Getting an HRT prescription can be like running across a battlefield and dodging landmines in enemy territory before finally reaching the safe zone. So pervasive and unnecessarily complex are the hurdles perimenopausal women face when they ultimately figure out that their hormones are in decline, and they try to take the next logistical step to help: replacing them.

Many women start at the first reasonable stop on this juncture – their primary care physician, family medicine doctor or gynecologist – often only to leave with bad advice (“dress in layers,” “start doing yoga,” and “drink herbal tea,” among them) or undesired prescriptions for antidepressants. And this frequently spells the end of what had previously been a pleasant, diplomatic patient-doctor relationship, as women feel minimalized, marginalized and made to feel absolutely crazy.

Sadly, far too many stop here. They give up and give in to all sorts of unproven antidotes for their hormonal symptoms of anxiety, insomnia, hot flashes, migraine headaches and more. They assemble a medicine cabinet full of tinctures, herbs and supplements like magnesium, chasteberry, St. John’s Wort and black cohosh. They order all sorts of lotions and creams that supposedly contain progesterone and estrogen from online retailers with absolutely no regulatory skin in the game.

And they continue to suffer.

Fortunately, the ubiquitous nature of online shopping has intersected with telemedicine. And this means that women can now shop around like a well-informed consumer with choices in obtaining a prescription for hormone replacement therapy (HRT). Here are some of the best-known virtual HRT providers, all staffed by actual physicians, nurse practitioners and registered nurses.

Defy Medical – Focuses on compounded, customized (not pre-packaged the ones you get off the shelf via prescription at the regular pharmacy) hormone therapy options, all intended to remediate perimenopause symptoms. These include estrogen in the form of capsules, creams, pellet implants, vaginal suppositories and injections, plus progesterone as capsules, creams, injections and vaginal suppositories. Unlike some other providers, Defy also prescribes testosterone to women and focuses on other hormones, like thyroid and pregnenolone, too.

Evernow – Offers perimenopausal treatment in the form of estradiol patches, pills and vaginal creams, as well as oral micronized progesterone. They also offer combined estradiol / norethindrone pills and ethinyl estradiol / norethindrone birth control pills (generic Loestrin 1/20). For those interested in non-hormonal options, Evernow has Brisdelle (generic paroxetine), which is a low-dose SSRI used for treating vasomotor systems like hot flashes and night sweats, with some potential benefit for low-level depression or anxiety, too. Finally, they also have venlafaxine, which is the generic for the SNRI antidepressant Effexor, which, too, treats hot flashes and night sweats. Evernow often runs a special promotion that allows women to try whichever treatment best suits them for free (paying only about $6 in shipping) for the first month.

Gennev – Provides virtual perimenopause care at a rate of $55 for a 20-minute appointment or $85 for a 30-minute appointment with a trained menopause specialist. Some online reviews suggest a level of dissatisfaction among women who wanted actual HRT but were prescribed standard birth control pills instead. However, Gennev claims to offer hormone replacement therapy, in addition to a range of supplements, like vitamin D, omega-3 and others.

HelloAlpha – Prescribes supplemental estrogen and progesterone in the form of capsules, patches and gels, offering name brand prescriptions and generics, with a fully transparent price list. They also offer combined pills and conventional birth control pills as options. For perimenopausal sleep problems, they have doxepin and Ramelteon. And if non-hormonal options are a need or preference, HelloAlpha offers brand name and generic Brisdelle (paroxetine) and Effexor (venlafaxine).

Winona  - An emerging player in the HRT market, Winona offers the full panoply of hormone management options for women. They have estrogen in the form of tablets, patches and body creams, as well as vaginal estrogen. Progesterone is available as a combined cream with estrogen, as standalone oral capsules or as a body cream. Winona also has DHEA, which may help women who need a testosterone boost. Winona stands out in that they offer both FDA-approved, regulated hormone products as well as custom-compounded formulas.

Now, many people will wonder if these providers accept insurance? In most cases, the answer is likely “no.” Most providers require or expect out-of-pocket payment for HRT, though some may be willing to provide a statement developed for a patient’s potential insurance reimbursement. Some patients use HSA (health savings account) funds toward their HRT; some grapple with their insurance to cover at least part of it and, most, sadly, pay for it themselves – even if they have “good” insurance. The headaches of bickering with insurance administrators and going back and forth to doctor’s offices in person just isn’t worth it to them.

