A Hormone Expert’s Experience with HRT

While I’m sharing my experience here, I do think we have to be very careful of influencers and experts online saying, “Hey, this worked for me so it will work for you too!” I’m always encouraging you all to be wary of people shouting: here is my transformation, I’m going to give you my exact plan and this is what you can expect too. Cuz that is just BS.

Here’s the thing:

What works for me will not necessarily work for you at all when it comes to my diet, my workouts or my medications or supplements for oh so many reason. However,  sharing my story here has value because many things that came up for me are things I hear every day in my practice from women. Also, expertise comes from working with 1000s of women in a variety of scenarios, with varying health histories and challenges as well as a variety of backgrounds and lifestyles – not from an n of one experiment, even if you have doctor as a title.

That said, I want to share how I navigated them and what I wish I’d done differently. I hope to arm you with more understanding, insight, and grace as you traverse midlife and the many questions around HRT in your own life.

For a less personal take on HRT, see these posts:

What Women Need To Know About HRT

Understanding Synthetic vs. Bioidental Hormone Therapy

Does HRT Cause Cancer?

I Needed Help and I Struggled to Find It

Most women see multiple providers as they embark on HRT before finding the right fit – if they ever do.

Research in the Journal of Women’s Health surveying over 1000 women ages 40-55 demonstrated that nearly 75% of women experiencing perimenopause symptoms do not get appropriate care. They showed that women had to visit up to 5 different healthcare providers before getting support and what’s worse: 68% of them were told their symptoms were all in their head or that their concerns were simply just part of “getting older”.

If that’s not enough, over half of the women surveyed were initially misdiagnosed with anxiety or depression with no discussion of their hormones being a root cause of those issues.

Was it different for me, the women’s hormone expert? Sadly, no.

Without a trusted functional medicine colleague in my area, I reached out to an online colleague and fellow hormone expert for a zoom call thinking this will be a cinch! Unfortunately I ended up buying some of her hormone supplements and told to take fish oil because I “looked so inflamed” – which I had figured was due to my waning estrogen and lack of sleep from low progesterone. She didn’t think I was ready for any HRT yet, even progesterone despite my anxiety and insomnia which had reached debilitating levels. I was surprised and disspointed that we weren’t on the same page.

So I next leaned on my primary care doc locally and she said, “Well you know more about this than me.” Ok, we’re getting somewhere….can can you write me a script for the progesterone in the dose that I believe I need so I can get some sleep and not want to murder the people I love for two plus weeks out of every month? Pretty please?

No, she said. She didn’t feel qualified. And suggested I see an OBGYN.

9 month wait list to get into anyone in my area as we had recently moved. At this point, my symptoms were really becoming problematic and while frustrated at the long wait time and based on my experience with my own patients, I knew full well not every OBGYN is up to date on current treatment recommendations for perimenopause and menopause so the wait wouldn’t necessarily guarentee results even if I muscle through the 9 months to geti an appointment.

Back to reaching out to colleagues and friends all over the country. Some were unwilling to go down the estrogen road in general and others couldn’t prescribe in my state.

Still frustrated. Still not sleeping. Still hating myself for not being able to control my mood, exhausted and unable to complete a workout – if I could even talk myself into going to the gym in the first place. So I thought I’d check out the myriad of online clinics for help.

Turning To Telehealth

Dr Brooke Googles: get HRT in New Jersey via telehealth.

All of the sites felt wayyyy too slick and the marketing language was so aggressive. I felt like I had too much hormone on me just by being on their site.

But I tried one. The push for pellet therapy had me clicking “leave meeting” faster than I could say, no thank you.

Read why I hate pellets in this article.

Back to Google. I found another telehealth service licensed in my state and the general vibe initially was OK, not perfect but definitely better than my other options so I went with it.

As a woman with PCOS, when DHEA and testosterone were the initial prescriptions for me I was very wary. I was also given that progesterone I was so desperately seeking so that was a win, but she recommended oral DHEA with pregnenalone and topical testosterone despite my concerns of breakouts and hair loss – which are already a PCOS symptom that crept back up as I entered perimenopause.

More on DHEA and pregnenalone as part of your HRT plan on this episode of the Dr Brooke Show. And more on PCOS + Perimenopause on this episode.

And this provider was also unwilling to even discuss estrogen as I was still cycling. I was very concerned about this approach.

I talk about why I prefer an estrogen and progesterone approach first in this post about testosterone and I cover all things unique to perimenopause when you have PCOS here.

 

ERROR: INVALID CTA ID

 

But I wanted to be the patient and not the doctor here and opted to try and just trust my provider, be a good girl ya know? And maybe with at least the progesterone I’d get some sleep and some of my low estrogen symptoms wouldn’t be as troublesome.

Taking the win and assumed as we grew our therapeutic relationship we’d be able to explore estrogen in the future. So I tried to stay open to the plan as she laid it out: oral progesterone, oral pregnenolone with DHEA and topical testosterone.

