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Welcome to The Modern Midlife Collective—where midlife isn’t a crisis, it’s a rebirth. Hosted by Dr. Ade Akindipe, DNP, and Dr. Jillian Woodruff, MD, this is the podcast for women ready to unapologetically own their power, thrive through the ups and downs of hormones, weight, and self-care, and show the world that thriving at 40 and beyond isn’t just possible—it’s your birthright.
Biweekly, we bring you science-backed insights on hormones, menopause, longevity, and sexual health—real tools to empower women in midlife and beyond. With a fearless blend of functional medicine, real-life wisdom, and no-nonsense empowerment, we’re here to challenge the norms, break through the barriers, and help you step into a life of vitality, confidence, and unstoppable strength.
Ready to rise? Let’s do this.
Jillian Woodruff, MD (00:00)
most common questions I get in my medical practice in my texts from friends and family is some version of this. I think I'm in perimenopause, my symptoms are so real, but how do I actually know when it's time to start estrogen? It sounds like a simple question, but most women asking it have already asked this before to their doctors, their providers, their trusted friends, and they were maybe told it depends. When my dear friend recently
Ask me this very question, that's the answer that quickly left my lips. I am a I'm ashamed to say this. Because it does depend. The answer is very nuanced and it isn't easy to explain. So I thought we should take the time to give this a real answer today. Scientifically, specifically, clinically, without the vague, it depends. Then many of you have probably already heard. I'm Dr. Jillian Woodruff.
Hello and welcome to the Modern Midlife
Before we get into it, hello. If you're new here, welcome. We're glad you found us. I'm Dr. Jillian Woodruff. I'm a board-certified OBGYN. I'm a surgeon. I am a Minipause Society Certified Practitioner, a sexual medicine expert, and the founder of Modern Gynacology and Skin in Anchorage, Alaska. Today you're getting just me.
My co-host and partner in all things midlife medicine, Dr. Ade Akendepe, is not with me today. Honestly, it is something I'm sure she is very sad about not talking with me today about. But I am recording this episode from Family Vacation. We are on the East Coast at the beach, and Dr. Ade and I could not get our schedules to align, but we felt like this conversation was
very necessary and I guess it's not a conversation with anyone but myself, but we definitely felt like this is something that we had to bring to you now instead of waiting. So it's been sitting in our queue for too long. I hope that I do it justice. Here is the reality about estrogen. Women are routinely told to wait until their symptoms are bad enough before starting estrogen.
Or they're told that they have to be in menopause before they can start estrogen or post-menopause. And I want to name that for what it is. It's a habit. And in many cases, it's gatekeeping that's dressed up as caution. There is no guideline from the menopause society or from ACOG, which is the governing body for obstetricians and gynecologists, or any other medical organization that I am aware of that says a woman must reach a certain level of suffering.
Before hormone therapy is appropriate. What the guideline actually says is that for healthy women who are symptomatic and under age 60 or within 10 years of menopause onset, the benefits of hormone therapy generally outweigh the risks of hormone therapy. That's the current consist consensus position. So here's what I want you to hear. If you are perimenopausal right now, you are likely already in that window.
The optimal time to have this conversation. The optimal time is not after menopause, it's not after years of suffering, it's now, while your body is still in this transition period, while your receptors to estrogen are still very responsive, while the protective effects of estrogen on your bones, your brain, your heart are most meaningful. Perimenopause is not something to wait through. For many women, it's the ideal time to begin.
Most women that are sitting in a medical appointment right now don't know that. They assume their provider is operating from current evidence when they're told it depends or they're told to wait until menopause. And many providers are operating under current evidence, but unfortunately, many providers aren't. Menopause has evolved so much in the last decade. Menopause care has changed.
significantly and not every provider has kept up with that evolution. I see it in my practice constantly and this is something you have to continuously study. Part of the reason this question feels so complicated is that it is actually it actually contains two separate questions that often get conflated. The first is are your symptoms affecting your quality of life enough that treatment is warranted? That's a symptom burden question. Two.
The second question. We are we in the optimal timing window where estrogen does the most good? For a woman in perimenopause, the answer to that second question is almost always yes. The window is open. The question is whether your individual clinical picture makes this the right time. And that is exactly what we're gonna work through today.
So, what are the actual signals that tell a woman it's time to have this conversation with her doctor or her provider? The first signal is new onset symptoms that coincide with menstrual irregularity. This is the perimenopausal window. Cycles that are changing in length, flow, or predictability. And if that is happening alongside new mood changes, sleep disruption, anxiety, brain fog, weight changes.