So, for those interested in HRT who have faced unreasonable hurdles with conventional, in-person doctors, there are alternatives available. The online HRT providers are staffed by medical personnel and most use FDA-approved body-identical hormone replacement products, not unscrupulous, questionable products from “the streets” or underground.

As with most things, buyer beware. Research online reviews, have an informational visit with a provider, check the doctors' credentials and history with the medical board in the state in which they are registered, ask as many questions as you need, comparison shop and even see how what they recommend corresponds with science and best practices. And then make a decision. 

“Oh, I’m so sorry; you should’ve been born with testicles. It’s probably going to make you pretty bitchy, too.”

Can you imagine someone telling you this? Let alone, hearing it from a healthcare professional, a doctor?

Well, one woman didn’t have to imagine; it actually happened to her. This was what Jennifer, a Washington State-based YouTuber, and meditation and pilates instructor was told by a male gynecologist when she went to him for help with her perimenopause symptoms.

“This is lonely. You struggle. I’m still struggling. That was where my calling came from,” says the military wife and mother of four. “Why didn’t anyone tell me this was going to happen?”

Jennifer, like so many other women, struggled to understand what was happening to her body – and mind – as she progressed through her 40s, the era when the hormonal swings that eventually build up to menopause start to manifest. Now 49 years old, Jennifer recalls her first perimenopausal symptoms beginning around the age of 43 or 44.

“What is wrong with this picture? It’s not right that we have to struggle so much before we get some answers. We’ve come so far in this world, but we’re so far behind in some ways. This should be taught in sex ed, and we should have many options when we go through it,” she recounts with frustration.

One of Jennifer’s first wake-up calls was her poor sleep.

“Sleep was my first indicator. I woke up one day and said, ‘Shit, I haven’t slept great in four years. But I connected it to my children. I always had children in my bed. I had a baby at 40. I thought I wasn’t sleeping because I always had a baby in my bed,” she explains.

The next tell-tale sign were changes with her menstruation. What was once like clockwork began to feel like a broken watch.

“My cycle go wonky. One would be heavy, like from hell. And the next one would be light,” Jennifer says. “The cycles became very short, like 17 days or 19 days – that happened from ages 43-45.”

The cycles became not only unpredictable, but the bleeding was like a levee had been breached and toppled over. So profuse was the flow that it bound her to the house, zapped her of energy and landed her in the ER.

“All of a sudden they started getting really heavy, almost hemorrhaging. I was stuck in the house three or four months before I started figuring something out. I was anemic, tired, couldn’t get up. No sanitary product would work, not even Super Plus. I was literally homebound for weeks and weeks and weeks. I ended up in the hospital, and that at point, they gave me progesterone to help control the bleeding.”

This experience ignited a fire under Jennifer, prompting her to action. Little did she know it would be the beginning of a complex and convoluted journey with the medical system.

“That’s when the fun with the doctors began,” she says.

Her first doctor, a male primary care physician, said she was too young for it to be perimenopause, since she still had periods (yet women still menstruate throughout perimenopause). Then Jennifer remembers she started experiencing her third main symptom, an involuntary attitude shift that affected her relationships. She reported this to the doctor, too.

“Around this time, I also noticed the symptom of not liking my husband, and I felt something was going on. Normally, after my PMS passes, I like my husband again, but this time it was different. The doctor looked at me and said, ‘Well, you’re not in menopause because you’re still getting your period. I’m going to write you a prescription, and get you some Zoloft.’”

Studies show that about 25 percent of all American women in their 40s and 50s are on some sort of antidepressant. Not surprisingly, this uptick in antidepressant prescriptions at this stage of life coincides with the time women are beginning perimenopause and transitioning into full menopause. Jennifer felt intuitively that she wasn’t a textbook depression case and decided not to take the Zoloft. “I knew I wasn’t depressed, and I knew there was something to it.”

She continued to take progesterone to control the bleeding, but it didn’t work as well or for as long as she’d hoped. So another doctor – the fourth by this time – put her on birth control pills. Sometimes doctors prescribe birth pills in lieu of hormone replacement therapy (HRT) as a less expensive stop-gap, one that overrides natural hormones rather than augments them like HRT does. But those proved to be far from the optimal solution.

“Birth control made everything worse – I was more moody and irritable, though it did help with the bleeding and made my periods regular.”

After being on birth control pills for eight months, Jennifer starting feeling sick, with nausea that reminded her of the hyperemesis she endured during pregnancy. By now, she was offered an ablation, which would have presented a surgical remedy to stopping the bleeding, but she decided against that. And then Jennifer found a helpful OB/GYN who suggested the Mirena IUD, which she’s had inserted for about six months without any negative symptoms yet.

