HRT & Perimenopause in Your 40s: When to Start, What to Take & What Matters | A Doctor’s Guide

I am 42 years old, and this year, out of nowhere, I developed PMS. My endometriosis, which was quiet for years, woke up in a rage, and that's a key word. And I had a panic attack for the first time in 8 years. So I did what any normal person would do. I went to my OB and I asked them, am I in perimenopause? And the answer I got was, we don't know. I don't think so. And here's the thing. As a board-certified dermatologist and a physician who went to medical school and who speaks the language, I walked out of that appointment More confused than when I walked in and with less answers. So I thought to myself, if I'm confused as hell, what chances do you guys have to navigate this stage of life which can take up to 10 years of our lives? So I decided to do some research, and in the next few minutes I'm going to give you guys the 5 answers that nobody would give me, starting with number 1: How do we diagnose perimenopause? And if there's no single test, what are we looking for? Number 2: What does birth control which I was offered, have anything to do with this? Number 3, why were our mothers told that hormones were the devil that would kill us, but we are being sold hormones like water? Number 4, what the F is HRT and what is it actually going to do to my body, but more importantly, my skin? And number 5, what are your options if HRT is off the table? So without further ado, let's jump in. And by the end of the video, I will share this beautiful view with all of you. So let's start with the real reason why you think you're going crazy and you're losing your shit. Perimenopause is absolutely real, but diagnosing it has become a gold mine for people trying to sell you a lot of unnecessary shit. And you cannot test your way into figuring out if you have a perimenopause diagnosis. No blood panel, no FSH number, no saliva kit, no urine test. None of that stuff is going to actually work to help you get to your answer. And it's not because medicine hasn't caught up, but it's because that is exactly what perimenopause is. It is a roller coaster mind F where one day your hormones are down, the next day your hormones are up. So if you went for a lab test on a Monday, it's going to tell you nothing about where your hormones stand on a Friday because it's a roller coaster. And until somebody comes up with some sort of device that is almost like a blood sugar monitor monitoring your estrogen and progesterone every single day and giving you 6 months' worth of data so you can see a trend, you're never going to get a snapshot picture of where you stand. So how is it actually diagnosed? It is a clinical diagnosis that stands on 3 things. Number one, have you had changes in your period cycle? Number two, your age, especially if you are 45 years old or older, even though perimenopause is a 10-year situation. And number three, your symptoms and what has changed. And that is it. That is the whole test. That is what the actual guidelines say, which is wild, but that is how you diagnose it. So number one, my physician who told me, I don't know, even though I wanted to go ahead and jump and strangle him because he's a man, was not wrong. He was practicing in good medicine and he wasn't really being dismissive. And number 2, if somebody is trying to sell you a $400 hormone panel to confirm that you are actually in perimenopause, I say they are selling you a load of crap and taking your money and running. So while we are here, I also wanna quickly talk about estrogen dominance, because if you are somebody who's been saying the word perimenopause or thinking about it, I'm sure your social media has trapped you with estrogen dominance. It is not a medical diagnosis. It is all over social media, and if you are really in perimenopause, estrogen dominance doesn't really mean much. What is happening is that your progesterone levels are falling before your estrogen levels fall. So there is a ratio shift, and that imbalance is part of why you're feeling the way you feel. But it is not a lab-diagnosable condition because, like we talked about, one day it's high, one day it's low. And so you do not need to be sold a protocol like you probably are being sold. You don't have to do an estrogen detox, and you definitely do not need to take a supplement to help yourself If you are quote unquote in estrogen dominance. So what symptoms actually count? And this is the part that nobody warned us about. The early ones do not look like what you are expecting. Number 1, anxiety that shows up out of nowhere. Number 2, sleep that is all of a sudden broken up. Number 3, closer together periods. Number 4, and this is a big one that you guys all told me about in this questionnaire that I asked you guys, rage. Rage is a big one and it's huge. There's also brain fog. And if you have those and you're in your 40s, you do not need a lab test to take yourself seriously. So do I think I am entering my perimenopause years? Abso-effing-lutely. And my hair got curly too. Now back to the appointment that made me super frustrated. So I told my OB that my endometriosis had been flaring again to the point where I had to literally