Should Women Start Menopause Hormone Therapy Before Menopause Begins?

For decades, women worried about taking menopause hormone therapy (MHT), formerly called hormone replacement therapy, or HRT. And they certainly wouldn’t consider taking “replacement hormones” before they reached natural menopause. But the latest research suggests that beginning MHT during perimenopause could offer meaningful long-term health benefits.

For many women, perimenopause can be an uncomfortable and distressing experience. Erratic periods. Mood swings. Sleepless nights. Uncomfortable sex. The symptoms are a lot to navigate, especially when you’re at the peak of your career, raising a family or taking care of aging parents.  

“Perimenopause symptoms can dramatically affect a woman’s quality of life, and she deserves support and treatment to help her navigate this transition,” said Alyssa Quimby, MD, an OB-GYN and a perimenopause and menopause specialist at Cedars-Sinai.  

What Happens in Perimenopause

Perimenopause is the transition leading up to menopause. During this time, ovarian hormone production becomes less predictable. Progesterone and estrogen can swing up and down from one cycle to the next. Periods may become shorter, longer, heavier, lighter or more widely spaced before they stop completely.  

“Menopause doesn’t begin until you’ve completed 12 consecutive months without a period,” said Sharon Winer, MD, a reproductive endocrinologist and menopause specialist at Cedars-Sinai. “But perimenopause symptoms can begin years, or even a full decade earlier, and sometimes while cycles are still fairly regular.”  

Symptoms of perimenopause often include:  

• Irregular menstrual cycles

• Mood swings

• Hot flashes

• Night sweats

• Sleep disturbances

• Vaginal dryness

You Don’t Have to Wait to Start Hormone Therapy

MHT is meant to supplement the hormones the body no longer produces in sufficient quantities to help alleviate symptoms. Those deficiencies begin during perimenopause, even if you’re having semi-regular periods.  

“The tricky part of treating women in perimenopause is how unpredictable this transitional period can be,” Winer said. “It’s not just that symptoms change from woman to woman, but also from cycle to cycle in the same woman.”

Unfortunately, there’s no test to detect whether a woman is in perimenopause. Estrogen levels fluctuate wildly during perimenopause, rather than following a straight decline, so clinicians can’t rely on blood tests to make an accurate diagnosis. Instead, they pay close attention to bleeding patterns, symptoms and health history—and they will also rule out other conditions that can cause similar symptoms, such as thyroid problems, fibroids and ovarian cysts.

“If perimenopausal symptoms are affecting your day-to-day life, it’s worth considering MHT,” said Quimby. “Studies suggest that starting MHT earlier not only helps relieve bothersome symptoms, it may also help protect against osteoporosis and support heart health.”  

Hormone Therapy for Perimenopause

MHT for a perimenopausal woman is not the same as treatment for a woman who has gone a full year without a period. A perimenopause regimen may need to change as symptoms and cycles evolve.

“During perimenopause, the ovaries are still producing hormones, just inconsistently,” said Winer. “Hormonal changes during this period are a moving target, and that makes it harder to treat.”  

For women in perimenopause, providers may prescribe:  

• Daily estrogen and progesterone for only part of the month (usually 12 to 14 days). This schedule makes menstrual cycles more consistent during perimenopause.  

• A standard menopause protocol, including combined daily regimens with both estrogen and progesterone.  

If you’re already using a hormonal birth control method, such as an oral contraceptive or hormonal intrauterine device, your provider may recommend continuing birth control instead of starting MHT. Hormonal birth control not only helps regulate your menstrual cycle and can alleviate symptoms, but it also prevents pregnancy, which can still happen during perimenopause.  

“Some women may choose to switch from birth control to MHT around age 50 when natural menopause is more likely to kick in, especially if they’re experiencing severe hot flashes and night sweats,” said Quimby.  

Types of Menopause Hormone Therapy

Whether you’re struggling with new onset symptoms during perimenopause, or you’ve been firmly planted in menopause for months, there is no one-size-fits-all method for menopause hormone therapy.  

“The type, dose and delivery method that’s best for you requires shared decision-making with a menopause-informed provider,” said Winer—and that’s because women have many options, including:  

• Estrogen-only formulations: This type of MHT is reserved for women who do not have a uterus, and it comes in pills, patches, gels, creams and a vaginal ring.  

• Combined menopause hormone therapy: Designed for women who still have their uterus, combined hormone therapy contains both estrogen and progesterone. In these women, combining estrogen with progesterone helps reduces the risk of endometrial cancer.  

• Local estrogen: The safest form of menopause hormone therapy by a wide margin, local estrogen formulations include creams, rings, tablets and an oral pill. These formulations are remarkably effective at treating genitourinary syndrome of menopause (vaginal dryness, urinary incontinence and sexual discomfort), with limited systemic effects.

The Benefits—and Limits—of Starting MHT Early

When to start MHT is a clinical decision based on symptoms, health history and your individual risk profile. Timing, age and the type of treatment all affect the balance between risks and benefits. Of course, the most obvious perk of MHT is symptom relief.  

“For many women, MHT eases hot flashes, night sweats, mood changes, sleep disturbances and some sexual symptoms,” said Quimby. “Women in perimenopause also have plenty of low-dose and transdermal options, which carry a lower risk profile.”

According to the National Menopause Society, the best time to start MHT is before age 60 or within 10 years of your final period. One important caveat: There’s not sufficient evidence—at least not yet—to support using MHT to prevent chronic disease, except for bone loss.  

“During early menopause, women experience rapid bone loss. Estrogen helps slow bone loss,” said Winer. “Starting MHT during perimenopause can help protect bones, especially for women who are at high risk of developing osteoporosis.”  

Deciding Whether Menopause Hormone Therapy is Right for You

MHT is not without risks. That’s why it’s important to work with a Menopause Society certified provider to determine whether MHT is right for you, and which type, dose, duration and timing of initiation make sense for your unique circumstances.  

Your provider will check whether you have any conditions that may increase risks associated with MHT, and are contraindicated, including:  

• A history of stroke, heart attack or hormone-sensitive cancer

• Active blood clots  

• Liver disease  

• Unexplained vaginal bleeding

If you have a uterus and use systemic estrogen, you typically will need a natural or synthetic progesterone to protect the uterine lining. Delivery method makes a difference, too. Depending on your risk factors and preferences, your provider may recommend an oral medication, patch, gel or vaginal ring.  

“Deciding whether to start MHT is a personal choice that should be discussed with a menopause informed provider,” said Winer. “Your treatment should be tailored to your needs, and include regular monitoring, to ensure the benefits continue to outweigh the risks.”

If you’re not a candidate for MHT, or at least not yet, work with your provider to explore nonhormonal treatment options, complementary therapies and lifestyle changes.  

“You don’t have to suffer through this transition,” said Quimby. “We have a lot of tools to help you weather the storm and start feeling like yourself again.”