Women's Hormone Health: HRT, Perimenopause, Menopause, and Treatment Options

The Short Version

Women's hormone care is not one prescription. A good clinic should be able to connect symptoms, age, menstrual pattern, medical history, risk profile, treatment options, follow-up, and the practical details of using medication safely.

The current evidence is more nuanced than the old "HRT is dangerous" story. Major menopause societies now frame menopausal hormone therapy (MHT, also called HRT) as an effective option for vasomotor symptoms and genitourinary symptoms when it is prescribed to the right patient, at the right time, with the right route, dose, and monitoring.

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Perimenopause, Menopause, and Why Symptoms Vary

Perimenopause can start years before the final menstrual period. Cycles may become shorter, longer, heavier, lighter, or unpredictable as ovarian hormone patterns become less stable. Menopause itself is diagnosed retrospectively after 12 months without a period, when no other cause explains the bleeding change.

Common issues clinics should be able to assess include:

• Hot flushes and night sweats
• Sleep disruption
• Mood changes, anxiety, irritability, or depressive symptoms
• Brain fog and concentration changes
• Vaginal dryness, discomfort with sex, urinary urgency, and recurrent urinary symptoms
• Libido changes
• Irregular or heavy bleeding
• Bone density risk
• Weight, insulin resistance, cholesterol, and cardiometabolic risk
• Thyroid, iron, B12, medication, sleep, stress, and alcohol contributors

The important point for BiohackMaps users: symptoms matter, but so does differential diagnosis. Not every midlife symptom is solved by HRT, and a strong provider should know when to investigate other causes.

What Current Guidelines Say

The Menopause Society's 2022 position statement says the benefit-risk profile of hormone therapy depends on age, time since menopause, symptoms, formulation, route, dose, duration, and individual health risks. It is generally most favourable for healthy symptomatic women younger than 60 or within 10 years of menopause onset, when there are no contraindications.

NICE updated its menopause guideline in November 2024, with further amendments in April 2026. The guidance supports informed discussion of HRT benefits and risks, recognises perimenopause and menopause clinically, and includes non-hormonal and behavioural options where appropriate.

The Australasian Menopause Society similarly frames treatment as individualised. Some women are good candidates for systemic hormone therapy, some need local therapy only, some need non-hormonal treatment, and some need specialist review because of personal risk factors.

Treatment Options Clinics May Discuss

Systemic MHT/HRT - oestrogen delivered by patch, gel, spray, or tablet. If a woman has a uterus, a progestogen is usually needed to protect the endometrium from unopposed oestrogen.

Local vaginal oestrogen - used for genitourinary syndrome of menopause, including vaginal dryness, irritation, discomfort with sex, urinary urgency, and recurrent urinary symptoms. Local therapy can be appropriate even when systemic treatment is not needed, but the individual risk context still matters.

Non-hormonal options - may include evidence-based medicines for vasomotor symptoms, vaginal moisturisers and lubricants, pelvic health support, CBT for symptom coping or sleep, and lifestyle changes around alcohol, temperature triggers, sleep, resistance training, protein intake, and cardiometabolic health.

Testosterone for women - current global consensus supports testosterone therapy for postmenopausal women with hypoactive sexual desire disorder after biopsychosocial assessment. Evidence does not support testosterone as a general treatment for fatigue, mood, cognition, or "optimisation" in women without that indication.

Thyroid, iron, libido, and metabolic care - good women's hormone clinics should not force every symptom into a menopause bucket. Thyroid dysfunction, iron deficiency, B12 deficiency, medications, sleep apnoea, depression, stress load, under-fuelling, alcohol, and insulin resistance can overlap heavily with perimenopause symptoms.

Bioidentical vs Compounded Hormones

"Bioidentical" means the molecule is structurally identical to a hormone produced by the human body, such as 17 beta-oestradiol or micronised progesterone. Some regulated products are bioidentical and have quality controls, dosing consistency, and safety information.

Custom compounded hormone products are different. They may be useful in limited situations where a regulated product is unsuitable, but major menopause organisations warn against assuming compounded hormones are safer, more natural, or more effective. A clinic should be able to explain why a compounded preparation is needed instead of a regulated option.

What a Good Women's Hormone Clinic Should Do

Before treatment, a clinic should take a real history: symptoms, menstrual pattern, bleeding, contraception, pregnancy possibility, migraine, clot risk, breast cancer history, cardiovascular risk, liver disease, medications, family history, mental health, sexual health, and goals.

Strong care usually includes:

• A licensed clinician responsible for diagnosis and prescribing
• Clear explanation of whether symptoms fit perimenopause, menopause, GSM, thyroid disease, iron deficiency, or another cause
• Shared decision-making on systemic HRT/MHT, local oestrogen, non-hormonal options, or referral
• Discussion of route, dose, progesterone need, bleeding expectations, side effects, and contraindications
• Follow-up to check symptom response, bleeding changes, blood pressure, side effects, screening context, and whether the treatment still makes sense
• Transparent pricing for consults, labs, scripts, medication, and follow-up

Red Flags

Be cautious if a clinic promises "balanced hormones" without a diagnosis, pushes pellets or compounded products as the default, sells testosterone for broad anti-ageing claims, ignores abnormal bleeding, minimises breast or clot risk, refuses to discuss non-hormonal options, or has no clear follow-up plan.

Questions To Ask Before Booking

1. Who is the prescribing clinician, and what menopause or women's health training do they have?
2. Do you manage perimenopause, menopause, GSM, thyroid overlap, libido, and bleeding concerns?
3. What treatment options do you offer beyond one default prescription?
4. If I have a uterus, how do you protect the endometrium when using oestrogen?
5. When would you use local vaginal oestrogen rather than systemic therapy?
6. Do you prescribe testosterone for women, and only for which indications?
7. How do you handle abnormal bleeding, breast cancer risk, clot risk, migraine, liver disease, and cardiovascular risk?
8. What follow-up is included, and what costs extra?

Sources and Further Reading

• The Menopause Society, 2022 Hormone Therapy Position Statement: Menopause journal
• NICE, Menopause: identification and management: NICE NG23
• Australasian Menopause Society treatment options: AMS treatment options
• Global Consensus Position Statement on Testosterone Therapy for Women: Endocrine Society summary