Soon after the IUD insertion, Jennifer wanted to address another common problem – her tanking libido. Her diminished sex drive was starting to cause marital friction, so she approached her primary care physician for some help, and she walked away with a prescription for Wellbutrin, an antidepressant now commonly prescribed off label for weight loss, smoking cessation and, yes, sex drive. Like many medications, antidepressants can be prescribed for all sorts of other reasons, including sleep, nerve pain, hot flashes and night sweats, anxiety and migraine headache relief, among others.

“I think Wellbutrin can be a life saver to get a woman back on track and help with the libido,” Jennifer says. “When I was on the birth control pills, I didn’t even want to be touched, by my husband or my children. I would literally be cringing. It was horribly upsetting. I knew I had to do this for my children. I have to be present.”

Still, Jennifer discontinued the Wellbutrin after about six months. She found the initial benefits to her sexual desire and mood declining as time went on, and she didn’t want to end up in a cycle of increasing the dose over and over again to maintain the same effect.

The journey for effective treatment and quality care continues for Jennifer, who plans to seek additional help for her symptoms, especially sex drive and feeling low at times.

“I still feel like we have to get to the root problem, which is imbalance of the hormones,” she says. “I may ask for testosterone supplementation. And I may pursue HRT.”

Though she’s still navigating the medical system and may end up trialing yet more options to treat her symptoms, that hasn’t extinguished the flame for progress in promoting understanding about perimenopause – a passion Jennifer now holds dear. She’s become quite the advocate – adding content that specifically addresses menopause to her YouTube audience of hundreds and educating her children about what this all means. In fact, her kids even help out with her YouTube video production.

“Let me tell you how educated my boys are. I am empowering and educating my boys,” she affirms. “They need to know, and as mothers, we should be teaching our sons and daughters that this is something that will come – just like we tell them puberty is coming.”
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Though some days are difficult, and she knows the road forward in her final destination to official menopause may be more years in the making, Jennifer finds moments of joy and humor in all this. For example, one day she overhead her 13-year-old son talking to his 8-year-old brother, saying, “Mom’s having a hard hormonal meno day. She’s going through puberty in reverse.”

Key Tips from Jennifer

Learn for yourself and advocate tirelessly.

“Our providers are not educated, and it’s not their fault. Unless they’re educated as a GYN or take steps to educate themselves, it’s not going to happen. Science hasn’t delved into it enough to figure it out for us.”

Find an outlet for self-care, emotional release and mental clarity.

“Meditation is my saving grace. I’m trying to really share with women that meditation can do wonders as well. To meditate, you don’t need to be spiritual or religious. It’s more about the breathing, the silence and being able to become still, and just focus on yourself – it is self-care. It’s your gift that you can do for yourself.”

Discover the right doctor or care team for you.

“I’ve been through six doctors. Find the doctor who is going to advocate for you, give you that support and help you find what you need. I do think it should be a woman and, more importantly, a woman who has gone through menopause. I am for you firing your doctor and finding one that works for you.”

Jennifer’s Perimenopause and Menopause Videos on her DivineThreeFold YouTube Channel
Symptoms of Menopause: Update on IF and ‘Are You Serious’? Vertigo
The 3 Most Important Tips to Help You Get through Menopause
Symptoms of Menopause – Diet and Exercise
Symptoms of Menopause – IUD for Perimenopause?
Pilates Strength and Stretch for Menopause Symptoms
Symptoms of Menopause: Can You Believe He Said That?
Meditation for Acceptance: For Help with Peri/Post/Menopause Symptoms
Menopause Weight Gain Full Body Workout  
Symptoms of Menopause: Why Is No One Talking About It?
 

​I recently volunteered to take part in a market research study for a brand-new development on the horizon for perimenopausal and menopausal symptoms. The upcoming product appears to be a first-in-its-class medication to treat the vasomotor symptoms of this time of hormonal change – vasomotor meaning, in everyday language, hot flashes and night sweats.

I was excited and eager to contribute in some small way to this historic happening in the world of menopausal medicine. As a newly declared perimenopausal woman (who’s likely had symptoms for at least the past two years), I believe that advocacy, information, education and the availability of proven options are paramount for women dealing with the symptoms associated with the drop in estrogen and progesterone – insomnia, first-ever experiences of anxiety or depression, skin changes, potential bone loss and much more.

