When most women think about hormone therapy, they often think about menopause.
But the conversation needs to start earlier than that.
At The Retreat Wellness + Aesthetics, we see it all the time: women in their mid-30s, 40s, and early 50s being told they are “fine,” “just stressed,” or “just getting older,” even though they are dealing with poor sleep, mood changes, bloating, breast tenderness, irregular cycles, hot flashes, low motivation, and feeling completely unlike themselves. In many of those cases, estrogen and progesterone are a much bigger part of the picture than they have been led to believe.
This episode of The Retreat Radio breaks down how estrogen and progesterone change throughout the cycle, how we use them in perimenopause and menopause, and why the right form of hormone therapy matters just as much as deciding to treat in the first place.
Why understanding the menstrual cycle matters
Before you can understand hormone therapy, you need a basic understanding of what estrogen and progesterone are supposed to be doing.
During the menstrual phase, both estrogen and progesterone are low. In the follicular phase, estrogen begins to rise while progesterone remains low. Around ovulation, estrogen reaches its peak, and after ovulation, in the luteal phase, progesterone should rise significantly. That progesterone peak is one of the most important things we look for when we are evaluating hormone balance.
This is why timing matters with lab work.
At The Retreat, we often like to run progesterone labs around day 19 to 21 of the cycle, because if ovulation happened around day 14, that window should capture the progesterone surge. If progesterone is not rising the way it should, that can explain a huge number of symptoms.
What estrogen does beyond reproduction
Estrogen is often treated like it only matters for fertility or menstrual cycles, but that is far from the full story.
Estrogen plays a major role in:
- cognition and mood
- skin health
- bone health and osteoporosis prevention
- temperature regulation
- cardiometabolic health
That is one reason women can feel such a dramatic shift when estrogen starts dropping in menopause. It is not just about periods stopping. It is about the loss of one of the body’s major regulating hormones.
Traditionally, estrogen therapy is used most often in menopause, when estrogen levels have significantly declined. There is growing discussion around whether some women may benefit from starting earlier, toward the later part of perimenopause, but your current practice generally reserves systemic estrogen for true menopausal patients unless there is another strong clinical reason to begin sooner.
Systemic estrogen vs vaginal estrogen
One of the most important distinctions in this conversation is that not all estrogen therapy is trying to do the same thing.
Systemic estrogen is used to raise overall estrogen levels throughout the body. This is what we think of when we are trying to improve broader symptoms like mood, temperature regulation, bone support, and menopausal hormone depletion.
Vaginal estrogen, on the other hand, is more localized. It is used to improve vaginal dryness, irritation, atrophy, pain with sex, lubrication, and even help reduce recurrent UTIs. Because the dose is much lower and primarily local, vaginal estrogen usually does not meaningfully raise systemic estrogen levels on its own. That means some women may still need systemic estrogen even if they are already using a vaginal cream.
That distinction is important, because many women are told they are “on estrogen” when in reality they are only treating local tissue symptoms.
The best forms of estrogen therapy
There are several forms of estrogen therapy, but not all of them perform equally well.
Estrogen creams
Systemic estrogen creams can be covered by insurance, but like testosterone creams, they can have inconsistent absorption. One woman may absorb well, another may not, and transference to children or pets is still a concern. That makes them a less predictable option.
Estrogen patches
At The Retreat, estrogen patches are a preferred option for systemic estrogen replacement. They are small, easy to use, and provide a more consistent delivery of estrogen over time. There are once-weekly and twice-weekly versions, and they allow for flexible dosing depending on patient needs.
The main downsides are that some patients react to the adhesive, and heavy sweating, hot yoga, saunas, or hot tubs can sometimes interfere with patch adherence. There is also currently a practical issue in the market: patch shortages, which can make certain strengths difficult to find.
Oral estrogen
Oral estrogen is not a preferred option in your practice. The main concern is that when estrogen goes through first-pass liver metabolism, it can increase clotting factors and clotting risk. Because of that added risk, you generally avoid oral estrogen unless future research provides a stronger safety case.
Why progesterone may be the most underrated hormone in women’s health
If estrogen gets most of the attention, progesterone is often the hormone quietly changing women’s lives.
Progesterone is one of the first hormones to decline in perimenopause, and that decline can create a long list of symptoms that are often dismissed as stress, aging, or mood issues. In reality, many women who are being offered sleeping pills, antidepressants, or told to “just manage stress” may simply need progesterone support.
Progesterone can help with:
- sleep
- irritability
- mood instability
- hot flashes and vasomotor shifts
- that “wired and tired” feeling many perimenopausal women describe
And if a woman is taking systemic estrogen and still has a uterus, progesterone is not optional. It is necessary for uterine protection. But even outside of that, progesterone receptors exist throughout the body, which is why it can still be extremely beneficial even when someone is not taking estrogen.
The real issue behind “estrogen dominance”
One of the most common patterns seen in perimenopause is not necessarily true estrogen excess. It is low progesterone relative to estrogen.
A woman’s estrogen may still be in a normal range, but if progesterone drops too low, that balance is lost. The result can look like “estrogen dominance” symptoms:
- bloating
- breast tenderness
- blemishes
- bleeding changes
- moodiness or irritability
This is why so many women feel awful even when a provider tells them their estrogen looks normal.
The problem is not always the absolute estrogen number.
The problem is the relationship between estrogen and progesterone.
Bioidentical progesterone is not the same as birth control
This distinction matters a lot.
Bioidentical progesterone is not the same thing as the synthetic progestins found in birth control. In fact, the progestin arm of the WHI study is one of the main reasons hormone therapy got such a bad reputation in the first place. That concern does not apply the same way to bioidentical progesterone.
At The Retreat, the primary form used is oral micronized progesterone, usually in 100 mg or 200 mg doses, often covered by insurance through a standard pharmacy. Compounded versions may be used when patients need a special dose, an extended-release option, or have a peanut allergy.
The bottom line
Estrogen and progesterone are not optional “nice-to-have” hormones. They are central to how women feel, function, sleep, regulate, and age.
If you are in perimenopause or menopause and struggling with symptoms that are being dismissed, there is a very real chance your hormones deserve a much more thoughtful look. And when hormone therapy is used, the form matters. The timing matters. The balance matters. And the provider guiding it matters just as much.
At The Retreat, we believe women deserve more than “you’re just getting older.”
They deserve clarity, real options, and treatment that actually makes sense for their body.
Want the full breakdown? Listen to this episode of The Retreat Radio, where Heather walks through estrogen and progesterone therapy, explains how these hormones shift through the cycle, and breaks down the forms of treatment that can make the biggest difference in perimenopause and menopause.
