The Ultimate Guide to Hormone Replacement Therapy for Women: Balancing Hormones in Your 30s & 40s
Why Understanding Hormones & HRT Matters
I am no stranger to Hormone Replacement Therapy (HRT). My journey with hormonal imbalances began at 24, when my hormone levels skyrocketed. Conventional HRT only made things worse, further elevating my already imbalanced hormones. Frustrated, I sought out a Doctor specializing in bioidentical hormones. It was expensive, but at the time, the relief was worth it.
Fast forward to age 40, after becoming a three-time cancer and transplant survivor, I was thrown into menopause overnight. While I was thankful for my knowledge and experience, I quickly realized how many women had little to no understanding of their hormones.
As women, understanding our hormones isn’t optional—it’s essential. Our hormonal health impacts everything—from energy, mood, and metabolism to bone health, brain function, and longevity. Whether you're considering HRT, navigating perimenopause, or simply trying to optimize your well-being, knowledge is power—and it’s time we start prioritizing it.
First, Understanding your Menstrual Cycle & Normal Hormone Ranges
If you're getting your hormones tested, it's essential to note which day of your cycle the test is done. Hormone levels fluctuate throughout the month, so without knowing your cycle phase, the results can be misleading or meaningless.
The menstrual cycle is divided into three main phases:
Follicular Phase (Days 1-14, Approx.) – Starts with menstruation and ends with ovulation.
Ovulatory Phase (Mid-Cycle, Around Day 14) – The brief window when ovulation occurs.
Luteal Phase (Days 15-28, Approx.) – Post-ovulation phase, preparing the body for pregnancy or the next cycle.
Each phase is driven by fluctuations in key hormones, including estrogen, progesterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH). Below are normal hormone ranges based on each phase.
Follicular Phase (Days 1-14)
What Happens: The cycle begins with menstruation as the uterine lining sheds. Estrogen levels gradually rise to stimulate follicle growth and prepare for ovulation.
Key Hormones & Normal Ranges:
FSH (Follicle-Stimulating Hormone): 1.4–9.9 mIU/mL (stimulates egg development)
LH (Luteinizing Hormone): 1.3–9.0 mIU/mL
Estrogen (Estradiol, E2): 20–200 pg/mL (peaks before ovulation)
Progesterone: <1.5 ng/mL (low in this phase)
Ovulatory Phase (Around Day 14)
What Happens: A surge in LH and FSH triggers ovulation, releasing a mature egg. Estrogen peaks, and progesterone begins to rise.
Key Hormones & Normal Ranges:
FSH: 4.7–21.5 mIU/mL
LH: 8.7–76.3 mIU/mL (spikes to trigger ovulation)
Estrogen (Estradiol, E2): 100–400 pg/mL (highest just before ovulation)
Progesterone: 0.8–3.0 ng/mL (begins to increase post-ovulation)
Luteal Phase (Days 15-28)
What Happens: After ovulation, the corpus luteum forms, producing progesterone to support a possible pregnancy. If no fertilization occurs, progesterone drops, triggering menstruation.
Key Hormones & Normal Ranges:
FSH: 1.4–9.9 mIU/mL
LH: 0.5–16.9 mIU/mL
Estrogen (Estradiol, E2): 40–350 pg/mL
Progesterone: 4.1–28.0 ng/mL (peaks in mid-luteal phase, then drops before menstruation)
Summary of Key Hormone Patterns
✔ Estrogen is low during menstruation, rises in the follicular phase, peaks before ovulation, and stays moderate in the luteal phase.
✔ Progesterone is low in the follicular phase, rises after ovulation, and peaks mid-luteal phase before dropping if no pregnancy occurs.
✔ LH & FSH are low in the follicular phase, surge during ovulation, and then return to baseline in the luteal phase.
Why This Matters
Understanding these hormonal shifts is crucial when assessing hormone imbalances, cycle irregularities, or determining the best timing for HRT. If you’re tracking your cycle or testing hormone levels, knowing where you are in your cycle can help interpret results accurately.
Understanding the Role of DHEA & Testosterone in HRT
DHEA: The Precursor to Key Hormones
Dehydroepiandrosterone (DHEA) is a precursor hormone that the body converts into estrogen and testosterone. It is primarily produced by the adrenal glands and plays a vital role in energy levels, mood, metabolism, and overall hormone balance.
Why It Matters in HRT:
DHEA naturally declines with age, impacting overall hormone production.
Low DHEA levels can lead to fatigue, low libido, poor muscle tone, and mood changes.
