122. What to Expect When You Start Hormone Replacement Therapy

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Starting hormone replacement therapy can feel both exciting and overwhelming. What should you expect? How do you find the right provider? Which delivery method is best? And how long does it take before you actually start feeling better?

In this episode of Perimenopause Simplified, Claudia Petrilli walks you through what the HRT journey can look like, from finding a hormone-savvy provider to understanding different delivery methods and the importance of starting low and going slow.

Claudia discusses why simply finding someone who can prescribe HRT isn’t always enough, what questions to ask when interviewing a provider, and why finding the right dose and combination of hormones can take some patience and fine-tuning.

She also breaks down progesterone, estrogen, testosterone, DHEA, and several different delivery options, including patches, creams, pills, troches, injections, and pellets. Plus, she shares some of her own experiences with HRT, including the changes she noticed when starting testosterone and the difference estrogen made for her period-related body aches.

If you’re considering HRT or have already started and aren’t sure what to expect, this episode will help you better understand the process and feel more prepared to advocate for yourself.

In this episode, we covered:

How to find an HRT provider
Different deliveries of hormone replacement therapy
Why hormone injections and pellets are not recommended
Side effects of hormone replacement therapy
Progesterone hormone replacement therapy
Estrogen hormone replacement therapy
Testosterone & DHEA hormone replacement therapy

Sources:

Women’s International Pharmacy
Institute of Bioidentical Medicine (IOBIM)-trained providers
The Academy for Preventive and Innovative Medicine (Worldlink Medical)
Institute for Functional Medicine
Carol Petersen, RPh, CNP
Dr. Phyllis Bronson

To learn about hormone therapy, grab Claudia’s FREE resource: 3-Day HRT Crash Course.

In just 3 quick emails, you’ll learn:

📌 What HRT is + how it works to improve symptoms
📌 The different types + how to choose for you
📌 Common mistakes (and how to avoid them)

How to Find a Provider for Hormone Replacement Therapy

Today I’ll cover what to expect if and when you start HRT, because so many women are scared to start, they don’t know what’s gonna happen, and quite frankly, in the online space, many tout HRT as being a “must-have” or a “silver bullet’.

And while I have certainly found a lot of relief using HRT, I realize not everyone will have my same experience. So like I always say, when it comes to your health, it’s important to be knowledgeable and then make an informed decision that works for you. Health is not black and white.

Finding a Provider for Hormone Replacement Therapy

First things first: you may be wondering how the heck do I find a provider who will prescribe hormones! Many women ask their doctor or OBGYN and they often say no, hormones aren’t necessary or they may even tell you they’re dangerous. I explained the reasoning for this in my last episode. So let me give you some tips on how to find what I call a “hormone-savvy provider”. This may be a doctor or even a nurse practitioner.

But please know just because someone can prescribe hormones doesn’t mean they’re hormone literate. So it’s important to work with someone who understands hormones, and knows that it’s a process. He or she shouldn’t just prescribe hormones and send you on your way. It can take several months to find your sweet spot – it requires patience, assessing symptom improvement, and frequent check-ins with your provider to make sure you optimize your regimen.

Ways to Find a Hormone-Savvy Provider

In The Perimenopause Method, as non-licensed practitioners, we don’t prescribe hormones. We educate, guide clients on their journey so they know what questions to ask, what to avoid, and how to advocate for themselves. And since searching for a provider can be overwhelming, we give our clients access to an HRT Providers Directory, which we constantly update and is organized by state. But I’ll give you a few tips if you want to start looking for a provider.

I’m all about the path of least resistance, especially in our peri years. We have enough on our plate. So if you love and trust your doctor, ask him or her about their experience with bioidentical hormone replacement therapy. You don’t ask, you don’t get. Sometimes they just don’t think to offer it, unless you’re complaining of symptoms.

Please know that most PCPs, OB/GYNs, and even endocrinologists do not have in-depth expertise or experience with HRT. So while he or she may be an awesome doctor, they just may not have the knowledge to help you. Truthfully, it’s MORE than likely that you’ll have to seek out a hormone specialist to get the support you need.

