Navigating Perimenopause: What you need to know about interventions such as HRT

If symptoms are starting to get in the way of life - your sleep, your mood, your energy, your relationships - you are not alone, and you do not have to push through.

What Is Perimenopause?

Perimenopause is the transitional phase leading up to menopause (the point at which a woman has gone 12 consecutive months without a period). This transition can begin anywhere from the mid-30s to the early 50s and typically lasts four to eight years, though this varies considerably between individuals.

During this phase, oestrogen and progesterone levels become increasingly erratic before eventually declining. It is this hormonal fluctuation (not simply low oestrogen) that drives many of the symptoms women experience. Common signs include irregular periods, sleep disruption, hot flushes, mood changes, brain fog, joint pain, and changes in libido or vaginal comfort.

For more information on how to identify whether or not you are in perimenopause, you can read this blog.

The Foundations: Why Lifestyle Still Matters

Before we get to specific interventions such as herbal medicine and HRT, it is worth emphasising something that the research is unambiguous about: how you live during this transition directly influences how you experience it and wider health outcomes.

The truth is - the basic pillars that apply to support health generally still apply in this season of life; they are evidence-based tools that can reduce symptom severity and more importantly, mitigate possible health concerns down the road. Importantly, we likely do not need to do some 'special perimenopause protocol' as often marketed online.

Sleep

Sleep is one of the first casualties of perimenopause. Falling and fluctuating oestrogen disrupts the architecture of sleep, reducing slow-wave (deep) sleep and increasing night-time waking. A 2021 systematic review found that sleep disturbance affects up to 60% of perimenopausal women, with hot flushes and mood changes frequently contributing to the picture.

Practical steps that are consistently supported in the literature:

• Keep a consistent sleep and wake time - even on weekends.

• Reduce alcohol, which fragments sleep architecture even in moderate amounts.

• Keep your bedroom cool (hot flushes are worsened in a warm environment).

• Limit screens and bright light in the hour before bed.

• If waking with anxiety or racing thoughts, consider whether stress management needs attention (see below).

Exercise

Exercise is arguably the single most evidence-supported lifestyle intervention in perimenopause. A 2023 Cochrane systematic review found that exercise (particularly aerobic and resistance training) significantly reduced the frequency and severity of vasomotor symptoms (hot flushes and night sweats) compared to no intervention.

Resistance training deserves special attention. From the mid-30s onward, women lose muscle mass at an accelerating rate: a process driven in part by declining oestrogen. This matters not just for strength and body composition, but for metabolic health, bone density, and long-term independence. Aim for at least two resistance training sessions per week in addition to regular cardiovascular movement.

Is there a special perimenopause workout I should do? Not really. Beyond doing resistance and cardiovascular training - there is no good evidence for this at this time for specific 'perimenopause' protocols. The truth is - How you decide to do some resistance cardiovascular training should be based on what is safe, what you prefer, what you will be consistent with, what works for you. Also - any exercise is better than no exercise.

Nutrition

There is no single “menopause diet”, but the fundamentals of good nutrition become especially important during this phase. Key evidence-backed principles:

• Adequate protein to support muscle retention and metabolic health.

• Fibre-rich foods to support gut health, oestrogen clearance, and blood glucose stability.

• A wide variety of vegetables and fruit for micronutrient density and anti-inflammatory benefit.

• Adequate micronutrients such as calcium and vitamin D to support bone health - particularly important as fracture risk rises post-menopause.

• Minimising ultra-processed foods, added sugars, and alcohol, which may worsen hot flushes, sleep, and mood.

Nutrition needs beyond the basics should be really looked at on a individualised bases - not just considering nutrient specific needs but also wider context factors such as preferences, home situation, time, resource/access, etc.

Stress Management

Chronic stress activates the HPA (hypothalamic-pituitary-adrenal) axis, which directly interacts with the HPG (hypothalamic-pituitary-gonadal) axis that governs reproductive hormones. Put simply: chronic, unmanaged stress compounds hormonal dysregulation and can exacerbate symptoms. Research has consistently found associations between high perceived stress and greater vasomotor symptom severity.

Mindfulness-based stress reduction (MBSR) has the strongest evidence base among mind-body interventions, with a 2019 meta-analysis demonstrating meaningful reductions in hot flush frequency and self-reported symptom burden. Yoga, breathwork, and regular time in nature are also well-supported for general stress physiology.

Social Connection and Community

This one is often overlooked but should not be underestimated. Social isolation is independently associated with worse mental health outcomes during perimenopause. Conversely, strong social support is protective against depression and anxiety, which are disproportionately common during this transition. Investing in meaningful relationships and community, whether that is friendships, a group class, or a support network , is genuinely therapeutic and associated with positive health outcomes.