Especially around the midsection, fatigue, that feels and you feel different than how you used to feel. That constellation of symptoms is telling you something. That is your body signaling a hormonal shift. And I want to pause on that word new, because that's the key. We're not talking about women who have always had anxiety or always struggled with sleep. We're talking about women who say, I don't recognize myself. Something has changed. This is not who I was two years ago. That newness, that shift.
That's the real clinical signal. The second signal, vasomotor symptoms. That's hot flashes and night sweats. When these are disrupting your sleep or your daily function, hot flashes are not just uncomfortable. Research published in the Journal of Menopause also from there's data from the study of women's health across the nation. We call it the SWAN study.
Has shown that frequent severe vasomotor symptoms are associated with increased cardiovascular risk, disrupted sleep architecture, and accelerated bone bone loss. These are not vanity complaints. They're physiological signals that estrogen deficiency is affecting multiple organ systems simultaneously. I think that's huge. And I don't know that people are aware of this data.
And how significant it is. So when a woman comes in saying, I'm waking up drenched throughout the night, I have to change my sheets, I'm not getting good sleep because of it, or you know, simply, I think I'm sleeping okay after I go back to sleep, after I've changed the sleep sheets, that's so not good sleep quality. And then she may have been told, try some black kohash or you know, change open your windows or use a fan.
That's a missed opportunity to intervene at a moment when intervention actually matters. And I want to be clear, estrogen is not always first-line treatment. Often we may start with progesterone, but estrogen should not be ruled out simply because a woman is not yet in menopause. The third signal, bone density. Estrogen is the primary driver of bone protection in women. The rate of bone loss accelerates.
Dramatically in the first several years after estrogen begins to decline. So that's not postmenopause. That's begins to decline. When your estrogen begins to decline, that's when we're seeing accelerated bone loss. And we're talking about perimenopause during this time. So it's not just after that final period. A DEXA scan showing early bone loss in a 47-year-old woman is a clinical reason to have the hormone conversation right now.
Not after she fractures a wrist at sixty-five. We're not just treating symptoms. We're protecting a woman's future. Her bones, her heart, her brain, these are all estrogen dependent tissues. And the window to protect them is not infinite. The fourth signal mood and cognitive symptoms that are new and have a cyclical quality to them. Perimenopausal depression is a real clinical entity.
Distinct from major depressive disorder. Research from Harvard and from Penn Center for Women's Behavioral Wellness has shown that women with a history of PMS or PMDD are at significantly higher risk for perimenopausal mood disruption. And the treatment for perimenopausal depression is not always an antidepressant. Sometimes it's estrogen.
I see women who've been put on antidepressants when what they actually needed was hormone optimization. And I'm not saying antidepressants are wrong. Sometimes they're exactly right. But if a woman's depression or anxiety started when her cycles became irregular, when her estradiol levels started to decline, when it fluctuates with her menstrual cycle, that is a hormonal pattern.
І не серв'я за горну евалюацію.
Jillian Woodruff, MD (09:19)
So let me address something else I commonly hear a year, my labs are normal. FSH and estradiol are notoriously unreliable in perimenopause. This does not mean that they should not be measured or would not lend value to the evaluation. Estrogen does fluctuate wildly, sometimes day-to-day during this transition. The menopause society is very clear that perimenopause is a clinical diagnosis.
Not a laboratory diagnosis. A normal estradiol level on a Tuesday does not mean you're not in therimenopause or that you are in therimenopause if it's abnormal. What matters is trends over time, not a single data point. And I tell my patients about to think about labs as your labs are a snapshot. Multiple snapshots you can put together to tell a story, but your symptoms are the whole movie.
So we treat you, not your lab report. I do get labs though. I find that there is significant value in labs, especially when you're able to monitor trends over time. But it does have to be put together with your symptoms. The second reason I hear for estrogen, the estrogen story, is I'm not in menopause yet.
This reflects a misunderstanding that is incredibly common. The idea that hormone therapy is only for postmenopausal women. Perimenopause is often the optimal time to begin. You're in the window, like I said before. Your receptors are responsive, the protective effects are maximized. Waiting until you cross the finish line of 12 consecutive months without a period is not a clinical requirement. The third thing I hear, I want to try to do it naturally at first. And I
Do genuinely respect that. Lifestyle medicine is a passion of mine. It's foundational. Sleep, nutrition, movement, stress reduction, these things matter enormously. And we talk about them constantly on this show. During periomenopause, when you are still producing your own estrogen, there are definite benefits to optimizing lifestyle. But there is a point at which symptoms are affecting quality of life and sleep and cognition and long-term health.
