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. 

​Yes, you read the question right: I really want to know if weight and size play a role in how a woman may experience the transition to menopause. Does being bigger help shield a woman from the worst perimenopause symptoms? And does being lean help guarantee that a woman is going to have a tougher time?

Even though I am inquisitive by nature and can always think of questions to ask about almost anything, I honestly don’t think I would have arrived at this line of inquiry on my own. It wasn’t until I was at an appointment with the doctor who finally really helped me at a root-cause level that I became quite interested in this idea.

She asked me, “When did your mother reach menopause?”

“Around 57 or 58, I believe,” I said, trying to recall what my mother had told me before.

“And what size is your mother?” the doctor asked.

“Well, she is shorter than me. And, at the time, she was a larger woman,” I answered, remembering my mother being between a size 16-18 in the years before she overhauled her dietary habits in favor of plant-rich, low-fat way of eating.

“That indeed explains it!” said the doctor.

“It does?” I asked, shocked.

“Yes, you could consider gaining 30 pounds,” she responded with humor.

I was aghast, for real. Through all my months of horrible non-sleep and what I later realized were night sweats that had been going on for well over a year, it had taken me time to realize these were clear symptoms of perimenopause. But even through all my thinking, digesting and research, I had never considered the role weight or size might have played in my experience.

***

I work out regularly. My “regularly” is probably the average person’s “Are you kidding me?” I am active most days of the week. Forcing myself to have a rest day is really hard sometimes. I am the type of person who feels different and a bit incomplete if I have not powered through a good workout in the morning. It helps to set the tone for my day and is as much a part of my life as is having a cup of coffee or brushing my teeth.

For years, in addition to cardio, I also weight trained consistently. I grew in strength and confidence, and eventually lifted heavy (for a woman). I was doing deadlifts, weighted squats, snatch-and-cleans and much, much more, enjoying my time in the weight room at the gym and at home. I cut back on the rigorous weight lifting after the collateral damage from a long-ago car accident (I was rear-ended by multiple vehicles more than 20 years ago, like one among a cascade of dominoes.) resulted in me eventually ending up in the operating room, having an anterior cervical discectomy and fusion (ACDF) surgery at one vertebral level in my neck.

Though my strength is still here, I have tempered down the workouts. I no longer run or jog; it’s just too jarring. I speed walk, either outside or on the treadmill. I also do other cardio, via stair climber or recumbent bike, and I have fallen more into “resistance training” rather than “full-blast weightlifting.” Being in the OR and now with titanium in my neck, it didn’t take much to let me know I needed to dial things back to prevent future surgeries, or at least delay another one by many years, if at all.

Related to perimenopause, I never thought my active lifestyle could work against me in any way. But my doctor’s comments made wonder.

***
So imagine my surprise when the doctor told me that, perhaps, my foray into perimenopause may not have been so challenging had I been bigger. Even though I am not a small woman, the doctor told me I don’t have much body fat. I am 5’7”, and I won’t say what I weight right now because I don’t want to read this later and regret pronouncing it to the public, should I blow up (ha, ha). But I am typically a size M in letter sizes and a 10 numerically. I am pear-shaped and naturally have a slimmer waist and bigger hips.

Of course, I laughed too when the doctor told me I could gain 30 pounds. That was not in my plan, but I did wonder if I had been larger, say 15 pounds bigger, and less committed to working out, would that have made a difference?

Serendipitously, on one of the Facebook communities I belong to, a fellow member posed a similar question. She asked what size the women were and how they were faring with menopause or perimenopause. Hundreds of women responded, and a theme emerged: The lean, thin or athletically fit women almost unanimously voiced having a hard time with symptoms like insomnia, anxiety, sweating, migraine headaches and more, while the plus-sized ladies said they had no symptoms or maybe one or two that were tolerable and manageable.

***

As I attempted to explore this from a more scientific point of view, most of what I encountered was focused on women gaining undesirable weight at midlife. I guess this is a more common phenomenon or a more popular consideration – women complaining about their body shape changing or gaining weight faster than ever before. According to the North American Menopause Society (NAMS):

“Although menopause may not be directly associated with weight gain, it may be related to changes in body composition and fat distribution. Several studies have shown that perimenopause, independent of age, is associated with increased fat in the abdomen as well as decreased lean body mass. This suggests that menopause plays a role in many midlife women’s transition from a pear-shaped body (wide hips and thighs, with more weight below the waist) to an apple-shaped body (wide waist and belly, with more weight above the waist)."