Some women supplement with low-dose DHEA to help support estrogen and testosterone levels without direct hormone therapy.
How to Test for DHEA:
Best Test: Blood test for DHEA-S (DHEA sulfate), which reflects adrenal function and hormone production capacity.
Optimal Range for Women: 35–430 μg/dL, but levels naturally decline with age.
Testosterone: Its Role & Why It’s Important for Women
Though often associated with men’s health, testosterone plays a critical role in women’s well-being by supporting:
✔ Muscle strength & tone
✔ Bone density
✔ Mood & cognitive function
✔ Sex drive (libido)
✔ Energy & metabolism
Why It Matters in HRT:
Low testosterone can contribute to fatigue, brain fog, low libido, and loss of muscle mass.
Too much testosterone can lead to acne, hair loss, irritability, and excess facial hair growth.
How to Test for Testosterone:
Best Tests:
Total Testosterone (measures all circulating testosterone)
Free Testosterone (measures bioavailable, active testosterone)
Optimal Ranges for Women:
Total Testosterone: 15–70 ng/dL
Free Testosterone: 0.5–3.0 pg/mL
When to Test: If you’re still cycling, test around Day 19–21. If postmenopausal, test anytime but remain consistent in timing.
Final Thoughts on DHEA and Testosterone
If you're on HRT or considering DHEA or testosterone supplementation, regular bloodwork is essential to ensure your hormone levels stay within the optimal range and to avoid over- or under-supplementation. Personally, I only take DHEA (which I get from Winona) because my testosterone levels are already within normal limits.
Lately, there’s been a rising trend of testosterone supplementation in women, and while it’s necessary for those who are deficient, I don’t agree with the push to boost levels well beyond normal ranges. I believe this approach is risky and ill-advised, with potential long-term consequences.
As a cancer survivor, I take a conservative approach to HRT, prioritizing balance and safety over trends.
Perimenapause Enters the Chat Room
Perimenopause is the transition phase leading up to menopause, typically starting in a woman’s mid-to-late 30s or 40s, though it can last years or even a decade as hormones fluctuate before menstruation stops.
Despite its impact, perimenopause is often overlooked in the HRT space—symptoms appear, but treatment is delayed until full menopause. For those of us who’ve undergone invasive cancer treatments, the transition often happens much sooner and more abruptly, yet support remains limited.
But that needs to change. Perimenopause deserves attention, whether it happens naturally or due to medical treatment. With monitoring, patience, and the right interventions, you can restore balance and feel better now, rather than waiting for menopause to arrive.
What Happens During Perimenopause?
During perimenopause, ovarian function declines, leading to irregular hormone production—particularly in estrogen and progesterone. This hormonal imbalance can cause a wide range of physical, mental, and emotional symptoms, including:
✔ Irregular Periods – Cycles may become shorter, longer, heavier, or lighter, and ovulation may become inconsistent.
✔ Mood Swings & Anxiety – Fluctuating hormones can impact serotonin and cortisol levels, leading to increased anxiety, depression, or irritability.
✔ Sleep Disturbances – Decreased progesterone can lead to insomnia, night sweats, and disrupted sleep cycles.
✔ Hot Flashes & Night Sweats – Sudden waves of heat, flushing, and excessive sweating are common due to shifting estrogen levels.
✔ Fatigue & Brain Fog – Many women experience mental fogginess, memory lapses, and exhaustion, even with enough rest.
✔ Weight Gain & Metabolic Changes – Declining estrogen affects insulin sensitivity and fat distribution, leading to changes in metabolism.
✔ Loss of Libido & Vaginal Dryness – Lower estrogen and testosterone can cause reduced sexual desire and discomfort during intimacy.
✔ Bone & Heart Health Changes – Estrogen helps protect bone density and cardiovascular health, so declining levels may increase risk factors for osteoporosis and heart disease.
Take Control
No woman should have to suffer through perimenopause just because she hasn’t reached menopause yet—especially those of us who have faced medical-induced hormonal shifts. Understanding what’s happening in your body is the first step, but knowing when and how to take action is just as important.
So, when is the right time to start HRT, and what’s the best approach? Let’s break it down.
How to Take Hormone Replacement Therapy (HRT) Based on Your Cycle
1. For Those Who Are Still Having Periods (Cyclic HRT)
Method: Hormones are taken in a cyclical pattern to mimic a natural menstrual cycle.
Example: Estrogen is taken daily, while progesterone is added for 12–14 days of the cycle to trigger a withdrawal bleed.
Best For: Those in perimenopause or with irregular cycles who still produce some hormones naturally.