Here are a few ways to do that and I’ll link to these in the show notes:

Call your local compounding pharmacy – you may want to go in and speak directly to the pharmacist. Ask who he/she recommends for bioidentical hormone replacement therapy in your area. Compounding pharmacists work with practitioners every day, so they should be able to refer you to someone who is well-versed.
Contact a national pharmacy – such as Women’s International Pharmacy.
Institute of Bioidentical Medicine (IOBIM)-trained providers – the founder is Dr. Daved Rosensweet who I just have so much respect for – I love learning from him. He founded IOBIM’s provider BHRT training program.
The Academy for Preventive and Innovative Medicine – by Worldlink Medical they educate providers on Hormone Replacement Therapy. They have a provider directory.
Check out the Institute for Functional Medicine and use the “Find a Practitioner” tab to search for a hormone specialist.

Different Deliveries of Hormone Replacement Therapy

So once you find a provider, know that there are many Different Deliveries of Hormone Replacement Therapy. Let’s go over them…

Pills – progesterone, DHEA and estrogen are available in pill form; estrogen in pill form isn’t typically recommended as it can increase risk of clotting, but there’s more research coming out on that and it seems more providers are fans of this option
Troches – small lozenges you place between your cheek and gum and you let them dissolve
Transdermal or topical – these are hormones mixed into a gel, cream, oil, or even a spray and applied to your skin
Patches – also considered “transdermal” because they’re a sticker-type delivery system applied to your skin. The estradiol “patch” is left in place for a specific period of time on the abdomen, hips or butt
Transmucosal – creams and gels that are applied to the vaginal area, or mucus membranes, like inside the labia or vagina
Injections – may be injected under the skin or in muscles.
Pellets – compounded hormones like estradiol or testosterone are pressed into a solid compound about the size of a grain of rice and inserted under the skin.

Starting Hormone Replacement Therapy: What to Expect

Once you start HRT, it’s an ongoing process. Patience is definitely required. And you may even feel worse before you feel better. There are some side effects, like tender breasts, weepiness, oily skin, acne, grogginess, your cycle length may vary and more, depending on which HRT you’re on. I shared how when I started testosterone my skin got very oily, I broke out and my periods changed a bit.

But symptoms are typically relieved in a few weeks or so…or you may need to adjust your regimen, until you find what works for you.

Most women start with progesterone (typically in an oral micronized form), then add estradiol (typically in a patch or gel), followed by testosterone (in a cream). That’s not always the case, as some providers will prescribe progesterone and testosterone first, as some are hesitant to give women estrogen. So please find a provider who is not afraid of estrogen.

Progesterone

So let’s break down each of these further…

Progesterone: most women start with this hormone, because it declines rapidly after the age of 35 and a reason behind many symptoms like anxiety, sleep disruption, PMS, heavy/painful periods, bloating, breast tenderness, and even hot flashes.

Consider discussing oral micronized progesterone with your provider. You’ll want to avoid PROGESTINS, which are synthetic progesterone, found in IUDs and other forms of hormonal birth control. There may be a time and place for that, but it should be a last resort in my opinion.

Progesterone is meant to be taken at night to help with sleep, but some providers will also recommend you take a low dose during the day if you experience anxiety. Most providers will suggest you take it during your luteal phase (around days 14-28 of your cycle, if you’re cycling regularly). But others may recommend you take it continuously. At the time of this recording, I take progesterone continuously and I feel much better when I do. The standard dosing for progesterone is 100 mg, but many if not most women need more than that. 200-300 mg is pretty standard.

If you cannot tolerate oral progesterone, it could be due to the inactive ingredients in the commercial prescription, such as peanut oil. In this case you may want to ask your doctor for oral micronized progesterone via a compounded pharmacy. But some women opt for a topical cream. There is some school of thought that topical does not offer the same benefits or protection of the uterine lining as oral, but typically this is because the dose isn’t high enough. I encourage you to check out the work of Dr. Phyllis Bronson and compounding pharmacist, Carol Petersen, on their extensive progesterone research.

