Perimenopause Symptoms: Why HRT Isn’t Always A Magic Bullet

Perimenopause can feel like an unpredictable roller coaster. Hot flashes, insomnia, mood swings, fatigue, weight gain, brain fog, irregular cycles—all signs that your hormones are shifting. And for many women, the go-to recommendation is hormone replacement therapy (HRT).

While HRT can be incredibly helpful for some women, it's not a magic bullet. It may ease symptoms temporarily, but if we don’t address the root causes that are stressing your system, symptoms often return or persist. In functional health, we go deeper to uncover why your body is struggling to keep hormonal balance in the first place.

Let’s look at four key factors that can drive perimenopausal symptoms:

1. Adrenal Dysfunction: Your Stress Response Is Exhausted

In perimenopause, your ovaries gradually slow down hormone production. Your adrenal glands (which produce stress hormones like cortisol) are supposed to help pick up the slack. But if you’ve been under chronic stress for years—working too much, sleeping too little, over-exercising, or carrying emotional burdens—your adrenals may be tapped out.

Signs of adrenal dysfunction include:

• Feeling tired but wired

• Energy crashes in the afternoon

• Trouble falling or staying asleep

• Sugar, salt, or caffeine cravings

• Irritability or mood swings

Supporting adrenal health through rest, blood sugar balance, and targeted nutrients is a foundational step in feeling better during perimenopause.

2. Gut Dysbiosis: Hormones Start in the Gut

Your gut microbiome influences everything from estrogen metabolism to neurotransmitter production. If you have gut dysbiosis (an imbalance of good and bad bacteria), it can impair how you clear excess estrogen, produce calming brain chemicals like serotonin, or absorb nutrients critical for hormone balance.

Signs of gut dysbiosis:

• Bloating, gas, or constipation

• Food sensitivities

• Brain fog

• Mood issues like anxiety or depression

• Worsening PMS or heavy periods

Healing the gut helps restore hormonal harmony. That means evaluating diet, removing inflammatory foods, using probiotics, and supporting digestion.

3. Hypothyroidism: Sluggish Thyroid, Sluggish Everything

Your thyroid hormones regulate metabolism, energy, temperature, and mood. During perimenopause, thyroid issues can become more pronounced—and often go undiagnosed because symptoms overlap with hormonal changes.

Signs of low thyroid function:

• Fatigue and low motivation

• Weight gain or difficulty losing weight

• Constipation

• Hair thinning

• Depression or brain fog

• Feeling cold all the time

A full thyroid panel (including TSH, Free T3, Free T4, and antibodies) is key. Supporting thyroid function through nutrients (like selenium, iodine, and zinc), stress management, and gut health can improve how you feel even if you’re not on thyroid meds.

4. Anemia: Missing the Oxygen Your Body Needs

Iron deficiency anemia is surprisingly common during perimenopause, especially if you have heavy or prolonged periods. Without enough iron, your cells don’t get the oxygen they need—which means more fatigue, dizziness, shortness of breath, and brain fog.

Signs of anemia:

• Extreme fatigue

• Shortness of breath with mild exertion

• Pale skin

• Hair loss or brittle nails

• Restless legs

• Irregular heartbeat

Checking ferritin (your iron storage protein) and a full iron panel is critical. If levels are low, increasing iron through diet and/or supplementation, while addressing underlying causes like poor absorption or heavy bleeding, can be a game changer.

The Bottom Line

Perimenopause is more than a hormonal transition—it's a window into your overall health. Hormone therapy can be a helpful tool, but real, lasting relief comes from addressing the underlying systems that are out of balance.

If you're navigating perimenopause and feeling overwhelmed or unheard, know this: your symptoms are real, and your body isn’t broken. Let’s look deeper, together.