I am an ardent researcher in matters perimenopause and menopause. I read medical journal articles, clinical trial reports, mass-market stories, medical society websites and personal stories of brave women who’ve spoken openly about their own experience. So when I heard about this market research study being conducted on behalf of a pharmaceutical company, I knew I wanted to help.

So, here are the details, as best as I can divulge.

The name of the company behind this is not clear. The market research interview was performed by a third-party company working with the pharmaceutical company. As a result, I don’t know which pharma company plans to release this new product or when they may do so.

It’s going to address vasomotor symptoms. As the questions continued, it became clear that this new product is one I’ve already read about. It will be a new class of medication focused on treating hot flashes and night sweats in particular. It is a non-hormonal drug called fezolinetant that has either concluded or is in the final stages of pre-market trials.

This is important because, to date, the most common options to treat hot flashes and night sweats are the gold standard, hormone replacement therapy (HRT), followed by antidepressants. Most antidepressants, usually in the SSRI class (but sometimes in the SNRI class, too) are prescribed “off label” for the treatment of hot flashes. “Off label” means that a medication is being used for a clinical purpose other than what it was originally created to treat. Brisdelle ® is the only SSRI antidepressant actually created to treat vasomotor symptoms; indeed it is a low dose (7.5 mg) of the antidepressant Paxil (generic Paroxetine). Other antidepressants commonly offered to treat hot flashes are Celexa (citalopram), Lexapro (escitalopram), Prozac (fluoxetine) and Effexor (venlafaxine).

Some women choose antidepressants over HRT for various reasons, including a personal history of cancer, prior embolisms and outdated and disproven information about the risks of hormone therapy (See WHI Wrong on HRT). At the same time, antidepressants can come with their own side effects – results that for some women are worse than the condition they’re intended to treat. So there is certainly a need for an alternative effective medication.

The pharmaceutical company is trying to get the right language and terminology together. Most of the questions I was asked pertained to certain word choices, phrases and definitions that team must be considering. I was asked to weigh and rank various words, sentences and themes. What I recall most are two things:

1. They referred to hot flashes and night sweats as a standalone “medical condition.” I didn’t agree that these should be categorized as a separate entity, but rather as a symptom of perimenopause and menopause. Maybe this is an attempt to further “medicalize” menopausal symptoms in order for insurance companies to cover the treatment or something else. But I felt like this ran the risk of splitting women’s bodies literally into parts and not looking at this stage of life as a total-body process, of which hot flashes and night sweats are symptoms. For this reason already, many women end up taking multiple medications, vitamins, supplements and more to treat each discrete symptom when, in reality, they could benefit from only HRT alone, or maybe just one or two medications.
2. They kept using the word menopause or menopausal, not perimenopause or perimenopausal. I thought this was a vulnerability and critical error since women become symptomatic many years before reaching actual menopause (12 months in a row without a menstrual cycle). Some women (and doctors) could mistakenly think such women didn’t qualify for the medication as a result. I advocated the use of the term perimenopause and menopause to ensure clarity and inclusion and reduce confusion.

There were many other specifics and nuances in the word choices, language and even the number of scientific and medical facts the company is thinking about including in its promotion of the medication.

It’s not clear if the medication will treat anything other than hot flashes or night sweats. Vasomotor symptoms was the central theme in the market research study. While the interviewer mentioned the impact of hot flashes and night sweats on quality of life, they did not state or imply that the new drug will treat other symptoms like mood changes, hair thinning, skin quality, vaginal dryness or any of the other dozens and dozens of potential perimenopausal and menopausal symptoms. So I think this drug must be laser-focused on night sweats and hot flashes alone. Of course, for some women, remediating those symptoms alone will have a major payoff in everyday life, so I don’t want to discount the benefit.

I bet the medication will be expensive, and most insurance companies won’t cover it. I have little factual basis for my claim here, but with many medications that are new to the market, they are prohibitively expensive for most people. And since they are new, and no generics are yet available, insurance companies may not cover it. Instead, I fear that women will want to try this new medication and won’t be able to because insurance only covers generics and / or they will route the woman to try an existing antidepressant used for that purpose instead. It may take years for the cost to come down or for there to be a widely available generic option.
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So these are my takeaways for now. I will likely be part of a follow-up survey and may have even more to say about it as the drug gets ready for its official launch. I am glad there is progress being made in learning more about – and developing solutions for – the symptoms of perimenopause and menopause. By the time my daughters reach this phase of life, hopefully there will be a full menu of hormonal and non-hormonal options for them that they don’t have to fight tooth and nail to access.