This change in body composition can even negatively impact the health profile of women who remain the same weight. In the Journal of the American Medical Association (JAMA), they report that:

“The standard BMI cutoff of 25 for overweight and 30 for obesity might be too high for postmenopausal woman because their body composition changes over time. As they age, women tend to lose bone and muscle mass, which are heavier than fat. So even if a 65-year-old woman weighs the same as she did at 25 years of age, fat accounts for a larger share of her weight. And that fat isn’t distributed in her body the way it was at age 25 years.”

As I went down the rabbit hole trying to find any research connected to larger size leading to fewer menopause symptoms, I predictably came across many articles about how to lose weight in the 40s and beyond, often with a focus on intermittent fasting, keto dieting, clean eating and weight training. I also came across sources saying that obesity is connected to worse menopause symptoms, not fewer. Also, total body fat also increases the risk of breast cancer.

The University of Rochester offers this interesting take on the estrogen-fat connection:

“Paradoxically, in menopause, a woman’s estrogen levels are inversely related to her weight. In a study of newly menopausal healthy women over a four-year period, women showed an increase in weight and body fat (primarily as visceral adipose tissue), which coincided with a drop in estradiol [the main type of estrogen in women] levels and a decrease in physical activity and energy expenditure . . . Studies have shown that estrogen incorporates crucial elements into the DNA responsible for weight control."

***

So, it’s hard to find a clear answer.

While my doctor seemed convinced that having more body fat leads to a less symptomatic perimenopause, and while legions of women in social media seem to agree based on their personal anecdotal experience, it’s hard to find corresponding research.

Most of what I found related to body fat and perimenopause or menopause was highly cautionary: metabolic syndromes, increased body fat leading to decreased muscle mass, higher breast cancer incidence, poorer cardiovascular health and other terrifying impacts.

I guess I will continue doing what I’ve been doing for years – working out more often than not and eating a pretty clean diet, save for special occasions, as there appear to be more upsides to staying the course than going off the rails.

But if an extra 15 pounds would have staved off the type of insomnia or night sweats I experienced, I would have signed up years ago.
 
 
 
 
 
 
 

Kitty Anderson is one of the few nationally Board-certified health coaches in the U.S. specializing in menopause education and recovery. By her count, there are only seven similarly credentialed health coaches in the United States.

When I first stumbled across her YouTube Channel, Create a Menopause Recovery, I knew that Kitty was someone special. As an ardent researcher myself, and as a woman just months into her own HRT treatment and recuperating from interludes with a medical system with few knowledgeable practitioners, I was immediately impressed by Kitty’s comprehensive approach to sharing information, truly helping women and focusing on multifaceted solutions. Kitty is not only a menopause expert, she has also been using hormone replacement therapy (HRT) to address her symptoms and improve her quality of life for 14 years.

Kitty Anderson graduated from The Mayo Clinic College of Science and Medicine’s accredited coaching program and passed the National Board Certification Exam, the same body that licenses physicians. In order to maintain her credentials, Kitty takes continuing education courses and is bound to adhering to precise ethical rules and a defined scope of practice. She has also completed coursework in health, psychology, neuroscience, counseling, wellness and nutrition, among others, at Wright State University and Sinclair College.

Kitty’s current paid offerings include one-on-one consultations and webinars, focusing on HRT, stress reduction, nutrition, relationships, movement, sleep and more.

I recently caught up with Kitty to discuss how women are dealing with – or rather, not really dealing with perimenopause – with a special emphasis on her concept of menopausal care as a social justice issue. While many online menopause evangelists may have a decided bent towards naturopathic or conventional medical remedies, or may seek to abandon to idea of any treatments since menopause is a “natural event,” Kitty is the first I’ve encountered who adds a socio-political and socio-cultural element to her advocacy.

Why do so few women seem to know about HRT, let alone use it, for their perimenopausal and menopausal symptoms?

Hormones do hundreds of things in our bodies, and that's how the body works. Only three percent of American menopausal women are getting HRT. Many women are denied HRT by their (conventional) OB/GYN. It is NOT the standard of care to offer HRT.  That means we can't sue our doctor if they say no. 

What about alternative ways to get HRT?

A functional medicine doctor or a functional pharmacy will be more generous with HRT, but it is more expensive. They may or may not counsel on diet. We pay extra for these services, and the product quality is lower than the FDA-approved products.

