What you Actually Need to Know

Hey there! It’s me—Dr. Kelly, pelvic floor expert and your friendly neighborhood pelvic physio, here to spill the tea on a HOT TOPIC that’s showing up everywhere lately: Hormone Replacement Therapy (HRT)!!!

If you’re in your 40s or 50s, odds are you’ve heard a little about hormone replacement therapy. But did you know that women enter perimenopause, the 10-year period before menopause, on average at age 37?!?   So we need to talk about this sooner!!  

I get asked questions about hormone replacement therapy on a daily basis.  While a lot of this IS outside of my professional wheelhouse, there ARE MAJOR ASPECTS that are 100% within my scope of practice as a Doctor of Physical Therapy to discuss, so I decided to write a blog post to answer some basic questions about hormone replacement therapy (HRT).  So without further ado, let's learn some basics about progesterone, estrogen, and testosterone—three major hormones that 100% matter TO YOU–as you transition through perimenopause and menopause, and yes, how they are even potentially related to your aches, pains & cognitive function!!!

Wait—What are Perimenopause & Menopause?

Great question. Don’t be embarrassed if you need to ask.  

• Perimenopause:
• The 10-ish years leading up to menopause
• Perimenopause typically starts in your 40s, but some recent studies are findings initial symptoms beginning at 37 years old!!
• A cardinal “first sign” is more frequent periods…that then become heavier…
• Remember that this a 10-year period where hormones are fluctuating here—therefore symptoms will show up before your periods stop, and even before your periods necessarily change.   
• ALSO...what if you don’t have a period...because maybe you have an IUD? ... or maybe  you take an oral contraceptive and “skip” your period? ... or maybe you “don’t have a uterus anymore???  THEN YOUR first symptom might be hot flashes, or irritability, or “quiet rage” or anxiety....those are all JUST AS REAL of symptoms or perimenopause as more frequent periods.   MIC DROP. 
• Menopause:
  • You’ve officially hit menopause when it’s been a full 12 months without a period.
  • This can happen naturally, or as a result of surgery or certain medical treatments.

Now let’s talk hormones...

1. Progesterone – The First to Dip

Progesterone is “the keeper of Estrogen”, the hormone that keeps Estrogen in check.  Progesterone is the first major hormone to drop during perimenopause. It generally does NOT drop all at once, but rather in dips throughout this 10-year period.  When it drops, a few things tend to happen:

• Estrogen dominance: With less progesterone around to balance it out, estrogen can feel "louder"—which can lead to heavier, more frequent periods, mood swings, irritability, anxiety and OH SO SORE BOOBS!!
• Increased pain sensitivity: Low progesterone has been linked to higher pain levels. Your body may feel pain when it shouldn’t—or feel it more intensely than expected.

📚 Nerd alert: The Vincent study backs this up—higher progesterone levels are generally tied to less pain. Full deets at the end of this post, fellow nerds!!  

📝 But a note for those with endometriosis: For some people, added progesterone might increase pain. So it’s NOT for everyone. This is why working with a primary care provider who understands your full picture is so important.  

2. Estrogen – The Tissue Transformer

Estrogen is the hormone that gives us most of our “classically feminine” traits—breast development, periods, etc. During perimenopause, it can run rampant (because progesterone isn’t always around to keep it steady), and when it eventually bottoms out, that’s when our periods stop, and after 12-months, menopause starts.  

Here’s what estrogen does that’s especially important, from a musculoskeletal, and pelvic floor perspective:

• Supports tissue health: When estrogen drops, collagen levels DROP, and all the body's tissues (including vaginal and bladder tissues) get thinner, drier, and less flexible.
  • This means that REDUCED ESTROGEN LEVELS can be associated with increase in wrinkles, pelvic organ prolapse, dropping boobies....etc, etc...so we actually need STRONGER MUSCLES and to BE MORE AWARE OF POSTURAL CONTROL DURING PERIMENOPAUSE & MENOPAUSE than at any other time in our life, because estrogen and collagen aren't there to help us.  #hardtruth
• Supplemental Estrogen CAN HELP REDUCE RECURRENT UTIs: Using vaginal estrogen (like a cream or patch) after menopause has been shown to reduce UTI risk—especially important for long-term health and quality of life.

⚠️ Caution for perimenopausal folks with pee hesitancy: Estrogen can “plump up” tissue. If there’s a slight urethral narrowing, it might briefly make peeing harder—but this side effect usually resolves within a few days. This is rare, but worth monitoring with your provider.

