Perimenopause, HRT, and the Feeling of “I Don’t Feel Like Myself Anymore”

One of the hardest parts about perimenopause is that you often do not recognize yourself anymore.

You feel more anxious, more reactive, more exhausted, less resilient, and often like something has shifted in your body or brain seemingly overnight. The biggest thing I hear in my office is:“I just don’t feel like myself anymore”, and that can be a really frustrating place to live in.

At the same time, you’re trying to navigate an overwhelming amount of information online.

On one side of the internet, you’re being told that perimenopause is going to be a hugely challenging phase of life and that the medical system is not set up to support you. Then on the other side of the coin, there is messaging that hormones are the answer to everything and that HRT should be for everyone.

Somewhere in the middle are women who are genuinely struggling and feel dismissed entirely.

You may have been told your labs are normal.You may have been told you’re too young.You may have been told it’s just stress.Or you may have been told this is simply part of getting older and something you need to push through.

This leaves a lot of women feeling confused about who to trust and where they are even supposed to start.

Perimenopause Can’t Be Seen On Lab Work

One of the biggest misconceptions I see around perimenopause is the idea that if your labs are normal, everything must be fine.

Perimenopause is not diagnosed through lab work. We use lab work to assess for other things that can look like perimenopause, act like perimenopause, and give many of the same symptoms, but we cannot diagnose perimenopause based on a hormone panel alone.

This distinction is really important.

If you are having symptoms that are clinically consistent with perimenopause, those symptoms deserve to be taken seriously even if your lab work looks “normal.”

There is also no age where symptoms should automatically be dismissed. We always need to think critically about what could be contributing to changes in mood, sleep, cycles, energy, or overall wellbeing, including the possibility of premature perimenopause when appropriate.

You deserve an actual workup and a conversation around your symptoms. There is no point in my clinic where you bring forward a concern and we decide it is something that should simply be ignored.

The Symptoms You May Not Realize Can Be Perimenopause

One of the most common symptoms I see in my office is this underlying feeling of anxiety that you cannot fully explain.

Sometimes you may have never struggled with anxiety before. Other times you may have always been predisposed to anxiety, but it had previously felt manageable. Then suddenly it feels like your anxiety is through the roof and you cannot understand where it is coming from.

Hormonal fluctuations can absolutely contribute to this, and so can things like iron deficiency from heavier menstrual bleeding, poor sleep, chronic stress, or blood sugar instability, which all become increasingly common during perimenopause.

There are also so many other symptoms that women often do not immediately connect to perimenopause like:

• changes in libido

• worsening PMS

• heavier or more irregular periods

• hot flashes

• vaginal dryness

• fatigue

• poor sleep

• changes in body composition

• brain fog

• feeling more emotionally reactive

  
  

All of these things matter, and all of these things deserve to be worked up properly.

What Actually Moves the Needle in Perimenopause

HRT can absolutely play an important role in perimenopause for the right person. At the same time, if the entire plan is simply “start hormones and carry on,” we are missing a huge piece of where support actually lives in perimenopause.

I often explain perimenopause like this: we are about to set sail on an ocean, and we have no idea what the landscape is going to look like. Some people will experience relatively mild symptoms, while others are going to experience much rougher waters.

Our job is to build your ship as strong as we possibly can before we hit those waves.

This is where perimenopause support really lives.

We need to optimize sleep and create as much consistency in sleep and wake times as possible. Sleep becomes incredibly important for mood, cravings, resilience, energy, and overall hormone health.

We probably also need to be lifting weights.

As we age, our muscle mass naturally declines, and strength training is one of the most important tools we have for supporting longevity, metabolic health, insulin sensitivity, bone health, and body composition.

Nutrition matters as well, especially protein intake.

In your twenties, your body has a much easier time turning protein into muscle. In your mid-thirties and beyond, you generally need more protein to support muscle protein synthesis and maintain muscle mass appropriately.

I also talk a lot about Mediterranean-style nutrition, fibre intake, blood sugar stability, and alcohol reduction. There really is no safe amount of alcohol from a health perspective, and many people notice significant improvements in sleep, anxiety, hot flashes, and overall wellbeing when alcohol intake is reduced.

Stress management matters too, although I think a lot of people are tired of hearing that phrase without anyone actually helping them understand what it looks like in real life.

Sometimes stress management means creating boundaries, saying no more often, asking for help, or reconnecting with things that genuinely light you up instead of spending all of your energy taking care of everyone else around you.

The Conversation Around HRT Needs More Nuance

One of the biggest frustrations I have around the conversation online about HRT is that it has become incredibly polarized.

There is one side saying HRT is dangerous and should be avoided at all costs. Then there is another side saying everyone should automatically be on HRT and that there are essentially no risks.

The reality lives somewhere in the middle.

HRT is not risk-free, and you deserve informed conversations around those risks. There absolutely can be considerations related to breast cancer risk, cardiovascular risk, or stroke risk depending on the individual.

At the same time, the risks are often significantly misunderstood or overstated online, particularly when outdated information is being used without context.

This is why individualized care matters so much.

For some people, the benefits of HRT very clearly outweigh the risks. For others, HRT may not be the right fit, or we may want to focus on different interventions first.

Generally, the strongest evidence for starting HRT is around symptoms such as hot flashes, night sweats, vaginal dryness, and bone health support. Sometimes you may also notice improvements in sleep, mood, or overall quality of life when those symptoms are treated appropriately.

If your only concern is sleep or mood, we still want to look carefully at the broader picture before automatically jumping to HRT as the first solution. At that point, the risks may outweigh the benefits, and we simply do not have strong enough data to say that HRT is the best first-line option in that situation.

You deserve a conversation that includes nuance, context, your medical history, your symptoms, your goals, and your personal risk factors. Fear mongering is not helpful, and blanket recommendations are not helpful either.

What I’m Not Doing in Practice

You will never catch me ordering expensive DUTCH testing or loading you up with large supplement protocols in an effort to “fix hormonal imbalance.”

There is no evidence saying we need to chase perfect estrogen or progesterone numbers in perimenopause, and there is no evidence telling us what to do with many of these expensive hormone tests once we have the information.

We are trying to support symptoms, quality of life, and long-term health in a way that is evidence-based and individualized.

You also will not catch me trying to biohack your way through perimenopause with a 12-step morning routine and a cabinet full of supplements.

I am very much a supplement minimalist.

We focus heavily on the foundations:

• sleep

• movement

• strength training

• nutrition

• stress management

• appropriate testing when it matters

• targeted supplements or HRT where needed

Supplements absolutely can have a place, and so can HRT for the right person. At the same time, those things work best when the foundations underneath them are strong.

Perimenopause Does Not Mean You Are Powerless

I think what I wish more people understood is that everyone’s experience with perimenopause is going to look different.

Some people will have very few symptoms, while others will struggle significantly. The way you support yourself through this transition matters, and building your ship as strong as possible before those waves hit can completely change how you experience this phase of life.

I want you to feel empowered around what is happening in your body, empowered around recognizing these changes, and empowered around having conversations about how to support yourself appropriately.

The goal is not perfection, and it is definitely not obsessing over every symptom or every hormonal fluctuation. The goal is understanding what is happening in your body, recognizing when you need support, and creating a plan that helps you feel like yourself again instead of feeling fearful about what is happening next.