It seems like so many women are on various prescriptions, potions, supplements or unproven lifestyle changes to get relief from menopausal symptoms. Why?

Our algorithms make it impossible to find valid consumer-friendly information. Everyone is selling something to replace HRT. There is just not a logical reason to use these other products in my mind. They are not the identical molecule to the hormones you used to make.

And there aren’t many accessible examples of women successfully navigating menopause in real life either, right? At least not in terms of symptomatic women talking openly about their symptoms and sharing what worked?

Women tend to look to other women, and there are few examples of women thriving on HRT. If you don't have a friend using HRT, you don't see the benefit. It seems unnatural. But the identical molecule is natural, right? Replace what's lost -- in a form that your body uses.  

There are various formulations and preparations out here that are all classified as HRT. How can there by so much variability in the market?

The broad category of drugs called HRT don't all perform equally for sleep, mental health and cognitive health. Our menopause society (North American Menopause Society - NAMS) doesn't focus on brain health. The research outcomes are focused on menopause symptoms and future bone health. Doctors treat all drugs in the HRT category as equal, and they are not. Our medical system allows this.

Research shows that women of color, and Black women in particular, may have a more difficult and earlier transition to menopause. How does this factor into your concept of menopause treatment as a social justice issue?

Women of color and low income women are about 30 percent less likely to have an HRT prescription. Health information and products are not as available. I think that the lesser quality and less expensive oral estradiol is available on Medicare as the first line of treatment. I have heard of some women getting transdermal estradiol, which is better. 

What are some other barriers to women’s success with hormone replacement therapy?

Not all women trust the medical industrial complex . . . for good reason, right? We have some drugs that are worse than the disease. It is a for-profit system. This works to our detriment. Seventy percent of women stop their HRT in the first year without talking to their doctor. And 70 percent of women do not read the directions to apply their HRT correctly. They are under-dosing.
 
Even smart, successful women are having a hard time getting quality information and the right treatments. Many end up with cabinets full of supplements, vitamins, tinctures and herbs. Others are prescribed medications that don’t fundamentally address the hormonal loss.

I have talked with extremely educated women who know research inside and out. They did not figure out that HRT was critical. The information never made it to them. I know female health coaches in their 50s and 60s, and they did not know what HRT does. They were not using it. 

How can they lead women to wellness without it? There are currently only seven menopause coaches with the Board Certification of NBHWC. There is no training for our Board-certified coaches. I created my own training from a multitude of sources.

What does this do to women over time, this lack of informational access and proactive engagement from their healthcare providers?

When a woman over 60 years old comes to me to talk about hormones, she is really broken. She has arthritis, she has autoimmune problems, she has fatigue, she lacks confidence and motivation, and she is fearful. Her body has gone without hormones for a decade. It has changed. In some ways, she will not recover. She just didn't get the right information at (or before) menopause. It's so sad. 

It seems like some of this is socially conditioned as well as structurally induced, within the systems of healthcare, education and media, this lack of open treatment discussions and awareness for women. Hence, this is really is a social justice issue, like you said. It involves equity, access, investment and repairing the fissures in our medical system.

Most women just think they should "tough it out" or “not bother anyone.” Women are accustomed to self-sacrifice and giving the doctor control of the outcome. They don't understand how to work the system to get what they want. No one is telling them that they are in charge of their health outcome. Doctors are looking for compliance typically, but they don't talk to us about whether or not we are getting enough HRT. 
They don't ever phrase this as, “HRT is good for you. You should feel really well.” And for some reason, there are no testosterone products off the shelf for women. Testosterone is a controlled substance. NAMS doesn't even cover testosterone in their training. (Editor's note: The International Menopause Society does address supplemental testosterone for women.)

I feel like we have to know more than our doctor to get this to work well. All three hormones – estradiol, progesterone and testosterone – are important and all are low at menopause. You can't expect your body to work with 1/20th the amount of reproductive age hormones at menopause.


You can learn more about Kitty Anderson at https://www.jumpstartaip.com/. She offers paid 1:1 consultations and webinars.

Highlights from her YouTube Channel are:

Perimenopause and Menopause HRT for Infection, Weight Loss, Alzheimer’s, Diabetes
Higher Dose HRT Works Best for Mental Health: How HRT Works
100 Ways Hormone Loss Gets to You: HRT Prevention and Recovery
HRT and Personality Changes: What to Expect – My Story, My Clients and Universal Laws of Hormones
No Rules for Menopause? Well, Guidelines, Yes.