I am far from being an HRT veteran. I’ve been using supplemental estradiol and progesterone to help treat my tumultuous perimenopausal symptoms for 20 months now. As most women who eventually decide to try HRT will tell you, it can take a while to get your optimal dosing and delivery routes mastered. At my age, I probably have a minimum of five years before I cross into official menopause.

Dosing refers to the amount, or prescription strength level, of estradiol or progesterone you are taking. For example, the typical dose of an ibuprofen pill is 200 mg. Similarly, estradiol comes in various standard dosages. Delivery route pertains to the manner in which you take your HRT. Generally, there are two mainstream routes – transdermal (through the skin) through a patch, cream or gel – and oral by taking pills. A less common route is beneath the skin through hormonal pellets, but you won’t find much information about that here.

Being on HRT for as long as I have, some might think I would have reached the height of results I could obtain. But I was wrong. While I was feeling much better – I’m talking leaps and bounds from the pits of my state in late 2020 – I was still experiencing periodic night sweats and rare episodes of what I call sub-threshold “alertness.” By that I mean that the rhythm of my day, usually night, could be thrown off kilter by anything that disrupted the predictability I now try to maintain in my daily regimen. An apt example would be the noise of a train outside rendering me hyper-alert even though I was just about to nod off into dreamland.

I knew that this was not entirely unusual. Women in perimenopause and menopause forums and communities online shared similar tales. Being more easily triggered by the mundane and having breakthrough sweats are associated with something being a bit off base hormonally. I was already at a relatively upper-limit-dose of estradiol, but I decided to proceed with my dilemma and visited my doctor anyway.

To make a long story short, it was decided that I could do a test run of changing my dosages and delivery routes. Though transdermal estradiol tends to be the go-to formula by most prescribers, this default choice may not take into account the differences in women and how we metabolize or process the supplemental hormones. In fact, many women complain that they don’t absorb estradiol well through the skin, especially with patches, or that they can feel the patch “run out” of hormones before it’s time to change it. Plus, estradiol patches are ridiculously expensive, even with insurance. The compounding cost over months and years, if totaled, can be astonishing.

So I am now taking oral estradiol for a spin. The results and differences so far are subtle, in that they feel completely natural and unforced. But the night sweats that were breaking through seem to have mostly ceased. (The treatment goal is not always complete remediation, but rather a statistical improvement. Yet that hasn’t stopped me from pursuing my personal hormonal Eureka.) Not only am I waking up dry, my mentality feels that much more dialed in. I am finding myself doing more of what I used to, somehow not overthinking to the extent I’m inclined to as a Type A person, and feeling less internal frustration with the theatrics and drama of having teenagers and a lot of real life stuff going on in the background.

These oral estradiol pills are where it’s at! At least for me right now.

The caveat and disclaimer here is that every woman is different, and the decision on the dosing and delivery of your hormonal therapy will need to be made in consultation with your doctor. Generally, oral estradiol is avoided for women considered at-risk, including being obese, diabetic, having a history of blood clots, smokers and others. Fortunately, I don’t have any of the risk factors that typically curtail doctors from prescribing oral estradiol in pill form.

Did I mention that it’s also much, much less expensive? Your mileage on cost may vary depending on your insurer or your budget, but I feel like it’s highway robbery for there to be such a premium on patches, when pills are exponentially cheaper and kinder to my wallet.

If you’re on estradiol patches and still not feeling quite right, my first recommendation would be to revisit the dose. Are you taking enough, or is your doctor playing it too safe and conservative? That is a common problem. Sometimes you may be able to convince your doctor to prescribe a higher dose, and other times you may have to seek out a provider who is more interested in helping you feel better than in doing HRT the lazy way – prescribing the same baseline dose to each woman.

If you increase your patch dosing and still are not satisfied, I think oral estradiol pills are a rationale proposal. I take mine in the morning each day, and I do not sense any diminishment in my day that could signal a hormonal slump. I feel level, even and balanced.
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I will also add that I do a lot of other stuff aside from my estradiol pills, but I am not going to promote my personal lifestyle and prescription plan because every woman is different. I will say that the only thing I’ve changed recently is the addition of estradiol pills, and it feels absolutely wonderful.

I haven’t updated this blog in months. That much is obvious.

