How to Start HRT for Perimenopause: A Step-by-Step Guide

You've Done the Research. Now What?

Maybe you've been awake at 3am reading forums. Maybe your doctor mentioned HRT and you felt a mix of hope and confusion. Maybe a friend started it and said it changed her life, and now you're wondering whether to try it too.

Starting hormone replacement therapy in perimenopause is one of the most impactful decisions you can make for your health during this transition. It is also one of the most misunderstood. This guide walks you through the process from the beginning: what to do before your first appointment, how to have a productive conversation with your doctor, what to expect in the early weeks, and how to know whether your current approach is working.

Why HRT Is Worth Understanding in Perimenopause

Hormone therapy works by supplementing the hormones your body is producing less reliably. In perimenopause, estrogen, progesterone, and sometimes testosterone fluctuate unpredictably before eventually declining. This fluctuation drives most of the symptoms people associate with the transition: hot flashes, sleep disruption, mood instability, brain fog, vaginal changes, and joint pain.

HRT does not stop perimenopause. But it can stabilize the hormonal environment enough that your body has a steadier foundation to work from. For many women, this means a significant reduction in symptoms. For some, it means near-complete relief.

Beyond symptom relief, there is growing evidence that HRT started early in the menopausal transition may support cardiovascular health, bone density, and cognitive function over the long term. The risk profile of modern HRT, particularly transdermal formulations, is meaningfully different from the older oral synthetic hormones that drove concerns in the early 2000s. Current professional societies including the Menopause Society and NICE support HRT use for healthy women in their 40s and 50s who are in perimenopause or menopause.

Before Your Appointment: What to Prepare

Walking into your doctor's office with clear information makes the conversation more productive for both of you. Before your appointment, write down your symptoms and when they occur in your cycle. Note which symptoms are most disruptive to your daily life and which you can manage. This helps your doctor understand your priorities.

If you have any medical history that may be relevant, such as blood clots, certain types of migraines, liver conditions, or a history of hormone-sensitive cancers, bring that information. It will shape which formulations are appropriate for you. Family history of cardiovascular disease, osteoporosis, or breast cancer is also worth mentioning.

Come with questions written down. Doctors have limited appointment time, and you will remember more if you are not trying to improvise. Useful starting questions: What type of HRT would you recommend for someone with my symptoms? Is there a reason you would suggest pills over a patch or gel? What blood tests will we do before starting? How long before we reassess?

The Types of HRT: A Plain-Language Overview

HRT comes in several forms and the right combination depends on your specific situation. Estrogen is the primary active hormone for most HRT regimens. It is available as skin patches, gels, sprays, and tablets. Transdermal options, meaning patches, gels, and sprays, deliver estrogen directly into the bloodstream through the skin, bypassing the liver. This reduces certain risks compared to oral tablets and is often the preferred starting point.

If you still have a uterus, you also need progesterone to protect the uterine lining. Body-identical micronized progesterone has a favorable risk profile and is often better tolerated, particularly for sleep and mood. Synthetic progestins are also used and effective. If you have had a hysterectomy, you typically take estrogen alone.

Some women are also prescribed testosterone, which supports libido, energy, and cognitive sharpness. Testosterone for women is used at much lower doses than those prescribed for men. It is not licensed for women in all countries, but many specialists prescribe it off-label for women with low libido or persistent fatigue that does not respond to estrogen alone.

Local vaginal estrogen is a lower-risk, separate category. Applied directly to vaginal tissue, it addresses dryness, discomfort, and urinary symptoms. It can be used alongside systemic HRT or on its own.

The Step-by-Step Starting Process

Step one is the initial appointment: share your symptoms, get a physical exam, and discuss your health history. Your doctor may order baseline blood tests, including thyroid function, iron, blood sugar, and lipids, to rule out other causes and establish a baseline before starting.

Step two is choosing a formulation. Your doctor will recommend a starting regimen based on your symptom profile and health history. This is often a conservative starting dose of transdermal estrogen plus progesterone if you have a uterus.

Step three is the first four to six weeks. Give your body time to adjust. Estrogen levels need several weeks to stabilize at a therapeutic level. Mild side effects like breast tenderness or bloating are common and usually temporary.

Step four is the three-month review. This is the key milestone appointment. Bring your symptom notes, describe what has improved and what has not, and discuss whether dose or formulation adjustments make sense. Most women need at least one adjustment in the first six months.

Step five is ongoing monitoring. Annual check-ins at minimum are standard. Blood pressure, breast exams, and periodic review of your regimen are part of long-term HRT management.

What to Expect in the First Three Months

HRT does not work overnight. Most women begin to notice changes within four to six weeks, but the full effect of a given regimen can take three months or longer to assess. Keep a realistic timeline in mind, especially in the first month when your body is adjusting.

Hot flashes often improve relatively quickly, within six to eight weeks in many cases. Sleep may improve around the same time. Mood stability tends to take a bit longer. Vaginal symptoms may take the longest to resolve fully, sometimes three to six months.

In the early weeks, you may notice some spotting or irregular bleeding if you are still having periods. Breast tenderness is common and usually settles. If you experience severe headaches, significant mood changes, or anything that feels alarming, contact your doctor rather than waiting.

Common Obstacles and How to Handle Them

One common obstacle is finding a doctor who is knowledgeable and willing to prescribe HRT. Not all general practitioners have up-to-date training in menopause medicine. If your doctor dismisses your symptoms or is reluctant without clear clinical reasons, it is reasonable to seek a second opinion or ask for a referral to a menopause specialist or gynecologist.

Side effects are another common obstacle. Breast tenderness, bloating, and headaches in the first weeks are often temporary. Mood changes can sometimes be related to the type of progestogen used. Switching from a synthetic progestogen to micronized progesterone, or changing the delivery method of estrogen, resolves side effects for many women. This requires a conversation with your doctor, not abandoning HRT entirely.

Cost and access can also be barriers. In the US, HRT coverage varies by insurance plan. Generic transdermal options are often affordable and effective. Some compounding pharmacies offer customized formulations, though licensed products are more consistently regulated.

Track Your Patterns to Know What's Working

One of the most useful things you can do while navigating HRT is to track your symptoms consistently over time. When you start a new regimen, a few weeks of notes can feel subjective and hard to interpret. A few months of logged data tells a much clearer story.

PeriPlan lets you log symptoms and track patterns across your cycle, so you can see whether symptoms are improving, shifting, or staying the same. This kind of organized information is genuinely useful when you return to your doctor at the three-month mark. Instead of trying to remember the last 12 weeks, you have actual records to share.

When to Contact Your Doctor Right Away

You Deserve to Feel Like Yourself Again

Starting HRT is not a sign of weakness or failure. It is a medical decision made in the context of a significant hormonal transition that your body is undergoing. The research supporting its use for healthy perimenopausal women is stronger than it has ever been, and you deserve a doctor who takes your symptoms seriously.

The process takes some patience, particularly in the first few months of adjustment. But for the majority of women who are candidates for HRT, it makes a meaningful difference. Adjusting the approach over time is expected. You are not stuck with how you feel right now.

This content is for informational purposes only and does not replace medical advice. Always consult your healthcare provider about your specific situation.