HRT Basics for Perimenopause: What You Actually Need to Know Before Talking to Your Doctor

If you've been reading about perimenopause, you've almost certainly come across the term HRT. And if you're anything like most people navigating this transition, you probably have a mix of curiosity, confusion, and maybe a little fear swirling around it.

That makes complete sense. Hormone replacement therapy has been surrounded by shifting headlines, conflicting advice, and incomplete information for decades. One moment it's described as a miracle. The next, it's painted as a risk you should avoid at all costs. With that much noise, it's hard to know what to believe or where to start.

You deserve clear, honest information. Not hype, not scare tactics. Just the facts about what HRT is, how it works, and what the current research actually shows. That's what this guide is for.

Understanding hormone replacement therapy and how it works

At its core, hormone replacement therapy (HRT) is exactly what it sounds like: replacing the hormones your body is producing less of during the perimenopausal transition. As your ovaries gradually slow down their production of estrogen and progesterone, your body experiences the ripple effects of that shift. Hot flashes, night sweats, mood changes, disrupted sleep, vaginal dryness, brain fog. These aren't random annoyances. They're your body responding to a new hormonal reality.

HRT works by supplementing your declining hormone levels, bringing them closer to the range your body has operated within for most of your adult life. The goal isn't to stop the transition from happening. It's to smooth out the ride so your symptoms become more manageable while your body adjusts.

Types of HRT

Not all HRT is the same. The type your doctor recommends depends on your medical history, your symptoms, and whether you still have a uterus.

Estrogen-only therapy (ET) is typically prescribed for people who have had a hysterectomy. Since estrogen without progesterone can stimulate the uterine lining and increase the risk of endometrial cancer, this option is reserved for those without a uterus. Estrogen-only therapy is effective for relieving hot flashes, night sweats, vaginal dryness, and supporting bone density.

Combined therapy (EPT) pairs estrogen with a progestogen (either natural progesterone or a synthetic progestin). This is the standard approach for people who still have a uterus. The progesterone component protects the uterine lining from the growth-stimulating effects of estrogen. Combined therapy can be given continuously, where you take both hormones every day, or sequentially, where progesterone is added for only part of each month.

Bioidentical hormones are hormones that are chemically identical to the ones your body naturally produces. Both FDA-approved bioidentical options (like micronized progesterone and certain estradiol formulations) and compounded versions exist. FDA-approved bioidentical hormones go through rigorous testing for safety and consistency. Compounded bioidentical hormones, mixed by specialty pharmacies, are not subject to the same regulatory oversight. This distinction matters, and it's worth discussing with your doctor.

Delivery methods

One of the things that surprises many people is just how many ways HRT can be delivered. The method you choose affects how the hormones enter your body, how they're processed, and in some cases, their risk profile.

Oral pills are the most traditional delivery method. You take a tablet daily. Pills are convenient and well-studied, but because they pass through your liver first (called "first-pass metabolism"), they can have a slightly higher impact on clotting factors compared to other methods. For most people, this is a small consideration. For those with elevated clotting risk, other routes may be preferable.

Transdermal patches deliver estrogen through your skin directly into your bloodstream, bypassing the liver. You typically apply a patch to your lower abdomen or buttock and replace it once or twice per week. Patches provide a steady, consistent level of estrogen and are associated with a lower risk of blood clots compared to oral forms.

Topical gels and sprays also deliver estrogen through the skin. You apply a measured dose to your arm, thigh, or abdomen daily. Like patches, they bypass the liver and provide steady hormone levels. Some people prefer gels because there's no visible patch.

Vaginal rings, creams, and inserts deliver estrogen locally to the vaginal tissues. These are primarily used for vaginal dryness, discomfort during intimacy, and urinary symptoms rather than systemic symptoms like hot flashes. Because the dose is low and localized, vaginal estrogen is considered very low-risk and is often recommended even for people who aren't candidates for systemic HRT.

Progesterone is most commonly taken as an oral capsule (micronized progesterone, often sold as Prometrium). It can also be delivered via an intrauterine device (IUD) like the Mirena, which provides local progesterone to protect the uterine lining while avoiding systemic progesterone side effects.

Who might be a candidate for HRT?

HRT is most commonly considered for people experiencing moderate to severe perimenopause symptoms that significantly affect daily life. Good candidates generally include those who are in the early stages of this transition or within 10 years of their final period, are under 60, and don't have certain contraindications like a history of breast cancer, active liver disease, unexplained vaginal bleeding, or a history of blood clots or stroke.

Your personal and family medical history plays a significant role in whether HRT is right for you. This is a conversation to have with a healthcare provider who understands your full picture, not a decision to make based on a single article or a friend's experience.

Benefits that go beyond hot flashes

While hot flash relief is the most well-known reason people start HRT, the benefits extend further than many realize.

Bone health is one of the most significant. Estrogen plays a critical role in maintaining bone density, and the decline during perimenopause accelerates bone loss. HRT has been shown to reduce the risk of osteoporotic fractures, including hip and vertebral fractures. For people at elevated risk of osteoporosis, this benefit can be substantial.