Regular Health Checks

Due to the physiological change that is happening (physiological change = stress on the body), perimenopause can be a window of increased vulnerability for certain health concerns. Oestrogen has a protective effect on cardiovascular and metabolic health - as it declines, risk profiles shift. Research shows that women with pre-existing metabolic dysfunction (e.g. insulin resistance, elevated triglycerides) tend to experience more severe vasomotor symptoms, and vice versa.

During this phase, it is worth discussing the following with your GP:

• Cardiovascular health: blood pressure, cholesterol (including LDL, HDL, and triglycerides).

• Metabolic health: fasting glucose or HbA1c.

• Bone health: consider a DEXA scan if you have risk factors for osteoporosis.

• Thyroid function: thyroid disorders are common in perimenopausal women and can mimic or worsen symptoms.

• Stress/mood - depression/anxiety, other mental health concerns may need more targetted comprehensive treatment. Individuals who have had a history of mental health concerns may be more at risk in this season of life to developing a mental health episode that needs support. Remember also that there is a bidirectional relationship between mental health and hormone health - in other words, mental health can impact how we go through perimenopause.

What About HRT?

“I’m doing all of the above and still struggling.” I hear you - this was me too. These foundations are not optional, but for many women they are not enough on their own. You do not have to just cope.

Hormone replacement therapy (HRT), now more commonly called menopausal hormone therapy (MHT), has had a complicated history. A large study published in 2002 (the Women’s Health Initiative) generated widespread fear about the risks of HRT, leading to a dramatic decline in prescribing that lasted nearly two decades. However, this study has since been extensively critiqued. Its findings were misrepresented in media reporting, the formulations studied are now considered outdated, and the risk data was largely driven by a specific subgroup (older women who started HRT more than 10 years after menopause).

The evidence we have today is far more reassuring. For example, the 2022 NICE (National Institute for Health and Care Excellence) guidelines on menopause concluded that for the majority of women under 60, or within 10 years of menopause, the benefits of HRT outweigh the risks. Similarly, the Australasian Menopause Society and the International Menopause Society have issued updated guidance aligning with this position. 

A few important points to understand about HRT:

• HRT does not restore hormone levels to what they were at 25. It supplements them sufficiently to buffer symptoms during the transition - think of it as taking the edge off a volatile process.

• HRT can be provided in different dosages, forms and combinations - depending on individual needs. HRT is often offered in a form that is bio-identical to our hormones such as estradiol and utrogestin.

• Combined oral contraceptives actually contain significantly higher doses of oestrogen than standard HRT. If you are still on the pill in your 40s, the idea of HRT being “high dose” is a misconception.

• Transdermal (skin patch or gel) forms of oestrogen carry a lower risk of blood clots than oral forms, and are generally preferred in modern prescribing.

• There are contraindications for a small proportion of women but even in some of these cases, options exist and research is continuing to be developed. For example, localised vaginal oestrogen (applied directly to the vaginal tissue) is not meaningfully absorbed systemically and may still be appropriate for women with a history of hormone-sensitive cancers who are experiencing genitourinary symptoms such as vaginal dryness, recurrent UTIs, or urinary incontinence.

Some of the systemic benefits of HRT include:

• relief from hot flashes and night sweats

• relief from vaginal dryness (vaginal estrogen)

• improved sexual health

• better bone health

• improved sleep

• lower risk of depression/anxiety

• improved joint pain, skin, hair

In Australia and New Zealand, these are the guidelines that GPs should be following:

AMS_Guide_to_MHT-HRT_Doses.pdf

Download PDF • 167KB

Potential side effects and risks of systemic therapy:

Possible side effects include:

• vaginal spotting or bleeding, which usually stops within 6 months

• temporary breast soreness

• bloating (fluid retention)

• headaches

Talk with your GP or ob-gyn if these side effects trouble you or last longer than expected. In some cases, dosages can be lowered alleviated these side effects. Furthermore, the form you use may be relevant to types of symptoms - the body processes different forms in different ways

Whilst the risks have been found to be far less than previous thought, HRT, like most medications still may pose some risks in some individuals. You should always ask your GP or OB-GYN what these small risks are and if they are relevant to you.

How long should I be on HRT

When to stop HRT is an individual decision that should be discussed with your GP or ob-gyn. Some women stop within five years or when their symptoms stop being bothersome. Most women will no longer have hot flashes by 7-10 years after their final menstrual period. But others continue to use HRT after their 50s to relieve sypmtoms. Use of HRT should always be based on their risks, benefits, and symptoms of each individual.

Coming off HRT can cause sypmtoms to come back. These sypmtoms can be temporary, however, for some they can be as severe as when they first started. Symptoms such as vaginal dryness should be expected to get worse when HRT stops, which underscores the importance of local (vaginal) hormone therapy.

As a naturopath and nutritionist, it is not within my scope of practice to prescribe medications including HRT. What is within my scope is to help you understand all the tools available, stay up to date with evidence, work collaboratively with your GP or specialist, and advocate for you within that relationship. If you feel your symptoms are not being taken seriously, I strongly encourage you to ask for a referral to a GP that has up-to-date menopause training or gynaecologist.

