Perimenopause and HRT: Empowering Women with Knowledge

Perimenopause, the transition to menopause, often catches women off guard, especially when symptoms are subtle or absent. Many women are unaware of the “invisible” effects of fluctuating hormones on heart, bone, and brain health, leading to confusion about whether Hormone Replacement Therapy (HRT) is necessary if they feel fine. At FROM WITHIN, we aim to clarify the benefits of HRT, particularly bioidentical forms, to empower women to make informed choices. Alongside HRT, targeted nutrition and supplementation strategies can further support health during this life stage, addressing both silent risks and any emerging symptoms.

Understanding the Invisible Effects of Perimenopause

Perimenopause, typically starting in the 40s, involves fluctuating oestrogen and progesterone levels, which can silently impact vital systems, even in women without hot flushes or mood swings. These “invisible” effects on heart, bone, and brain health are critical, as they influence long-term wellbeing, especially where women live well into their 80s (Australian Institute of Health and Welfare [AIHW], 2020).

Heart Health

Oestrogen supports heart health by regulating cholesterol, promoting blood vessel flexibility, and reducing inflammation. Its decline increases cardiovascular disease (CVD) risk, which affects 1 in 4 Australian women (AIHW, 2020). A 2019 meta-analysis showed that HRT, started within 10 years of menopause, reduced coronary heart disease risk by up to 50% compared to later initiation (Boardman et al., 2015). Transdermal oestrogen, widely used in Australia, further lowers clotting risks, making it a safer option for cardiovascular protection (Canonico et al., 2016).

Bone Health

Oestrogen maintains bone density by balancing bone formation and resorption. During perimenopause, its decline accelerates bone loss, raising osteoporosis risk, a condition affecting 1.2 million Australian women (Osteoporosis Australia, 2021). A 2017 study found HRT reduced hip fracture risk by 40% in women under 60, with greater benefits for those with early menopause (Lobo et al., 2017). For women without symptoms, this protective effect is a key reason to consider HRT, especially if at risk for low bone density.

Brain Health

Oestrogen supports cognitive function, mood stability, and is neuroprotection. Its fluctuations can increase risks of brain fog, depression, or dementia, even in asymptomatic women. A 2020 Australian study reported cognitive complaints in 60% of perimenopausal women, regardless of other symptoms (Gurvich et al., 2020). Early HRT may preserve cognitive health, with a 2018 trial showing improved memory in women starting HRT before 60 (Maki et al., 2018). While long-term dementia prevention data is mixed (Shumaker et al., 2015), stabilising hormones can support mental clarity during perimenopause.

Benefits of HRT for Long-Term Health

HRT, which replenishes oestrogen and progesterone, is not just for symptom relief, it’s a proactive strategy to protect against silent health risks. In Australia, the Australasian Menopause Society (AMS) supports HRT for women under 60 or within 10 years of menopause, highlighting its benefits for heart, bone, and brain health (AMS, 2020).

Why Consider HRT, Even Without Symptoms?

• Cardiovascular Protection: Starting HRT early reduces CVD risk, a critical benefit given heart disease’s prevalence in Australian women (Boardman et al., 2015).

• Bone Preservation: HRT prevents bone loss, reducing fracture risk by up to 40%, especially vital for women with early menopause or family history of osteoporosis (Lobo et al., 2017).

• Cognitive Support: Early HRT may enhance memory and mood, addressing subtle cognitive changes that women may not yet notice (Maki et al., 2018).

• Premature Menopause: Women with menopause before 45 face heightened risks across all three systems. HRT is recommended until at least age 51 to mitigate these (AMS, 2020).

Bioidentical HRT: A Safer Choice

Bioidentical HRT, using hormones such as oestradiol and micronised progesterone, mirrors the body’s natural hormones, offering a safer profile. A 2019 study found micronised progesterone posed a lower breast cancer risk than synthetic progestogens (Fournier et al., 2019). Transdermal oestrogen (patches, gels), common in Australia, minimises clotting risks, aligning with AMS guidelines (AMS, 2020). Unlike compounded bioidentical hormones, which lack Therapeutic Goods Administration (TGA) approval, regulated bioidentical HRT is evidence-based and widely accessible.