I filled all the prescriptions but only started the progesterone and pregnenolone with DHEA and just held on to the testosterone because I was very nervous about my androgens going high, losing my hair, breaking out, impacting my ovulation (where I was eeking out at least a bit of hormone still) despite her telling me her “other PCOS patients did fine with this”.

The progesterone worked like a dream and my sleep and anxiety improved.

If you didn’t have a great response to progesterone, I cover why that might be on this episode of the Dr Brooke Show.

The pregnenolone and DHEA helped initially with energy and I felt strong in the gym again. Overall, I was on an upswing. Still afraid of adding testosterone so I didn’t start that, but I was doing better. Of course, I threw in some supplements to help ward off sideeffects and metabolize these androgens.

I did feel that I’d likely traded my overall hormone balance for a shot of getting my androgens up with the pregnenolone and DHEA and that an inevitable problem was coming. A mistake I see all too often, with testosterone, especially with pellets and injections. More on that in this article.

Within about 6 weeks though I had lost about half of my hair, had a face full of breakouts and felt so aggressive that I could’ve strangled anyone that looked at me sideways. I asked my provider to check my DHEA and it was over 400 (normal range for my lab is 41.2−243.7 mg/dl).

I had to stop the pregnenolone and DHEA and let my levels come back down. Breakouts started to clear, mood stabilized and it took over 6 months for my hair to start to regrow.

After a few months I was still sleeping well 2 weeks of the month on progesterone but my brain fog had hit epic heights and while going into a room with no clue what I was there there for is annoying.

My libido was in the toilet and my mood was awful. The slightest thing would have me spin into a spiral of fear and I began entering a serious depression. I felt full of despair and unable to concentrate, to write, to work, to think. My sleep started to fall apart again and my wardrobe became relegated to stretchy workout pants because my waistline was expanding at an alarming rate.

Hot flashes? No. Some night sweats but only during ovulation and the night before my period, but they were not awful.

But I did have what felt like near debilitating joint pain. Working out just felt impossible because the next day I was so sore, my joints so creaky, in so much pain it hardly seemed worth it. I’d hobble down the stairs each morning feeling a hundred years old instead of approaching fifty. And after I dragged myself to the gym because my motivation was about zero, most days I just couldn’t finish. I became a ghost of my former self that loved to lift and be active.

And of course I felt super guilty for not figuring out a way to just push through it.  I hated how I felt, I hated how I looked. It was the most isolated and depressed and exhausted I’ve ever been.

My inflammation was on full tilt with the joint pain, puffy face, brain fog and weight gain. My body was  crying out for some estrogen.

The physical symptoms were terrible but probably the worst part was I just didn’t feel like myself. If was a stranger in some body that I barely recognized and I couldn’t see a way out. My usual feel good tricks didn’t work. If I could drag myself to workout it was a wimpy one at best but worse, I paid for it so much the next day it was hardly worth it. Walking didn’t make me feel better anymore. Hugging my kids offered only a boost of oxytocin and some temporary relief and ironically it often inspired more depression as I felt this new sense of: ugh, my life is over and I am not going to be the mom I have always tried to be for them anymore. Instead I am just sad, in pain, tired, frumpy and my best days are over.

This was NOT good.

Friends would invite me out and I’d decline both because I felt so terrible in all of my clothes and also I’d developed some serious social anxiety. In part because my general anxiety was at an all time high anyway due to the low hormones, but also because I felt so far from myself. I was just so dang uncomfortable in my skin.

My motivation to do work or keep my health in check was at a low I’d never experienced.  I’d walk into the gym after dragging myself there, do a set and just leave. I’d never walked out on a workout in my life – even after I herniated a disc. Which is dumb I know, but you get my point: I was not myself.

I asked again to discuss estrogen and was finally given vaginal estrogen at a very low dose.  Of course this did nothing for my brain fog, joint pain, mood or weight gain.

If you have questions about how different delivery methods i.e. vaginal vs. systemic estrogen work, see this post.

Back to searching for another telehealth option. Thankfully I was able to find the right fit and get on both estrogen and progesterone. It absolutely took some tweaking and I’ve been on various forms of both progesterone and estrogen including patches, gels, compounded and FDA regulated products. For more on compounded vs. FDA regulated medications see this article.

For the first time in four years I am doing better. Thankfully!

 

Here Are the Mistakes I Hope You Can Avoid

Protocols Instead Of  A Customized Prescription

My first HRT prescriber was lovely but I felt like I got her standard protocol. She gave me oral progesterone, which was great but she pushed back at my inquiry about estrogen and gave me a lot of androgens without testing and even with my PCOS history. After seeing other patients that used this service, this is very much standard issue from them even though my case was very different from these other women.

As well, providers need to be able to roll with it and adjust as you respond or don’t and not be married to a certain type of delivery system (i.e. estrogen patch vs. cream) or a certain type of medication (i.e. FDA regulated vs. compounded).

Women need options and your provided needs to be willing to play with your options until you get it right. For example, I’d been on 200mg of compounded oral progesterone for a year with no issue and when I switched providers they gave me 200mg of FDA regulated oral progesterone which should’ve been the same thing, but I felt awful. My new provider was open to switching me back to the compounded no questions asked.