📚 Reference: Rzepecki and Tan-Kim studies

3. Testosterone – Not Just for Dudes

Now this is fascinating:

• In men: Higher testosterone levels are sometimes linked to more pain.
• In women: Higher testosterone is often linked to less pain. Wild, right?

🧠 The Li-Ling study showed that testosterone plays a very different role in pain perception based on sex. And while we’re still learning, there's exciting potential here—especially for women recovering from soft tissue injuries or struggling with persistent pain.

💉 Some of my physician colleagues have seen women who were healing slower than expected get microdoses of testosterone—and their pain improved!

👩‍⚕️ I don’t prescribe hormones, but I can absolutely point you to trusted providers for more info. Think of me as your pelvic health quarterback, helping you build the right care team. 

Local Hormone Rockstars I Trust With My Pelvis

If you’re in the Teton Valley/Jackson, WY area, you’re in luck! Some amazing hormone-savvy providers are here to help you feel your best:

• Anna Gunderson, PA-C at Teton Valley Health – Functional Medicine trained, hormones are her jam.  (Poop is also her jam...which is ANOTHER reason why I love her so much) 
• Emily Bonder, APRN, PMHNP–BC at Mariposa Mental Health – Mental health support specifically for perimenopause and menopause.  Emily literally saved my marriage by increasing my progesterone.  I'll tell you the whole story some other time. 

(And yes—these are the people I personally see for my own care. They can't tell you that, or even confirm it, but I can tell you that.  That’s how much I trust them.)

Oh, and on the interwebs, I also love Kelly Casperson and Rachel Rubin as AMAZING resources on prescription hormones.  They have incredible resources for medical professionals as well as “normal people”.  This is an ever-evolving topic, so you FOR SURE want to stay on top of it.  

TL;DR – Hormones & Pain: What to Know

(TL;DR means “too long; didn’t read”...it’s from my new social media managers…my middle schoolers…we’ll see how long it lasts in the blog.  I initially said 2 months, but this is the second post...and I feel very "cringe", I think they say... about using the abbreviation...  :) 

• Progesterone 
  • The hormone that drops intermittently in perimenopause, the 10-year period, that precedes the time when your periods stop for good
  • When progesterone drops, Estrogen is unchecked, and this HIGH ESTROGEN  leads to:
    • increased (and more frequent) bleeding (if you have a uterus)
    • increased anxiety and feelings of 'quite rage' (like you could be "THAT LADY" at the airport or grocery store" on the wrong day
    • HOT FLASHES!!!
    • can even increase how sensitive you are to pain!!
• Estrogen 
  • Drops in menopause (when your period actually stops for a period of 12 months). 
  • Estrogen supports vaginal/bladder health → so when it finally drops, you have less collagen and tissue support, and therefore supplemental estrogen can help improve tissue integrity and reduce UTIs.  
• Testosterone in women 
  • may help reduce pain, increase energy
  • mprove cognitive function
  • improve seggsy-time drive, and speed up healing.

RECENT GOOD EVIDENCE SUPPORTS THAT REAL HORMONE REPLACEMENT THERAPY (NOT FAKE STUFF) CAN BE GOOD AND HELPFUL TO PEOPLE . 

Old evidence sucked, and said all hormone replacement therapy was bad. 

Talk to YOUR primary care provider about what might be right for you. 

I Hope You Had As Much Reading About HRT As I Had Researching And Writing About It :) 

There truly is no one-size-fits-all solution, but understanding the basics can help you ask better questions, make more informed decisions, and find the RIGHT primary health providers for you.  Remember, I'm JUST a Physical Therapist.  Above is JUST THE TIP of the iceberg as far as what Hormone Replacement Therapy might be able to do for YOU.  If you want more info, get your cute butt into a primary care provider who has more training in this.  

Got questions or wonders? DM me on Instagram @therealpelvicfloored. I’m working on more blog posts like this and would love to know what you’re curious about.

Until next time—you pelvic superstar, you! 🌟
—Dr. Kelly

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References (Because Science Rules!!!

• Vincent K, et al. “Luteal Analgesia” and Progesterone’s Role in Pain Perception. Front Endocrinol. 2018. link to study here
• Rzepecki AK, et al. Estrogen-Deficient Skin: Topical Therapy Review. Int J Womens Dermatol. 2019. link here
• Tan-Kim J, et al. Vaginal Estrogen for UTI Prevention. Am J Obstet Gynecol. Link here
• Li-Ling Hope Pan, et al. Sex-Specific Associations Between Testosterone and Pain Perception. J Pain. 2024. Link here