Who Should Consider HRT?

• Women under 60 or within 10 years of menopause, especially those with risk factors such as early menopause, low bone density, or family history of CVD.

• Women with premature menopause (before 45), who face significant long-term risks without HRT.

• Asymptomatic women seeking to proactively protect heart, bone, and brain health.

Who Should Avoid HRT?

HRT isn’t for everyone. It’s contraindicated for:

• Women with hormone-sensitive cancers (e.g., breast, endometrial), where non-hormonal options are safer (AMS, 2020).

• Those with undiagnosed vaginal bleeding, requiring medical evaluation.

• Women with severe liver disease or clotting disorders, though transdermal HRT may be an option (Canonico et al., 2016).

• Women over 60 starting HRT, due to increased stroke risk, though those already on HRT can often continue (Boardman et al., 2015).

Nutrition and Supplementation

At FROM WITHIN we emphasise that nutrition and supplementation are powerful tools to complement HRT or support women who cannot use it. These strategies address both invisible risks and emerging symptoms, offering a holistic approach within a preventive healthcare framework.

Key Nutritional Strategies

• Calcium and Vitamin D: Critical for bone health, as women lose up to 10% of bone mass post-menopause (Osteoporosis Australia, 2021).

• Phytoestrogens: Soy, flaxseeds, and whole grains contain plant-based oestrogens that support bone health and may reduce subtle symptoms. A 2018 study showed soy isoflavones improved bone density in postmenopausal women (Lambert et al., 2018).

• Mediterranean Diet: Rich in vegetables, whole grains, and healthy fats (e.g., extra virgin olive oil, nuts), it reduces CVD risk and supports brain health. A 2020 Australian study linked it to lower heart disease rates in women (Pant et al., 2020).

• Anti-inflammatory Foods: Omega-3s (salmon, walnuts) and antioxidants (berries, spinach) combat inflammation, supporting heart and brain function (Buckland et al., 2015).

Evidence-Based Supplementation

• Vitamin D: Essential for calcium absorption and bone health, especially in Australia, where deficiency is common (Osteoporosis Australia, 2021).

• Omega-3 Fatty Acids: Support heart and brain health, reducing inflammation. A 2019 study showed omega-3s improved mood in perimenopausal women (Wong et al., 2019).

• Magnesium: Supports sleep and mood, addressing subtle perimenopausal symptoms.

• Herbal Options: Black cohosh may ease mild symptoms, though evidence is mixed. Always choose TGA-approved products for safety.

Lifestyle Synergies

• Exercise: Weight-bearing (walking, yoga) and resistance training build bone strength, while aerobic exercise supports heart health. Australian guidelines recommend 150 minutes weekly (Department of Health, 2021).

• Stress Management: Cortisol can worsen hormonal imbalances. This can be addressed through mindfulness or meditation which has shown to reduce cortisol. A 2019 Australian study found mindfulness alleviated perimenopausal depression (Wong et al., 2019).

• Sleep Hygiene: Prioritising 7–8 hours of sleep mitigates cognitive and mood changes (Gurvich et al., 2020).

How FROM WITHIN Can Support You

FROM WITHIN offers personalised guidance to optimise perimenopausal health. We can:

• Assess Individual Needs: through blood tests and functional testing we can identify deficiencies to personalise interventions.

• Design Targeted Nutrition Plans: rich in calcium, phytoestrogens, and anti-inflammatory foods to address specific risks and symptoms (Lambert et al., 2018).

• Recommend Evidence-Based Supplements: aligned with TGA standards, ensuring efficacy and safety.

• Integrate Lifestyle Strategies: with exercise, stress, and sleep to enhance overall wellbeing (Wong et al., 2019).

• Collaborate with GPs: work alongside medical professionals to align with HRT or other treatments, ensuring a cohesive and collaborative approach.