Again, more on strange progeserone reactions on this episode of the Dr Brooke Show.

 

Not Up On Current Info + Best Practices

Multiple providers I spoke with were very gunshy about estrogen and simply said no until I wasn’t cycling anymore despite my symptoms of severe brain fog, weight gain, depression, terrible sleep (even on progesterone) and night sweats – all clear signs of low estrogen. This witholding estrogen is an outdated practice so be sure your provider is up to date with current menopause best practices.

Learn how both estrogen and progesterone impact your sleep here.

 

Testing Is Helpful, But It Shouldn’t Drive All HRT Decisions

Several providers told me that until my estrogen was low on a blood test they would not give me any estrogen. And while I knew better, you may have heard that there’s no point in testing hormones during perimenopause as they are wildly fluctuating.

Lab tests aren’t useless as some providers say and lab tests are also not always needed to start or adjust dosing. Your provider needs to understand nuances and what specific testing can tell us including:

Are your estrogen levels high enough to provide benefit or just alleviate sytmpoms?

Are they using FSH as a urseful tool to monitor feedback loops and not merely to diagnose menopause?

Are they testing and testing testosterone before starting therapy is very wise. It’s not as simple as a value being high or low, it all has to be taken into context both with your clincial picture (symtpoms, improvement, etc.) and your other hormones (cortisol, estrognen, insulin, progesterone, tesosterone, etc.).

When it comes to testing: any hard line about yes or no is a red flag to find a new prescriber.

As well, serum tests have value and more functional testing like the DUTCH test have value too and should be part of a comprehensive and holistic plan.

I cover how to consider testing in perimenopause in this article.

 

Trying Too Hard To Be A Good Patient

I expressed my concern about the DHEA/pregnenolone combo as well testosterone because I have PCOS and already struggle with hypersensitivity to androgens, she simply told me that her “I don’t know what you do in your practice but my other PCOS patients like you have done well with this”.  In my mind of course I was like: um, how?? But I kept quiet.

It’s not that any woman with PCOS will never have lower testosterone or DHEA at times or might never need replacement of either or both of these hormones, but that at the very least we should we test these hormones first, and then proceed very cautiously. Again, more about that in this post.

I felt nervous. I felt dismissed – as a patient, but I was also dismissed as  a PCOS expert – but I tried to stay open and didn’t want to be know it all or otherwise difficult. We’ve all been there.

 

If You Feel Uneasy, Get a Second Opinion, Trust Yourself

Now I know my situation is a bit unique because I have decades more hormone education than the average woman and even more than a few of my doctors given my unique area of specialty. Remember my first family doc simply saying: you know more than I do here!

So while it’s different for me, you are both in the novice and expert role here. You are likely navigating perimenopause or menopause alone as our mother’s didn’t talk about it much in most cases and as for your friends, they are right there with you in the confusion and mixed info.

But remember you still know an awful lot about yourself. If something feels off, like the testosterone did for me, ask questions – and demand good answers! Or enroll another expert in your process  – like me, this is what I do all day!

It’s such a shame that even with female providers, women still need to fight to be heard and understood. You’re about to take a hormone for crying out loud, you deserve to fully understand what’s going on and why they feel this is the best course for your unique case.

 

I realize this is tricky.

Your doctor has a level of expertise and of course deserves some respect for that. And your family doc or your OBGYN has likely been with you through some big life changes, maybe even delivered your babies. This is significant and it warrants respect, but it may simply be they aren’t up to date on what is considered best menopause medicine these days – and it’s Ok to disagree and it’s OK to ask questions.

You as the patient and the customer deserve good answers to your questions, to have your fears heard and validated. You deserve to feel good about your choices. Your concerns from past experience may be applicable to this case (as was mine with the testosterone and DHEA) or they may be unrelated, but your provider should to explain that.

 

Lastly, HRT Isn’t The Full Puzzle. It is Merely a Piece

This one isn’t a mistake I made, but it is one I see every day online and in my practice.

Midlife is about more than HRT. It can be a real reckoing and a complete upheaval  – they don’t call it a midlife crisis for nothing.

HRT can really help you get back into a place where you feel capable of handling the rest of what you need to do: nutrition, exercise, etc. But what gets forgotten in this midlife conversation is that we do still have to do those things and they do still need to be dialed in for both midlife and in a way that honors your other hormones or conditions. For example, women with PCOS need to put even more dedication towards these things because they arrive at perimenopause with more inflammation and hormone dysregulation.

A very holistic approach is needed for women in midlife – it’s just not as easy as getting on HRT and you’re all set. HRT needs to be metabolized properly and come into a good host. This means looking at what support you need to metabolize your HRT, pathways that can be nudged so you tolerate it better, the balance of your gut microbiome to better balance your estrogen levels as well as how to eat and exercise for this phase of life.

This is all doable and what I do in my practice. Please reach out, I can help!