2. For Those Whose Periods Have Stopped (Continuous HRT)
Method: Estrogen and progesterone (if needed) are taken daily without breaks, providing a steady hormone level.
Example: A combination of low-dose estrogen and progesterone is taken daily to avoid fluctuations and prevent uterine buildup.
Best For: Postmenopausal women or those who no longer menstruate due to medical reasons.
Bioidentical vs. Synthetic Hormones: Understanding the Differences
When choosing Hormone Replacement Therapy (HRT), it’s important to understand the difference between bioidentical and synthetic hormones. Both can be effective, but their structure, source, and how they interact with the body differ.
Bioidentical Hormones
What They Are:
Bioidentical hormones have the exact molecular structure as the hormones your body naturally produces. This means they are recognized and metabolized in the same way as endogenous hormones, making them a closer match to what your body naturally produces.
Where They Come From:
Derived from plant sources, such as yams or soy, and then processed to be structurally identical to human hormones.
Examples of Bioidentical Hormones:
Estradiol (E2) – Found in Estrace (pill), Vivelle-Dot (patch), Estrogel (gel)
Progesterone (Micronized) – Found in Prometrium (capsule), compounded creams
Testosterone (compounded or AndroGel) – Available in creams, gels, and injections
How They Are Taken:
Available in FDA-approved forms (patches, gels, pills) and custom-compounded options (creams, troches, lozenges, and injections).
Often prescribed by functional medicine doctors and integrative practitioners.
Pros:
✔ Structurally identical to natural hormones, allowing for a more natural response.
✔ Typically well-tolerated, with fewer reported side effects. Available in various forms, including compounded options for personalized dosing.
Cons:
✔ Custom-compounded bioidentical hormones aren’t regulated as strictly as FDA-approved versions, so dosing may vary.
✔ Most insurance companies don’t cover compounded bioidenticals, making them more expensive.
Synthetic Hormones
What They Are:
Synthetic hormones have a different molecular structure than human hormones but are designed to mimic their effects. They bind to hormone receptors in the body but may produce stronger or different effects compared to natural hormones.
Where They Come From:
Often chemically derived from animal sources (e.g., pregnant mare urine in Premarin) or lab-synthesized compounds.
Examples of Synthetic Hormones:
Estrogen: Premarin (conjugated equine estrogens), Cenestin (synthetic estrogen blend)
Progestins (Synthetic Progesterone): Provera (medroxyprogesterone acetate), Norethindrone
Testosterone (Synthetic Anabolic Steroids): Methyltestosterone (not commonly prescribed for women)
How They Are Taken:
Pills, injections, patches, and IUDs (like Provera or Premarin).
Often prescribed by conventional doctors and gynecologists.
Pros:
✔ FDA-regulated and widely available.
✔ Often covered by insurance, making them more affordable.
✔ Have been studied extensively for long-term use.
Cons:
✔ The molecular differences may lead to stronger or unintended effects, increasing the risk of side effects (e.g., blood clots with synthetic ✔ estrogen, mood swings with progestins).
✔ Some synthetic progestins (like Provera) have been linked to increased risks of breast cancer, making them a controversial option.
My Take on HRT
Based on my own experience, I believe that bioidentical hormones are a better choice than synthetic options. If cost is a concern, estradiol and Prometrium are both covered by most insurance plans and can be easily prescribed by an OBGYN, eliminating the need for expensive visits to an uninsured practitioner.
That said, Prometrium can cause side effects when taken orally, but those effects can often be reduced by using it vaginally instead. Personally, I take estradiol (covered by insurance) and choose to purchase my progesterone cream from Winona—an additional out-of-pocket expense, but one that works best for me. I’ve found Winona to be one of the most affordable options for bioidentical hormones, as it eliminates the high practitioner fees that often come with bioidentical HRT.
At the end of the day, HRT isn’t one-size-fits-all—it’s about finding what works best for your body, your budget, and your long-term health.
Pros & Cons of Different Types of Hormone Replacement Therapy (HRT)
1. Pills (Oral HRT)
How they work: One of the most common forms of HRT, oral pills are taken daily and provide a consistent dose of hormones. While convenient, they must be processed through the liver, which may increase the risk of certain side effects.
Pro: Easy to take and widely available.
Con: Must be processed through the liver, which may increase the risk of blood clots or other side effects.
My two cents: For estrogen, this is my preferred way of delivery. Estradiol is cost effective and works.