Empowering Informed Choices

Perimenopause is a critical window for women to protect their long-term health, even if symptoms are absent. The invisible benefits of HRT, safeguarding heart, bone, and brain health are compelling reasons to consider it, especially for women under 60 or with early menopause. Bioidentical HRT, supported by Australian guidelines, offers a safer, effective option. Complementing HRT with nutrition and supplementation, guided by FROM WITHIN, creates a holistic strategy to address both silent risks and subtle symptoms. By understanding these benefits, women can make informed choices, taking control of their health during perimenopause and beyond.

References

Australasian Menopause Society. (2020). Menopause management. https://www.menopause.org.au/hp/information-sheets/menopause-management

Australian Institute of Health and Welfare. (2020). Cardiovascular disease in Australian women. https://www.aihw.gov.au/reports/heart-stroke-vascular-diseases/cardiovascular-disease-in-australian-women

Boardman, H. M., Hartley, L., Eisinga, A., Main, C., & Figtree, G. A. (2015). Hormone therapy and cardiovascular disease: Benefits and harms. The Lancet, 385(9969), 627–637. https://doi.org/10.1016/S0140-6736(14)61611-0

Buckland, G., Travier, N., Huerta, J. M., Fonseca-Nunes, A., & González, C. A. (2015). Healthy lifestyle and risk of cardiovascular disease among postmenopausal women. American Journal of Clinical Nutrition, 101(5), 1058–1066. https://doi.org/10.3945/ajcn.114.102616

Canonico, M., Plu-Bureau, G., Lowe, G. D., & Scarabin, P. Y. (2016). Hormone replacement therapy and risk of venous thromboembolism: Population-based case-control study. BMJ, 352, i1149. https://doi.org/10.1136/bmj.i1149

Department of Health. (2021). Australia’s physical activity and sedentary behaviour guidelines. https://www.health.gov.au/health-topics/physical-activity-and-exercise/physical-activity-and-exercise-guidelines-for-all-australians

Fournier, A., Fabre, A., Mesrine, S., Boutron-Ruault, M. C., & Clavel-Chapelon, F. (2019). Use of different postmenopausal hormone therapies and risk of breast cancer. Breast Cancer Research, 21(1), 36. https://doi.org/10.1186/s13058-019-1122-9

Gurvich, C., Gavrilidis, E., Worsley, R., Hudaib, A., & Kulkarni, J. (2020). Menopause and mental health: Cognitive and psychological impacts. Australian & New Zealand Journal of Psychiatry, 54(7), 672–680. https://doi.org/10.1177/0004867420924087

Lambert, M. N. T., Thorup, A. C., Hansen, E. S. S., & Jeppesen, P. B. (2018). Combined red clover isoflavones and probiotics improve bone health in postmenopausal women. Nutrients, 10(3), 313. https://doi.org/10.3390/nu10030313

Lobo, R. A., Pickar, J. H., Stevenson, J. C., Mack, W. J., & Hodis, H. N. (2017). Back to the future: Hormone replacement therapy as part of a comprehensive strategy for women’s health. Climacteric, 20(4), 297–303. https://doi.org/10.1080/13697137.2017.1319207

Maki, P. M., Gast, M. J., Vieweg, A. J., Burriss, S. W., & Yaffe, K. (2018). Hormone therapy in menopausal women: Effect on cognitive function. Menopause, 25(6), 665–672. https://doi.org/10.1097/GME.0000000000001053

Osteoporosis Australia. (2021). Osteoporosis facts and statistics. https://www.osteoporosis.org.au/statistics

Pant, A., Gribbin, S., McIntyre, J., Mishra, G. D., & Galea, M. P. (2020). Mediterranean diet and cardiovascular disease risk in Australian women. Heart, Lung and Circulation, 29(7), 1016–1024. https://doi.org/10.1016/j.hlc.2019.11.013

Shumaker, S. A., Legault, C., Kuller, L., Rapp, S. R., & Coker, L. H. (2015). Conjugated equine estrogens and global cognitive function in postmenopausal women. JAMA, 313(20), 2027–2036. https://doi.org/10.1001/jama.2015.4952

Wong, C., Yip, P., Lau, J., & Tang, J. (2019). Mindfulness-based intervention for perimenopausal women with depressive symptoms. Australian Psychologist, 54(5), 419–428. https://doi.org/10.1111/ap.12395