily given in the form of an injection. In rare cases, however, a topical may be used.

Bottom line

Hormone replacement therapy is a personal decision and women who contemplate using it should consult experts to review the pros and cons of all the available therapies. Periodic testing is strongly encouraged to monitor hormone levels, estrogen metabolites and activity.