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by Sara Hover, RPh, FAARM, PCCA Director of Clinical Services
Perimenopause is a unique phase in a woman’s life, marked by fluctuating hormones and a wide range of symptoms. Hormone replacement therapy (HRT) can offer relief, but a one-size-fits-all approach may not yield the best results. A personalized approach, tailored to each woman’s unique hormonal profile, lifestyle and symptoms, can make all the difference in managing this transition effectively. Let’s explore the factors that contribute to low estrogen, the role of cortisol and progesterone, and why a customized approach to HRT is essential for perimenopausal women.1
Estrogen is a key hormone for various bodily functions, from reproductive health to mood regulation. During perimenopause, estrogen levels fluctuate and eventually decline when menopause is reached. Several factors can contribute to low estrogen levels during perimenopause.
First, the natural abatement of ovarian function plays a major role; as women approach menopause, ovarian follicles reduce in number and function, resulting in decreased estrogen production. Genetic predisposition can also influence estrogen levels, as some women have genetic factors that may lead to an earlier or more abrupt drop. Additionally, lifestyle factors, including diet, stress and physical activity levels, significantly impact estrogen. For instance, poor nutrition or extreme physical training can suppress estrogen production.2 Another crucial factor is high cortisol levels. Chronic stress increases cortisol, which may inhibit the body’s ability to produce adequate estrogen.3
By identifying these factors, healthcare providers can develop a more precise treatment plan, addressing not only hormonal imbalances but also lifestyle factors that might be exacerbating symptoms. During perimenopause, women are still making estrogen — maybe in an erratic fashion — but identifying the cause of low estrogen is most important. We should not give estrogen until there is certainty that the patient has entered menopause. Keep in mind that the testing results are a one-time snapshot of that moment and results may vary over time.1
Cortisol, often referred to as the “stress hormone,” is produced by the adrenal glands and plays a significant role in managing stress and regulating metabolism. For perimenopausal women, high cortisol levels can have several consequences. Elevated cortisol can lead to increased fatigue and mood swings, as it causes feelings of exhaustion, irritability and mood fluctuations. It also disrupts other hormones; high cortisol can hinder estrogen production, exacerbating symptoms like hot flashes, insomnia and night sweats.
Furthermore, cortisol impacts progesterone levels due to a phenomenon known as “pregnenolone steal.” Since cortisol production draws on the same hormonal precursor (pregnenolone) that produces progesterone, the body under stress prioritizes cortisol production over progesterone, potentially leading to imbalances.4 By managing cortisol levels through stress reduction techniques, exercise and lifestyle modifications, women can help balance their hormones and reduce the intensity of perimenopausal symptoms.
Progesterone plays a vital role in regulating estrogen, stabilizing mood, promoting restful sleep and reducing anxiety. During perimenopause, progesterone levels begin to decline as ovulation becomes irregular, leading to several potential challenges.
One significant issue is estrogen dominance; when progesterone is low, estrogen may dominate, resulting in symptoms such as weight gain, bloating, breast tenderness and mood swings. Progesterone also affects sleep and anxiety levels, as it has a calming effect on the brain. Low levels of progesterone may lead to sleep disturbances and heightened anxiety, making this transitional phase more challenging.5 In addition, progesterone supports bone health, so declining levels can impact bone density over time.6 Replenishing progesterone through bioidentical hormones or other supplements, as determined by a healthcare provider, can help mitigate these symptoms and maintain hormonal balance.
A personalized HRT approach considers each woman’s unique hormonal profile, lifestyle factors and symptom severity. This approach offers several distinct advantages. First, targeted hormone support is possible by measuring hormone levels and monitoring symptoms, allowing health care providers to recommend specific combinations and dosages of estrogen, progesterone and other hormones based on individual needs.
Personalized HRT plans address underlying causes; beyond hormone therapy, they may include lifestyle and nutritional adjustments to address root causes such as high cortisol or low progesterone. Ultimately, a personalized approach enhances a woman’s quality of life by addressing a broad range of factors — from hormonal imbalances to lifestyle changes — so she can experience a smoother perimenopausal transition with improved energy, mood and sleep quality.
Perimenopause doesn’t have to be a time of discomfort and uncertainty. A personalized approach to HRT empowers women to navigate this transition with a clear, effective and safe plan. With proper guidance, perimenopausal women can regain control over their bodies, ensuring that their unique needs are met. Whether through bioidentical hormone therapy, lifestyle changes or stress management, each woman deserves an individualized strategy that supports her well-being through this important life stage.
PCCA members with clinical services access may contact our Clinical Services team to answer any questions about HRT and other compounding concerns.
These statements are provided for educational purposes only. They have not been evaluated by the Food and Drug Administration, and are not to be interpreted as a promise, guarantee or claim of therapeutic efficacy or safety. The information contained herein is not intended to replace or substitute for conventional medical care or encourage its abandonment.