What I Wish I Knew Before Perimenopause: My Journey to Hormone Replacement Therapy

I distinctly remember my first hot flash. My husband and I had stopped for breakfast on our way to Atlantic City for an overnight stay. Sitting in the booth across from him, I suddenly felt heat rising through my body—like someone had turned up my internal thermostat. I started laughing. “I think I’m having my first hot flash,” I said. Moments later, I stood up and walked outside. It was as if I had heated up the air around me and needed to move.

That was more than six years ago.

The First Hot Flash—and the Perimenopause Symptoms That Followed

For me, perimenopause started with hot flashes. During the day, they struck mostly while I was eating. In mid-winter, I would jump up from the table to go stand outside. As someone who has been perpetually cold, it was odd.

Then came the night sweats—waking up with my PJs so drenched that I would change my clothes, only to wake up drenched again a couple of hours later.

Next was the insomnia. I had always slept like a champ, falling asleep almost as soon as my head hit the pillow. I could still fall asleep easily (most nights), but I would wake up at 2 a.m. It was as if my body and brain were on two different rhythms. My brain and nervous system were tired, but my body was so awake. I swear I could actually feel the pulses of energy running through my legs. Sometimes I would get out of bed. Sometimes I was so tired I would just lie there feigning sleep.

I could handle the occasional sleepless night, but sometimes several of these nights would occur back-to-back. By the third or fourth day, I felt like garbage and my brain was mush.

My Symptoms Were Brushed Off for Years

I mentioned the night sweats and insomnia to both my primary care physician and my nurse midwife at each visit for years. Each time, they assured me it was all “normal” and “part of the transition.” I trusted them. And—on some level—I think we all assumed these signs were an indication that menopause was around the corner and, therefore, these symptoms would come to an end anytime now. But they didn’t. They got worse.

I mean, the average woman reaches menopause (officially: the day that you’ve gone a full 12 consecutive months without a menstrual period) at age 51, and I’m 54 now. It made sense.

Only, menopause wasn’t around the corner. I still get my period like clockwork.

Perimenopause Brought Me A Miserable Monthly Cycle

In the last two years, my perimenopausal symptoms got worse and worse. And while they didn’t all occur every month, I started keeping notes and realized that most of them occurred cyclically, often hitting mid-cycle. Things like:

Painful ovulation and period cramps
Constipation
Bloating
Red, swollen, bleeding gums
Mouth sores
Vulvar swelling and irritation
Sore, swollen breasts
Low libido
Days when I’d randomly wake up feeling anxious, sad, or pissed off

In short, I was miserable. The sleepless nights and revolving door of symptoms made most days feel like a complete slog. I just didn’t feel like myself. (Little did I know how common this is!)

Finally Finding Help

Desperate, I found a new gynecologist and went to my visit with notes, prepared to discuss my symptoms and determined to ask if hormone replacement therapy was an option. I wasn’t halfway through my list before he dismissed most of the symptoms. I didn’t push—who wants to work with a doctor who gaslights them?

After the appointment, I sat in my car and cried. I was so frustrated. And I felt like I was back at square one.

I’m not alone.

The Medical System’s Menopause Gap

Despite the fact that nearly 90 million women in the U.S. are expected to be postmenopausal by 2060, menopause remains a profoundly underserved area in medicine.

Most women will spend about one-third of their lives in this stage, yet both patients and providers are often unprepared for what it brings.

Research shows that while 85% of women experience menopausal symptoms that significantly impact their quality of life, a staggering 75% of those who seek help walk away untreated.

Meanwhile, only 54% of women can accurately define menopause, and 32% say they lack basic knowledge about it.

Unfortunately, the providers they turn to may not be much better equipped: 80% of internal medicine residents report feeling unprepared to treat menopause, and only 20–30% of OB/GYN residencies include formal menopause education.

Read that again: Only 20–30% of those who go to medical school to work with people who have uteruses are formally educated in menopause!

Much of the confusion around hormone replacement therapy (HRT)* can be traced to the 2002 release of the Women’s Health Initiative (WHI)—a large, government-sponsored study that linked HRT to increased risks of breast cancer, stroke, and heart disease.