Estradiol

Moving along to estrogen…after you fine tune your progesterone, you may want to consider estradiol (or a combination of estradiol and estriol, known as Biest). Because of the fluctuations of estrogen in this stage of life, it’s advised to give the body some estrogen to communicate to the brain that you have enough on board. Essentially, it helps mitigate the erratic fluctuations of estrogen in this stage of life. If you struggle with low estrogen symptoms such as vaginal dryness, waking up in the middle of the night, frequent urination or UTIs, dry skin, achy joints…you would likely benefit from estrogen.

If you happen to have menstrual migraines, they can be triggered by low estrogen at the end of the luteal phase (as you transition into your period). Low estrogen can cause prostaglandin release (causing pain/inflammation), and low serotonin (which has to do with your perception of pain). Some women experience joint pain or flares before their period – I used to get these and since starting estrogen HRT, it has helped me so much.

So consider discussing estradiol in a topical cream or gel, or an estradiol patch with your provider. They all come in a variety of doses, depending on your needs.

Lastly, some providers prescribe oral estrogen, but because it goes right to your liver to be processed (known as first-pass liver effect), versus your bloodstream (like transdermal forms) and can increase risk of clotting, it’s not typically advised. That said, more research is coming out on the benefits of oral estrogen, such as lowering lipid levels, so as always, it’s important to weigh your individual risks and health history vs. benefits with a trusted provider.

Vaginal Estrogen

Vaginal Estrogen: in addition to or in lieu of transdermal estrogen, your doctor may suggest vaginal estrogen. This is typically given to women with symptoms such as vaginal dryness, burning, irritation, lack of lubrication, pain with intercourse, urinary urgency and frequent UTIs. This does not enter the bloodstream, so it’s safe for all women.

Testosterone and DHEA

Testosterone: there are no FDA approved commercial testosterone options available for women; however, you can get it via a compounded pharmacy. The cream can be applied to the lower abdomen, behind the knees, forearm, or shoulders – anywhere hair does not grow. It’s typically used in the morning and taken continuously.

Like I mentioned earlier, many providers do not recommend testosterone pellets, as you cannot titrate the dose once they are inserted. It’s a surgical procedure every time you need them, which can increase risk of infection. Once the dose tapers off, you can experience symptoms of very low testosterone.

Some providers will prescribe DHEA to support adrenal health and to help with fatigue. But it shouldn’t be used in place of testosterone. They are typically prescribed together.

Starting Hormone Replacement Therapy

When it comes to HRT, low and slow is the way to go! Make sure your provider understands this and doesn’t start you on high doses right off the bat. Like I said, it’s a process and takes some time to fine tune your regimen. And you’ll know that your doses aren’t optimal, b/c you won’t feel better! Symptoms don’t lie. Some providers will test your hormones once you’ve started HRT to gauge your levels, but it’s best to pay attention to your symptoms.

Conclusion

So that was a very basic overview of HRT – this barely scratches the surface, as it’s a complex and nuanced topic. Every woman is different and has unique needs. In The Perimenopause Method, we provide more education, help you find a prescribing provider or better advocate for yourself with the one you have, and guide you during the process.

We also help you optimize your nutrients so hormones can do their job, as well as support gut and liver health so you can properly metabolize the hormones efficiently – and so you can feel your best.

Sources:

Claudia Petrilli is the host of Perimenopause Simplified podcast and an Integrative Nutrition Health Coach helping high-achieving women 40+ navigate perimenopause with clarity and confidence. After being dismissed by doctors in her 20s over debilitating periods and unexplained health issues, she took her health into her own hands and never looked back. When perimenopause brought a new wave of symptoms in her late 30s, she used that same evidence-based approach to feel like herself again.

She’s the creator of The Perimenopause Method, her signature coaching program, where she helps women rebuild the foundations — nutrition, movement, sleep, and stress — that actually support their hormones through this transition, while also teaching them to self-advocate and make informed choices about their care. Because you don’t have to just get through midlife, you can thrive in it.