Cardiovascular health is another area of active research. When started early in the transition (before age 60 or within 10 years of menopause), estrogen appears to have a protective effect on blood vessel walls, helping maintain their flexibility and reducing plaque buildup. This is a nuanced topic with important timing considerations, which we'll cover in the research section below.

Mood and cognitive function often improve with HRT. Estrogen influences serotonin and other neurotransmitters that regulate mood, and many people report feeling more emotionally stable and mentally clear after starting treatment. While HRT is not a treatment for clinical depression, it can help with the mood fluctuations and brain fog that come with hormonal shifts.

Sleep quality frequently improves as well. Since many sleep disruptions during perimenopause are driven by night sweats and hormonal instability, addressing the underlying cause with HRT can lead to more restful, uninterrupted nights.

Vaginal and urinary health benefit significantly from estrogen. Vaginal dryness, discomfort, and recurrent urinary tract infections often improve with either systemic or local estrogen therapy.

Skin and joint comfort are additional areas where some people notice improvements. Estrogen supports collagen production and joint lubrication, and some research suggests HRT may help maintain skin elasticity and reduce joint stiffness.

What does the research say?

The story of HRT research is one of the most important examples of how scientific understanding evolves over time.

In 2002, the Women's Health Initiative (WHI) study made global headlines when it was halted early due to findings that a specific type of combined HRT (oral conjugated equine estrogen plus synthetic progestin) was associated with a small increase in breast cancer, heart disease, and stroke risk. The reaction was immediate and dramatic. Millions of people stopped their HRT overnight. Doctors pulled back from prescribing it. Fear replaced confidence.

But in the years since, researchers have re-analyzed that data extensively, and the picture is far more nuanced than those early headlines suggested. The average age of participants in the WHI was 63, well past the typical perimenopausal window. Many had started HRT a decade or more after menopause. The type of hormones used (conjugated equine estrogen and medroxyprogesterone acetate) are not the same as the bioidentical formulations commonly used today.

What has emerged is the "timing hypothesis," which holds that the risks and benefits of HRT depend heavily on when you start it. For people who begin HRT during perimenopause or within 10 years of their last period, the research consistently shows a more favorable risk-benefit profile. Cardiovascular protection appears strongest when HRT is started during this window. The breast cancer risk, while still present with long-term combined therapy, is small in absolute terms, comparable to risks associated with regular alcohol consumption or obesity.

The current position of major medical organizations, including the North American Menopause Society and the International Menopause Society, is that HRT remains the most effective treatment for vasomotor symptoms and that the benefits generally outweigh the risks for symptomatic people under 60 or within 10 years of menopause.

What this means for you

With all of that context, here are the key takeaways to carry with you.

1. HRT is not one-size-fits-all. The type, dose, delivery method, and duration should be tailored to your specific symptoms, health history, and goals. What works for someone else may not be the right fit for you.

2. Timing matters. Starting HRT during the perimenopausal window or early postmenopause is generally associated with the most favorable benefit-to-risk ratio. If you're considering it, earlier conversations with your doctor are better than later ones.

3. Transdermal delivery has advantages. Patches, gels, and sprays bypass the liver, which may reduce clotting risk. If you have risk factors for blood clots, transdermal options are worth discussing specifically.

4. Bioidentical does not automatically mean safer. FDA-approved bioidentical hormones are well-tested and regulated. Compounded bioidentical hormones are not held to the same standards. Ask your provider about the difference.

5. The benefits go well beyond hot flashes. Bone protection, cardiovascular support, mood stability, better sleep, and vaginal health are all part of the picture. Understanding the full range of benefits helps you weigh the decision more completely.

6. Your risk profile is personal. Breast cancer history, clotting disorders, liver disease, and cardiovascular risk factors all influence whether HRT is appropriate for you. A thorough conversation with your doctor should include your full medical and family history.

7. You can revisit the decision over time. Starting HRT doesn't mean committing forever. Many people use it for a defined period and then taper off. Others continue longer because the benefits remain meaningful. Regular check-ins with your provider allow you to adjust your approach as your body and needs change.

Putting it into practice

One of the most useful things you can do before an HRT conversation with your doctor is to arrive with data. When you can describe your symptoms clearly, including their frequency, severity, and how they affect your daily life, your provider has a much stronger foundation for making recommendations.

Tracking your symptoms over several weeks or months reveals patterns that are easy to miss in the moment. You might notice that your hot flashes cluster around certain days of your cycle, that your sleep disruption is worse during specific weeks, or that your mood shifts follow a recognizable rhythm.

PeriPlan is designed to make this kind of tracking simple. Daily check-ins take just a few seconds and build a picture over time that becomes genuinely useful when it's time to sit down with a provider and discuss your options.

Navigating the world of HRT can feel overwhelming, but it doesn't have to stay that way. You now have a solid foundation of what HRT is, how it works, what the research shows, and what questions to bring to your next appointment. The most important thing is that the decision is yours, made in partnership with a provider who respects your experience and your goals.

Your body is going through a real transition. You deserve real support.

This article is for informational purposes only and does not constitute medical advice. Hormone replacement therapy involves individual risks and benefits that should be discussed with a qualified healthcare provider. Always consult your doctor before starting, changing, or stopping any treatment.