take the needle out of the patient's face and I fell to the ground while treating a patient. And his answer was, let's get surgery. I've already done surgery. I don't want more scar tissue in my uterus. So I said, no, I'm not into that right now. His second answer was, go on birth control pills. That was the whole conversation. That was it. And I kind of felt annoyed because I'm like, isn't my endometriosis flaring because of perimenopause, plus the other symptoms and the anxiety and all of this? And I don't care if this sounds ignorant, but birth control, HRT, are they the same thing? Are they different? What the hell are we talking about here? Plus, I have melasma and I don't really want to go on birth control. So the answer to the second question is they are not HRT and birth control pills are very different. So the pill uses a synthetic estrogen known as ethinylestradiol, and at doses strong enough to basically shut down your ovulation and take over your cycle. Whereas HRT is the opposite philosophy. It's using a much lower dose, usually just of estradiol, the same molecule that your ovaries will make, and it is topping up what is declining. So birth controls are suppressing and HRT is replacing. So they're different molecules doing different profiles and different jobs. Here's the part that kind of got angrier and made me a little bit angrier when I actually sat with it, right? The pill may have been the right call, especially for me, and especially if you have endometriosis, which is an estrogen-sensitive disease. Perimenopause hormone swings can absolutely wake up your endometriosis, and suppressing your cycle with a birth control pill is textbook first-line management. So the medicine is right. But what is wrong was the lack of the explanation from birth control pill to HRT, because your endometriosis flaring at 42 might be a sign that your hormones are shifting. And that is perimenopause conversation that we should be starting. But nobody explained that you take a birth control pill in the beginning to bridge the gap, especially for women, and to help them manage their endometriosis from flaring and the chaos that's happening so that they can transition properly to HRT. And I had to go read all about that myself, and I didn't get those answers during my visit. So if you ever left an appointment with a prescription or a surgical date, but zero explanation, you are still owed an explanation. And I think you have to start asking those questions because people oftentimes just are working on a 1, 2, 3. And it's so important that you understand what are your options, especially as each person is different. I don't know if you have endometriosis or not, but what are you supposed to be doing to bridge the gap? And these are all missing conversations in our healthcare system, especially as women, especially if you're in your 40s. So before we get into exactly what is HRT, I just want to touch on why is it that our mothers were sold this notion that hormones were going to kill them, but we are being sold hormones like water. So in 2002, there was this study by the Women's Health Initiative which studied one hormone regimen in women whose average age was 63, so more than a decade than the average age of menopause, using a formulation that's barely used anymore. And they did find real risks in that population. But the message, unfortunately, because people love sensationalizing things, got collapsed into 3 words: hormones cause cancer. And boom, overnight prescriptions stopped and women started white-knuckling their ways through menopause. And if you are somebody my age, you probably dealt with your mother who was raging. Fast forward to 2026. This past February, the FDA approved label changes on 6 hormone products, removing the cardiovascular risk disease, the cardiovascular risk, the breast cancer risk, and the dementia statements from the boxed warnings. But this is where I want to be very, very precise, because not being precise got us here in the first place over the past 25 years. This does not mean that HRT is safe for everyone. Okay? That is not what it means. It is not the same blanket scare label that we had 25 years ago that didn't match the evidence. This means that the risks have not vanished. Age still matters, the timing still matters, your history still matters, and the route in which you take the hormones still matters. And this is my worry because I'm watching my own social media feed and reading the news, and we have spent now 2 decades in irrational fear, and now we are sprinting towards irrational enthusiasm. And these 2 things are the same thing because professional societies do not recommend HRT for longevity, for preventing chronic diseases, for staying young, for the fountain of youth. It is a treatment for a symptom and has very specific indications, person by person. So fear and hype are the exact same mistake, just in opposite directions. And this is where this stops becoming a policy story by the government or by these societies and becoming a reality when it comes to your prescription. Because right now in the US, there is an estrogen patch shortage. It's not a recall. It's because of demand. Because so many women are