2. Creams (Topical HRT)
How they work: Topical hormone creams are applied directly to the skin, allowing hormones to be absorbed into the bloodstream. They offer flexibility in dosing but require consistency in application and may transfer to others through skin contact.
Pro: Absorbs through the skin, bypassing the liver and reducing certain risks.
Con: Can transfer to others through skin contact if not fully absorbed.
My two cents: I’ve had little success absorbing estrogen through my skin, and I know other women who have faced the same issue. However, topical application is my preferred method for progesterone, as it’s the only form that doesn’t cause me side effects.
3. Shots (Injections)
How they work: Typically administered every few weeks, hormone injections deliver a concentrated dose directly into the muscle. This method allows for steady hormone levels but may cause fluctuations as the dose wears off between injections.
Pro: Provides a longer-lasting dose, reducing the need for daily application.
Con: Can cause hormone fluctuations, with peaks right after the shot and dips before the next dose.
My two cents: They can be expensive and require biweekly visits to a center, often with an additional visit fee, further increasing the cost. On top of that, I didn’t like the intense hormone surge all at once—it felt inconsistent and a bit too overwhelming for the perimenopausal phase.
4. Implants (BioT Pellets)
How they work: Tiny hormone pellets are inserted under the skin and release hormones slowly over several months. This method provides long-term, steady absorption but requires a minor procedure for insertion and removal.
Pro: Delivers consistent hormone levels for several months without daily upkeep.
Con: Requires a minor surgical procedure for insertion. It also requires a consistent dosing schedule, making BioT a more suitable option for women who are postmenopausal.
My two cents: I’m not considering implanted hormones until I’m fully postmenopausal. I have friends who use BioT testosterone, and when they finally get their bloodwork checked, their levels are often 300% higher than normal. I prefer a more controlled approach, so for now, it’s not for me.
5. Troches (Sublingual Lozenges)
How they work: Small, dissolvable lozenges placed under the tongue or in the cheek, troches allow for direct absorption into the bloodstream. They bypass the liver, making them a good alternative for those who experience side effects from oral HRT.
Pro: Absorbed directly into the bloodstream, bypassing the liver for faster and more efficient absorption.
Con: Can be inconsistent in absorption, depending on how long it stays in the mouth and individual saliva production.
My two cents: I relied on troches exclusively in my 20s to help balance my hormones and absolutely loved them. However, like injections, they require frequent visits to an out-of-pocket specialist and can be quite expensive. If I had a trust fund, I’d definitely reconsider!
Monitoring Your Hormone Replacement Therapy (HRT) Journey
Choosing the right HRT approach is just the beginning—I often joke that’s the easy part. The real work comes in ongoing monitoring to ensure your hormone levels stay balanced and your treatment continues to support your body’s needs. As a three-time cancer survivor recovering from multiple rounds of treatment, I’ve learned that hormone adjustments are a constant process, evolving as my body continues to heal.
Here’s how to stay on top of your HRT journey:
1. Regular Bloodwork Checks
If you’re still having periods, test on day 19-21 of your cycle when progesterone is highest.
If you’re postmenopausal, you can test anytime, but consistency in timing is key.
Standard panels should include estradiol (E2), progesterone, testosterone, FSH, and LH, plus DHEA and thyroid markers (TSH, Free T3, Free T4) if relevant.
2. Track Your Symptoms
Bloodwork is important, but how you feel matters just as much.
Keep a journal or use a symptom tracker to monitor energy, sleep, mood, hot flashes, libido, and overall well-being.
If you experience new symptoms, it may be time to adjust dosing or delivery methods.
3. Evaluate Your Delivery Method
Not all forms of HRT absorb the same way—if you’re experiencing side effects or no improvement, you may need to switch from pills to patches, troches, or creams.
If taking oral progesterone, but struggling with drowsiness or bloating, consider vaginal use to minimize side effects.
4. Work with a Knowledgeable Provider
Not all doctors specialize in HRT, so seek out an OBGYN, endocrinologist, or integrative practitioner who understands bioidentical and synthetic options.
If using compounded hormones, ensure your provider monitors levels closely, as custom formulations can vary in potency.
5. Adjust as Needed
Hormone needs change over time, so what works today may need tweaking in the future.
Review your bloodwork and symptoms every 3-6 months and adjust accordingly.
If you’re postmenopausal, annual testing may be sufficient unless new symptoms arise.
Final Thoughts
HRT is not a one-and-done approach—it requires consistent monitoring and adjustments to keep you feeling your best. By tracking your symptoms, testing your levels, and working with the right provider, you can optimize your hormone therapy and make informed decisions about your long-term health.