My retreat wasn’t planned or deliberate – it just happened. It happens that as my symptomatology resolved, I felt less inclined and driven to write about my experience and post information about the still-unspooling world of perimenopause.

I was so stunned, shocked, upset and in utter disbelief about my entrée into perimenopause that I felt I had no choice but to shout from the rooftops. My form of shouting took the form of starting this blog, researching fervently and attempting to share my story with others.

I could not believe the medical community was so clueless about a transition that will affect more than half of the population. I could not believe that I had to see 10 doctors in various disciplines before finally diagnosing myself properly and getting the help I so sorely needed.

I could not believe that I had been having night sweats and daytime sweating when doing basic things, like running the vacuum or folding laundry, and doctors couldn’t connect the dots – even though I was a woman in her early 40s, the age range deemed perimenopausal by default. I was dismayed that I had endured a near-breakdown and somehow had mustered the resilience to wade through it on my own, with little to no sound medical guidance.

I could not believe the extent to which I had to lead the way. Most of the physicians I consulted with were shooting in the dark, incredulous at the idea of perimenopause and apparently unschooled on the potential 30+ manifestations of perimenopause, of which my main life-debilitating symptoms were sudden-onset insomnia and a level of anxiety that finally convinced me that anxiety can be, in fact, a real condition (previously I thought it was an excuse for those who needed to pull themselves together, toughen up and develop better coping skills).

I could not sleep. My mind was in a continuous whirl. I was more sensitive to sounds and noises. My body trembled. My appetite declined. And I was paralyzed with fear as nighttime approached.

* * *
Now that I am more than a year removed from that harrowing and life-changing event, I can now describe and see my prior symptoms and previous state for what they were. I can detail it in words without the fear of stigma and without the cloak of shame.

I am not without symptoms. Do not get me wrong. By all predictions, I am still in the thick of this phase. I am likely years from reaching actual menopause.

I still sweat at night, sometimes. And I occasionally get turned up and start thinking about random topics at the most inopportune times. But my symptoms have abated by about 90 percent, and that is a world of difference from where I was before.

I’ll take it.

I’ve had to make peace (still working on it) with going from being who I was to who I now am. I think this experience has changed me almost just as much as having children did. I have transformed my mind to realize there was Former State Me who is no more, to the forthcoming Future State Me. And in the meantime, I have to find contentment and resolve in the Current State Me. The Current State Me requires medications and a panoply of life changes to retain homeostasis and structure. The Former State Me was prescribed no meds that I took on a regular basis, and I could be much more freewheeling with my days and decisions.

These days, I know that certain things are essential to my well-being, and my cadence is at times procedural and fixed.

I know I have to work out 60-90 minutes a day, if not for my body for my mind. This is a non-negotiable. It’s what I do in the morning after drinking coffee.

I now take prebiotics and probiotics, and drink kefir, because I’ve read enough about the gut being the “second brain,” and I know these are things I can do to help optimize my well-being.

I don’t drink any afternoon coffee anymore because I just can’t risk it.

I also take a medication that has conquered the midlife headaches I developed (I was having 5-6 headaches a week), resolved most of the anxiety I had and ensures a peaceful nighttime.  

I say no more often. But more than saying no, I fall back and don’t put my peace on the line as much anyway.

I thank God each and every morning. I really do. They are the first words out of my mouth.
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I do not know what the future holds. But this I do know: “[S]he is a new creature; the old things passed away; behold, new things have come.”

​Perimenopause and menopause are being featured in headlines and mainstream media coverage perhaps like never before. Every week, some health magazine, lifestyle publication or mainline news outlet is covering perimenopause and menopause, it seems. Reporters are tackling topics like hormonal mood swings, midlife weight gain and sex after the age of 40 week after week. In most of these cases, menopause is the centerpiece or, at the very least, it gets a passing mention.

Believe me, I believe it is better for perimenopause to be ushered out of the shadows, kicked out of the closet and the tape removed from its proverbial mouth of silence than the alternative. For far too long, women have felt ashamed of their symptoms, scared to speak to their friends about it and isolated, feeling absolutely crazy and about to lose the plot.

But as I examine this new heyday of perimenopause, part of me considers the profitable ecosystem surrounding all of this fanfare. As much as women need and deserve to be helped and heard, many businesses, companies and individuals are looking to get paid. The profit motive is real.