What About Natural Alternatives?

Herbal Medicines

Several herbal medicines have some reasonable evidence for symptom support in the later stages of reproductive phase and earlier stages of perimenopause, or for women where HRT is not appropriate or not desired. However, they must be individually considered - what works well for one hormonal pattern may be counterproductive for another. Furthermore, we can also use herbal medicine and nutrients to support HRT in some contexts based on presentation and needs.

A couple herbs that come up frequently in media deserve some honest context:

• Black cohosh (Cimicifuga racemosa): Has some evidence for vasomotor symptoms in the early phases. A 2010 Cochrane review and several subsequent meta-analyses support a modest but meaningful reduction in hot flush frequency. It does not appear to have oestrogenic activity, however, which is why it has less efficacy in the later phases of perimenopause and will not support wider systemic symptoms associated with estrogen decline.

  
  

• Chaste tree / Vitex agnus-castus: Primarily useful in the earlier perimenopausal period, where progesterone deficiency relative to oestrogen is more relevant. Evidence supports its use for luteal phase symptoms (e.g. PMS-type changes, breast tenderness, irregular cycles), and primary ovarian insufficiency, especially when trying to support fertility. It is Less useful once ovulation has largely ceased and is appropriate in some presentations such as a higher LH:FSH ratio often seen in PCOS phenotypes. 

  
  

• Soy Isoflavones: The Nuanced Case

Of all the non-pharmaceutical options, soy isoflavones have the strongest and most clinically relevant evidence base for support perimenopause and menopause. They are also relatively safe and can be used across a range of contexts.

Soy isoflavones act as phytoestrogens, plant compounds with a weak oestrogen-like structure that can bind to oestrogen beta receptors and modulate their activity. Crucially, they appear to behave differently depending on the hormonal context: they have a mild oestrogenic effect when oestrogen is low (as in menopause), and may have a mild anti-oestrogenic effect when oestrogen is relatively high.

For more information on soy isoflavones - I wrote another blog on soy isoflavones here. 

An important reality check: once oestrogen is genuinely declining and ovulation is no longer occurring (meaning progesterone is not being produced), herbal medicines cannot replicate the physiological role of these hormones. No herb equates to HRT when true hormonal depletion is the issue.

HRT can be extremely helpful - but it may not be the magic bullet social media is telling us it is

I want to be transparent: I am a strong advocate for HRT and have personally benefitted enormously from it. But it would be doing you a disservice to present it as a complete solution in isolation, which is what is happening online in some cases. 

Here is what HRT does and does not do:

• HRT can significantly improve sleep, hot flushes, mood stability, and brain fog. Better sleep and mood have downstream benefits for energy, motivation, food choices, and the capacity to exercise.

• HRT does not build muscle on its own - resistance training does that. (This claim circulates on social media and is not supported by evidence.)

• HRT does not correct metabolic dysfunction. If insulin resistance or elevated HbA1c is part of your picture, targeted nutrition and lifestyle intervention is still essential.

• Alcohol will still disrupt your sleep on HRT. Sleep hygiene still matters.

• HRT does not replace the protective value of exercise for cardiovascular health, bone density, and muscle mass.

• HRT can improve mood, however, if depression/anxiety is still getting in the way of day to day life, it is important that this is followed up with appropriate support. 

The truth is the most effective approach to perimenopause is not any single intervention - it is a genuinely a comprehensive and holistic one. Furthermore, the basics outlined above still crucially matter. HRT (where appropriate and desired) works best as part of a broader strategy that includes the foundations covered above.

Where to From Here?

If you are in the perimenopause transition and want personalised support - whether that is navigating your options, working on the foundations, or preparing for a conversation with your GP, I offer a complimentary Vitality Strategy Call to help identify where to start. You can book directly at wellkind.co.nz.

We also have a monthly fireside chat, a free online group call to address topics covered over the month in newsletters and blogs. 

Key References

American College of Obstetricians & Gynecologists. (2026). Menopause: What your ob-Gyn wants you to know.

Vis N.E. et al. (2015). Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Internal Medicine, 175(4), 531–539.

Baber R.J., et al. (2016). IMS Recommendations on women’s midlife health and menopause hormone therapy. Climacteric, 19(2), 109–150.

Daley A. et al. (2015). Exercise for vasomotor menopausal symptoms. Cochrane Database of Systematic Reviews, (9).

Franco O.H. et al. (2016). Use of plant-based therapies and menopausal symptoms: a systematic review and meta-analysis. JAMA, 315(23), 2554–2563.

Peng W. et al. (2019). Mind-body therapies for menopausal symptoms: A meta-analysis. Climacteric, 22(4), 359–369.

Rietjens I.M.C.M. et al. (2017). The potential health effects of dietary phytoestrogens. British Journal of Pharmacology, 174(11), 1263–1280.

This blog is for educational purposes only and does not constitute medical advice. Please consult a qualified health professional before making changes to your health management.