*Editor’s Note: Menopause hormone therapy (MHT) or simply hormone therapy (HT) are the currently-accepted terms from the Menopause Society and the Endocrine Society for the practice of prescribing hormones related to menopausal symptoms. As pointed out by Dr. Jen Gunter here in her Substack, The Vajenda, use of the terms “Hormone Replacement Therapy or HRT implies that menopausal women have a disease.” We highly recommend every midlife woman subscribe to Dr. Gunter’s Substack.

The findings were broadcast widely and prompted millions of women to discontinue HRT, while physicians were advised to prescribe it sparingly. What many headlines left out, however, was the nuance: the average participant in the WHI was 63 years old, over a decade past the average age of menopause. Most had pre-existing health conditions, and the hormones used in the study—oral Premarin and synthetic medroxyprogesterone—are now known to carry higher risks than the currently prescribed bioidentical hormones delivered transdermally.

In the years since, follow-up studies and re-analyses have shown that when started closer to the onset of menopause, HRT—especially formulations using bioidentical estradiol and micronized progesterone—can be not only safe but beneficial, improving quality of life and reducing risk of cardiovascular disease and osteoporosis. Yet the stigma and misinformation from the early 2000s continue to influence medical guidelines, media narratives, and public opinion.

Finding the Right Doctor is Key

The weekend after my disastrous appointment, I met a couple of friends for breakfast. I filled them in on my worsening symptoms, my frustration, and the disappointing visit with the new doctor. One of my friends—Jen—had been just as frustrated with her perimenopausal symptoms and told me she’d found a local practitioner on a list of recommended practitioners. She had already scheduled an appointment with Dr. Mary Ann Yehl and would share her thoughts after.

“Gals: Two thumbs up for this menopause doc I saw today,” Jen texted after her appointment.

That was all I needed to hear. I promptly scheduled an appointment with Dr. Yehl.

Afterward, Jen and I talked more about our mutual frustrations navigating perimenopause in a broken healthcare system. “Between the two of us, we had to cycle through six doctors just to find one who had the knowledge—and the willingness—to talk about what we knew was happening to our bodies,” she told me. “One doctor literally said, ‘We don’t give hormones just so someone can sleep.’ That might be the most enraging thing I’ve ever heard from a doctor.”

What stuck with her most was the inequity of it all:

“I’m lucky to have a supportive partner and the means to afford out-of-network care—but I kept thinking about all the women who won’t get the help they need because they don’t have the same privilege. I was relieved to find Dr. Yehl—but also furious. It just shouldn’t be this hard to get basic care.”

The Appointment

My appointment with Dr. Yehl was everything a doctor’s visit should be. She asked me to tell her my story—and then truly listened. She didn’t just focus on the obvious symptoms; she asked about diet, exercise, and my emotional, mental, and physical health in equal measure. The validation she offered was priceless. And she was so thorough that she caught something both my primary care doctor and previous gynecologist had missed: uterine fibroids. (But that’s a story for another post.)

Two months into hormone replacement therapy, I could cross off every single symptom on my list. No more sleepless nights. No more constipation. No more mouth sores or bleeding gums. No more feeling like I was unraveling mid-cycle.

As Dr. Yehl later shared with me:

“In an ideal world, we’d sit down with women around age 35 to give them a preview of perimenopause and menopause—what symptoms to look out for and how to prevent chronic disease. So many women feel like they’re losing themselves as anxiety, depression, cognitive changes, and physical symptoms creep in. It’s a very isolating time for many women when their bodies and minds change in unsettling ways. If they only knew that there are doctors who understand—and can recognize and treat these symptoms. There is hope, and there is help.”

The Cost of Going to a Menopause Specialist

Most menopause specialists are out-of-network for health insurance. The few practices I reached out to charged anywhere from $400 to $975 for an initial visit—though things are admittedly pricey in the NY/NJ area.

Add to this the fact that most health insurance companies only cover some forms of estradiol and often don’t cover progesterone or testosterone at all. At present, I shell out $67 a month for HRT.

Many women don’t have the resources to jump through the hoops necessary to get the care all women should have access to. That’s the part that’s hardest to swallow.

You Are Not Alone

If you’re struggling with perimenopausal or menopausal symptoms and feeling dismissed or confused, you’re not alone—and you don’t have to suffer in silence. The lack of menopause education in our healthcare system leaves too many women untreated and unheard. But there are providers who are knowledgeable, compassionate, and ready to help. To find a menopause-informed practitioner near you, visit The Menopause Society.

How has your perimenopause journey been going? —Karin

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