How do you know if you need Estrogen in Perimenopause?  

Great question.  I'm Dr. Kelly Sadauckas, double board certified pelvic physiotherapist, here to help demystify hormone replacement therapy for you.  This is an important discussion because as of 2023, <10% of graduating internal medicine, 

What is Estrogen's Role in The Body

Estrogen is the primary female sex hormone.  Surprisingly to many, we have the lowest concentration of Estrogen in our body, when compared to Progesterone (the most prevalent) and Testosterone (second most prevalent).  

Estrogen is commonly known to be responsible for females developing "female characteristics"', meaning breasts and labias, as well as "fluffs up" the endometrial lining, to be ready for implantation of a fertilized egg.  

But that's not all it does.  Estrogen is ALSO responsible for bone and soft tissue health; heart health; optimizing our cholesterol levels; managing blood sugar and energy balance; neurological and cognitive function; digestive function AND MORE (Zhu, Zhou, et al, 2023)

How Do the Levels Change in Perimenopause

Perimenopause, which is the 10-year period before menopause, involves a WILD fluctuation of hormones, before they finally calm down, and result in a 12-month timeframe without periods, at which point you are considered to be in Menopause.  

In Perimenopause, Progesterone is the first hormone to dip, resulting in cognitive and behavioral changes long before period changes.  Estrogen begins to dip about 12 years before your last menstrual period.  But the Estrogen levels do not decline in a smooth, predictable line. 

Patel, et al, in the Swiss Perimenopause Study, found that the levels fluctuate WILDLY, going from large dips, to sudden increases.  Ovulation becomes inconsistent, and as these Estrogen fluctuations are happening alongside a gradually reducing Progesterone, we can be Estrogen dominant even if we have "less Estrogen than usual", which results in Estrogen dominant symptoms of sore breasts, heavy periods and elevated moodiness. 

In Climacteric, 2023 (the official journal of the American Menopause Society), found that in over 1000 women, a HUGE proportion (74.9%) had some form of joint or muscle pain, ranging from mild to severe.  That is something to grab your attention!

How Do I Know if I Need Estrogen in Perimenopause? 

1. You need it, vaginally. 

This is an important TRUTH to SHOUT from the rooftops!!  If you are in the first year postpartum OR if you are over 35 years old, and have a vagina, YOU NEED VAGINAL ESTRADIOL!!!  

This is for many reasons, but mainly to protect your vagina against prolapse and symptoms of pee urgency AND to prevent urinary tract infections (and death), which is VERY important. 

It is frankly amazing that the vagina works as well as it does, for so long. Pelvic Physo works to quickly address common symptoms of frequent pees, pee leaks, etc, and is successful in 8 out of 10 cases in eliminating the complaint, via training you to improve your pelvic pressure management, and most importantly training you to use your deep core (abs and glutes) without overusing your pelvic floor.  

This leaves the vagina, however, which is NOT a muscle, but is a connective tissue.  And just like our face and boobs don't look the same at 40 as they did when we were 20, our vaginal tissue is also thinning.  This makes us MORE SUSCEPTIBLE to pelvic pain, leaks, etc due to increased laxity (thinning) of the vaginal tissue.  

BUT, THIS VAGINAL CHANGE IS NOT UNAVOIDABLE!!  We can use topical vaginal estradiol cream, 2-3x/wk, applied DIRECTLY to the vagina, to improve the tissue health.  Check out this fun Instagram Reel I posted recently about the best way to apply vaginal estrogen.   I also have a blog about that topic, if you're interested. 

 

 

 

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A post shared by Dr. Kelly Sadauckas, DPT, OCS, WCS | Pelvic Floor Expert (@therealpelvicfloored)

2. You could benefit from SYSTEMIC Estradiol if...

Vaginal and Systemic Estradiol are the same drug, but have very different applications and purposes. 

Vaginal estradiol improves LOCAL estrogen concentration in the vagina.  A 0.01% gel/cream applied 2-3x/wk has a LOCAL positive and protective benefit for your vagina.  It does NOT have a systemic effect.  

SYSTEMIC Estradiol, via an Estrogen Patch or Pill, is useful in the following cases: 

- If you notice reduced cognitive capacity (like you can't remember, or organize as well as you used to).  HELLO adult diagnosed ADHD--your Estrogen levels might have been protecting you all these years, and now that they are dropping, you can no longer compensate effectively and are suddenly diagnosed with ADHD.  Yes, stimulants can help.  Also try systemic Estrogen!!

- If you are experiencing ANY body pain.  Yes, as a physiotherapist, I understand the importance of exercise and normal range of motion and strength to keep joints healthy. I also know that Navarro, et al, in 2025 found that frozen shoulder was linked to lower Estrogen levels!  

- If your serum estradiol is <60pg/dL.  Scientifically, a woman requires Estradiol levels of 60pg/dL to minimize risk of fractures.  This number was proposed in 1992 by the Reginster Study, and validated in 2026 with the Piette Study.  

YES, YOU CAN (& OFTEN SHOULD) BE ON BOTH VAGINAL AND SYSTEMIC ESTROGEN!!!

Vaginal and Systemic Estradiol have their own unique places and you often SHOULD be on both. Systemic Estrogen will NOT give specific local vaginal benefits, and local vaginal estrogen will NOT give systemic benefits.  

Those are the key reasons you might need to start Estrogen HRT in Perimenopause

I hope you found this interesting and informative.  Please drop questions below, and share this with any friends or family who needs access to information.  References are below, so you can research these items more yourself, and THANK YOU for being here!  Don't forget to follow me on social media for more free, fun information!! 

XOXO 
Dr. Kelly

References: 

Navarro-Ledesma S. Frozen Shoulder as a Systemic Immunometabolic Disorder: The Roles of Estrogen, Thyroid Dysfunction, Endothelial Health, Lifestyle, and Clinical Implications. J Clin Med. 2025 Oct 16;14(20):7315. doi: 10.3390/jcm14207315. PMID: 41156183; PMCID: PMC12564958.

Patel P, Patil S, Kaur N. Estrogen and Metabolism: Navigating Hormonal Transitions from Perimenopause to Postmenopause. J Midlife Health. 2025 Jul-Sep;16(3):247-256. doi: 10.4103/jmh.jmh_75_25. Epub 2025 Sep 5. PMID: 40951853; PMCID: PMC12431702.

Piette, P. C. M., & Simon, J. A. (2026). Optimizing estradiol serum levels for optimal skeletal and cardiovascular health during transdermal menopausal hormone therapy. Gynecological Endocrinology, 42(1). https://doi.org/10.1080/09513590.2026.2694742

Reginster JY, Sarlet N, Deroisy R, Albert A, Gaspard U, Franchimont P. Minimal levels of serum estradiol prevent postmenopausal bone loss. Calcif Tissue Int. 1992 Nov;51(5):340-3. doi: 10.1007/BF00316876. PMID: 1458336.

Santoro N. Perimenopause: From Research to Practice. J Womens Health (Larchmt). 2016 Apr;25(4):332-9. doi: 10.1089/jwh.2015.5556. Epub 2015 Dec 10. PMID: 26653408; PMCID: PMC4834516.

Zhu J, Zhou Y, Jin B, Shu J. Role of estrogen in the regulation of central and peripheral energy homeostasis: from a menopausal perspective. Ther Adv Endocrinol Metab. 2023 Sep 15;14:20420188231199359. doi: 10.1177/20420188231199359. PMID: 37719789; PMCID: PMC10504839.