Perhaps the worst part of the profitability of perimenopause is that so many women still get bad advice or negligible help, sometimes after shelling out hundreds or thousands of dollars. So this made me think about the types of professionals and “experts” menopausal and perimenopausal women should consider avoiding – or proceeding with caution – when seeking and paying for their help.

Health Coaches. First of all, health coaching is a somewhat specious profession. There are various associations and organizational bodies that credential coaches, and sometimes such people have no experiential or high-level educational knowledge of anatomy, physiology, pharmacology, psychology, biology or chemistry.

Health coaching certifications can come from a range of providers, including personal training organizations, integrative health membership associations, holistic health societies and more. Most take only three to 12 months to complete. There are some programs at accredited colleges and universities, and many of those are actual associate, bachelor and master degree curricula, ending with an academic degree.
With health coaching being a field littered with ambiguity in how to get there, finding a veritable, trusted and knowledgeable health coach can be difficult. And even if you do find one, health coaches can only do so much. They can chat you up about nutrition, exercise and lifestyle, but they can’t prescribe medications or dispense medical information.

Health coaches usually charge $50-$500 per session, and insurance doesn’t cover their services. I believe the time and money women would spend on health coaches would better be used buying books, reading science journal studies and articles, and watching videos by experienced, established professionals and real women who share what’s worked for them (and are not selling anything).

Integrative or Holistic Health Providers. I previously explored this group in “Are Functional Medicine Doctors and Naturopaths Medical Quacks?” If I read more story, hear another anecdote or receive another email from a woman who’s been misguided and done wrong by a functional medicine or naturopathic “doctor,” I may scream.

More often than not, I hear about women paying hundreds or thousands of dollars on unnecessary – and possibly meaningless – lab tests. They are being coaxed into test after test after test, then being “prescribed” a growing list of expensive supplements and vitamins in the name of “balancing” every seen and unseen system in their bodies. Such tests may include measuring gut permeability, adrenal stress and heavy metals, among many, many others.

Some providers in this camp do provide perimenopausal and menopausal women with hormone replacement therapy (HRT), but often at microdoses (like 25mg of progesterone), inadequate delivery routes (progesterone creams, when progesterone is not well absorbed through the skin) and potentially dangerous options (like high-dose testosterone pellets that cannot be adjusted or removed once inserted).

The name of the game with naturopaths seems to be: “Let’s find a way to keep her coming back,” with the hopes of having a customer on the hook for life, test after test, imbalance after imbalance, lab after lab, and supplement after supplement.

I’ve literally communicated with dozens of women led astray by functional medicine and naturopathic providers that I no longer feel like I need to hold back on calling it like I see it.

Perimenopause and Menopause Tech Companies. Telemedicine has been a godsend for the delivery and access to medical care, replacing the needless commute, office wait time and total inconvenience of the typical doctor’s visit. And there are some virtual care providers in the perimenopause space who are bringing true value to their patients, including Evernow, which actually prescribes pharmaceutical, FDA-approved HRT along with non-hormonal options, such as SSRIs.

But some tech companies trying to cash in on the perimenopause gold rush aren’t providing much novel or new at all. More than anything, I believe women who are symptomatic with hot flashes, night sweats, insomnia, anxiety, depression, headaches and more want RELIEF. They want to be free from and rid of debilitating symptoms that compromise quality of life. They don’t need motivational speaking, more expensive supplements, beauty tips, exercise advice or creative recipes for cooking.

Let’s take a look at Phenology, which is offering “lucid lift refreshing mints” for $19, a “cooling mist” for $19 and a “fresh start skin roller” for, yes … you guessed it, $19! Wile is shilling “Hormonal” hats, sweatshirts and T-shirts, along with CBD oil and . . . more supplements!
Do we really need more of this?
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I don’t think so. What we do need are more clinicians – general medicine, adult medicine and internal medicine physicians – who understand perimenopause and menopause. We need more endocrinologists, psychiatrists and OB/GYNs who do more than dabble in diabetes, bipolar disorder and delivering babies, respectively. We need trained providers with a sincere interest in and commitment to patient health, including the health of half of the world’s population who are women, apt to begin perimenopause by their early 40s and likely to outlive their male counterparts by quite a few years.