asking to go on HRT and on an estrogen patch, the supply this year ran out. So what happens when it runs out? Ran out, all these women were then told to switch to the oral pill. But that is not a lateral move because oral estrogen, the first pass it goes through in your body is your liver. The patch does not. And that first pass is exactly why oral estrogen carries a higher risk for clotting and transdermal does not. So if your pharmacy just switched you from the patch to the oral form without giving you an explanation or understanding your medical history, or if you have any risk factors for clotting, You are owed an explanation because they are not the same thing. So what the F is HRT? Number one, the easiest way to understand it is through these 3 decisions. What hormones do you really need? Because the backbone of HRT is estrogen, estradiol to be more specific. And this is what does the very heavy lifting. This is the one that helps with your hot flashes, that helps with your night sweats, that helps with vaginal dryness, that can help with your bones as well. But if you have a uterus, you cannot just be on estrogen alone because estrogen stimulates It stimulates the lining of your uterus. So you're also going to need to be on progesterone, which helps to calm things down and that has more of a protective role. If, however, you had a hysterectomy, meaning your uterus has been taken out, you do not have to worry about progesterone. Estrogen alone is totally fine. Now, there are 2 versions of these hormones. Before I get to question number 2, there's bioidentical, meaning that they have the same molecule that your body makes. Estradiol and micronized progesterone. And then you have non-bioidentical, which is a different molecule that acts similarly. Another side note that I just want to bust once and for all is bioidentical does not mean compounded, and there is no evidence that getting compounded bioidentical hormones is better than the approved stuff on the market. That is all bullshit. Now, decision number 2: how are you getting these hormones into your body? Are you getting it orally? Are you getting it through a patch? Are you using a gel? Are you using a spray? Like we just talked about, transdermal is increasingly more attractive because it bypasses that first pass through your metabolism, which can increase your clotting risk, like with oral estrogen. So topical doesn't really have that increased risk. Decision number 3, if you need progesterone, how and when do you take it? So there are 2 basic sequences. Number one is sequential and cyclical, meaning you're taking estrogen daily and you're saving progesterone for that second half of the month. And this is usually what's used in perimenopause when people still get their periods and you're still cycling. Then you have continuous HRT where you're basically taking estrogen and progesterone every single day. And this usually happens after menopause when the goal is no bleeding at all. Now, people always ask me what I would do, but given that I have endometriosis in the picture, estrogen alone is not an option for me. It's not part of the guidelines. And so I have to be on an estrogen-progesterone regimen when and if and how and whenever I decide to go on this journey, which I haven't yet made up my mind. But that is what it means to really personalize your care. Now, 2 other questions that I often get that are really unrelated to me, but kind of, is number one, will HRT make me lose weight? And the answer is a big no. No, you will not lose weight if you go on HRT. I'm sorry to break it to you. When you're going through this phase, you become a little bit chubbier in your midline. You hold on to more fat, you lose muscle. But anybody selling you HRT as a weight loss drug is selling you a lie. What HRT can do is make it easier for you to manage your weight. But it's not going to replace the fact that you have to go to the gym and you have to lift weights and you have to build muscle strength and bone density. It will not replace that. So unfortunately, the hard stuff still exists. And my favorite is, is it going to fix your skin? Am I going to look like a fetus? And no. So estrogen, it does do real things, right? So it's going to help with the look of hydration and crepiness, especially if you apply it topically. But the trials that look specifically at wrinkles did not find any meaningful difference. Because sun damage has nothing to do with your hormones. And unfortunately, your hormones cannot undo that damage. So it will not be a facelift in the bottle. And the other thing that it will not do is it will not help with your melasma. It might actually make it worse. So this is why if you have predispositions to pigmentation that are hormonally linked, like melasma, being on a solid over-the-counter skincare routine from now is essential. Knowing how to manage it is key. If you are somebody who is a candidate for oral tranexamic acid, Potentially trying it out before you go on HRT to see how you respond to it. I have not done that yet because I've always been testing out my products. But the day that I decide to start HRT, I will pause and first start tranexamic acid so that I can have an eraser in