HRT for Perimenopause: A Real Patient Case Study
51 year old female in the late stages of perimenopause (maybe having 2 cycles a year at this point) with main concerns of vaginal dryness, pain with sex, low libido, fatigue + brain fog.
I know what you’re thinking: lots of shit can cause those issues. You’re damn straight. It’s why I leave no stone left unturned.
I double dog dare you to check out the intake form I use. I promise its THE MOST comprehensive thing you’ve ever filled out about your house.
I digress. I want to talk about the top 5 non-HRT recommendations I made for her that will move the needle for her and the HRT recommendations I made for her and WHY! Lets fucking go.
Sleep Study. If you open my intake form you can see I specifically screen for airway issues. This patient will NOT feel better unless she gets her untreated sleep apnea under control. PERIOD.
Remove Gluten. I am NOT a elimination practitioner but this patient has a known history of significant negative reactions to gluten (swelling, migraines, constipation) and family history of celiac. She “kind of” avoids gluten. But if you have an issue with gluten being “kind of” gluten free” is like being “kind of” pregnant.
Meal Breaks. This patient has difficulty saying no to work and so we discussed putting time blocks for breakfast + lunch in her calendar so she can sit and eat. No food = no energy.
Vitamin D. Her vitamin D level was 22. Optimally I like to see this closer to 60. Vitamin D plays a role in the functioning of our testosterone receptors, mood, energy and so much more.
Magnesium Glycinate. Her RBC Mag was pretty low and magnesium is involved in 600+ enzymatic reactions in the body.
Here is the thing: hormones do NOT operate in a silo/vacuum. We need to address the whole person and their whole body. This is such a big part of what makes me different from your cookie cutter med spas busy over dosing women on pellets cause they make a fuck ton of money from it.
Now, what you’re all here for. What did I recommend HRT wise and WHY?
I personally never initiate more than one hormone at a time. We need to know the impact it is having, if there are side effects etc. But here is word for word what I sent her in her follow up document!
VAGINAL HORMONES: This being one of the top ones. One thing about vaginal hormones is that they are lower dosed and DO NOT have systemic impact, so you can be on both vaginal estradiol and systemic estradiol and they do different things. I would suggest for sure vaginal estrogen for you because of the bladder issues and also dryness. This will change your world (and probably your sex life). I would start this first and then also consider low dose vaginal testosterone or DHEA (both of these are androgens) DHEA is especially helpful for blood flow to the area, but both will help with pelvic floor and pain with sex!
SYSTEMIC TESTOSTERONE: Honestly the goat for sex drive, energy, body composition, mood, etc. I know you have acne prone skin so this is something I would proceed with caution, but honestly when done appropriately-- should NOT cause issues. I personally prefer injections and think of all the methods they give the best results but there are some gel products that can also help (need to consider lifestyle and transferring to others for you cause you are always touching people with your job with this)
SYSTEMIC ESTRADIOL: The benefits here are honestly endless-- mood, joint pain, energy, libido, energy. I know its "old school" but I do prefer patches or injections for estradiol as well.
SYSTEMIC PROGESTERONE: I am curious if you had conventional prometrium (nothing wrong with it) but it is made with peanut oil and my more "sensitive girlies" tend to do better with a compounded product that is NOT made with peanut oil. Biggest benefits here are improved sleep and mood!
She is SO FAR along in perimenopause that cycling her HRT really isn’t “worth it” to try and preserve maybe one more ovulation— my biggest goal (and hers) is her quality of life and feeling better. Now, she has a lot of lifestyle levers to pull (which we talked about).
We decided to start with vaginal estrogen, utilize that for a few weeks and then decide where to go from there if she wants to add more. Of course, there is always a conversation about risks, benefits and shared decision making! Excited to see where this patient goes and how she feels in a few months!!
If your brain is like FUCK YES I’ve been looking for you. Sign up for a Hormone Strategy Session Here.
If you want to know more you can always book a consultation call so you have the clarity + understanding you need (and yes again, with me— not a sales person or a bot :)
Disclaimer: The information on this blog is for educational purposes only and is not intended to diagnose, treat, cure, or prevent any disease. It should not replace personalized medical advice. Always consult your healthcare provider before making changes to your medications, supplements, diet, or treatment plan.