my back pocket because the melasma can flare dramatically. Which leads me to, what if I can't take HRT? And I'm not talking to you if you have melasma. You hopefully will help your quality of life over your melasma. We can be vain, but we have to help ourselves first. Let's answer, what if you can't take HRT? What if you are one of those people where HRT is truly off the table for you? And I know how frustrating that can feel for you. I'm going to start off by saying the bad news, which is the off-the-table list is real. So if you have had a history of breast cancer, uterine cancer, unexplained bleeding, blood clots, cardiovascular disease, hormone replacement is generally a no. And this needs to be a discussion that you have with your specialist because they need to understand your full medical history. And I'm not going to pretend other Otherwise, as I've always been somebody who pushes that you get an answer, I think no is usually the answer, but I still think you are owed and you deserve an explanation and you deserve a reason as to why you can't be on it. But there are 2 things that almost nobody tells you. Okay. One, even inside those categories, there are still exceptions to the rule and never is not exactly never. So let's take BRCA, right? So people have BRCA genes who are more likely to develop breast cancer. And let's say they had their ovaries removed preventatively to get thrown into surgical menopause young. In the pooled research, right, hormone therapy after that surgery was not associated with higher breast cancer risks in carriers who had not had cancer. That doesn't make it simple. It becomes, though, a very complicated discussion that you need to have with your specialist and not just allow for the door to be slammed in your face. Number 2, hot flashes, night sweats, especially in people who have had breast cancer. Turns out now there are 2 new FDA-approved drugs with zero hormones in them, and I'm going to butcher how you say this: fisolinatant, approved in 2023, elinzanatant, approved last October. And the way these 2 medications work is that they basically work on your brain, on the switchboard that misfires when estrogen drops. And in trials, it cut hot flashes by more than half. And these 2 drugs, for example, are being prescribed for people who are breast cancer survivors and the exact same women who have been told for decades, sorry, there is nothing for you. So you need to keep asking questions as things are evolving. And one more, because this one does get wrongly lumped in, low-dose vaginal estrogen for dryness, painful sex, recurrent UTIs is a local treatment on the exterior of your privates. Very little will reach your bloodstream, and it's not the same risk conversation as systemic HRT. And for a lot of women, it's on the table even when the pill or the patch is out. So this is something that I think you should be discussing with your provider and understanding in more depth and really kind of understanding the nuance that is associated with each. So where does that leave me as a 42-year-old who has PMS, who had an anxiety attack, and who now has really bad endometriosis? And my honest answer is I still don't know. I'm not decided yet. And I think the picture of endometriosis makes it a little bit more complicated for me. And I really do not want my melasma to flare up as somebody who does own a brand. And I really pride myself on using my products and not being on the prescriptions. So I'm going to continue to watch my cycles, continue to track my symptoms, and continue to have these conversations. And when I do decide to start HRT, I will bring you along with me. But for you, after watching this video, I want you guys to come out with this, with 4 questions for yourselves at your next appointment. And the first one is, do my symptoms and do my cycle changes sound like I'm in perimenopause? Why and why not? I think that's a big one that you guys should be discussing. Number 2, is it reasonable for me to consider starting HRT? Am I a reasonable candidate given my specific history? Number 3, if yes, what hormones and which route am I going to take and which one is the best for me? And number 4, if I am not a candidate, what other options do I have? And I think these are very important questions for you to have with your provider. And if you get real answers, you have an amazing doctor. And if you don't, then this is your basically allowance to go find another doctor because we do not need to be suffering in silence. If you guys like this video, subscribe to my channel. I'm thinking of doing more women's health initiative videos, especially as I navigate my journey in my 40s. And I'm so curious to hear your experience below. Let me know in the comment section what is the most useful— useless answer a doctor has given you? What are your feelings about perimenopause? Where are you in this journey? And I hope we can all come together to help each other out. But until then, I hope you have beautiful Saturday. And as promised, this is the view. Ignore my pajama shorts. It's absolutely stunning. And we are currently in the mountains in the south of France, somewhere alone and discreet. I hope you guys have a beautiful Saturday.