In ways that lifestyle alone cannot fully address. At that point, waiting is not a natural, it's not a neutral choice, I should say. It has consequences. And I do want to speak also to the women who for whom this conversation requires more, even more individualization. Women with a personal history of a hormone-sensitive cancer, such as ⁓ estrogen responsive estrogen receptor.
Positive breast cancer, excuse me, or women that have active cardiovascular disease, or women who've had blood clots in their legs or in their lungs before. They need a more nuanced conversation with a clinician who is current in menopause medicine. These things do not automatically mean the answer is no, you cannot take estrogen or no, you can't have hormones. It means
The conversation needs to go deeper, and you deserve a provider who knows how to have it. You're going to want to talk with a MENAPAWA specialist about your specific situation. I believe that every woman deserves and needs individualized attention and a discussion of their individual risk-benefit ratio. But especially in these women, you need to make sure that you're having those discussions and not just hearing a no.
I also want to address something else that can cause a lot of confusion when it comes to estrogen. And that's what happens to your periods. If you're in period menopause, you may still be having periods. They may be erratic, irregular. So, what happens when estrogen enters the picture? Because estrogen can make periods better and it also can make periods worse. And understanding why is one of the most important things I think I can leave you with today. In
Early perimenopause, the dominant hormonal problem is often not estrogen deficiency. It's usually progesterone deficiency relative to estrogen. Here's why. As perimenopause begins, ovulation starts to become irregular. It may not happen every month. And when you don't ovulate, you do not produce progesterone. But the ovaries are still producing estrogen. Sometimes it surges.
And these surges are actually higher than a woman's normal baseline. So what you end up with is estrogen that is no longer being adequately balanced by progesterone. This is called relative estrogen dominance. The uterine lining builds up in response to estrogen without the progesterone singling it to stabilize it. So your periods become heavier, they're more irregular, they're more prolonged, and
probably unpredictable. So in that hormonal environment, estrogen dominance, progesterone deficiency, adding more estrogen without first addressing the progesterone deficit can absolutely make things worse. If you add estrogen to a woman who is already in a relatively estrogen dominant state without ensuring adequate progesterone coverage, you can worsen uterine lining building buildup, intensifying heavy irregular bleeding. And in women who have
underlying estrogen sensitive conditions like fibroids that grow in response to estrogen or endometriosis. You can stimulate fibroid growth, you can trigger endometriosis flares from this added estrogen. Estrogen can also worsen breast tenderness and bloating in women who are already in an estrogen dominant phase of perimenopause.
This is one of the key reasons why in early perimenopause, particularly for women presenting with heavy or regular periods, the initial conversation isn't about progesterone. excuse me. The the conversation is about progesterone.
Jillian Woodruff, MD (14:57)
This is one of the key reasons why in early perimenopause, particularly for women presenting with heavy or irregular periods, the initial conversation is often about progesterone first, either cyclic or continuous. So taking it every day of the month or taking it for only half the month, rather than immediately reaching for estrogen. Progesterone stabilizes the uterine lining, reduces bleeding, and often improves sleep and mood at the same time. It's doing multiple things at once.
And there's something here that is absolutely non-negotiable. Any woman, and I think most people are aware of this. Any woman who has a uterus and is taking systemic estrogen must have progesterone coverage. That means progesterone or progesterone. Always. This is not optional. Unopposed estrogen, so estrogen without a progesterone in a woman who still has her uterus.
significantly increases the risk of endometrial hyperplasia, which is overgrave overgrowth of the uterine lining. And over time it can increase your risk of endometrial cancer or uterine cancer. That's not a theoretical risk. That's a well established risk in medical literature. And it's why estrogen is never appropriately prescribed alone in a woman who still has her uterus. So if you've been given an estrogen prescription, you have a uterus and you didn't get progesterone,
You need it. Unless you have something like a progesterone releasing IUD. You do not necessarily need to take another form of progesterone. So when does estrogen actually help with periods? The picture shifts a little later in perimenopause. A woman whose cycles are becoming less frequent, whose periods are getting lighter, whose estrogen levels are genuinely trending downward. That is a different hormonal environment.
Adding a low dose estrogen in this context can actually stabilize things. It reduces the wild, unpredictable fluctuations in estrogen that drive psychoalurricularity. And it often improves the mood symptoms like mood, emotions, irritability.
Tends to regulate and eventually help suppress cycles as they naturally wind down. The same hormone can make it better or worse depending entirely on where a woman is in her cycle and what is driving her cycle change, which is exactly why the evaluation matters and why this is never a one-size prescription. And one more thing: if you are in perimenopause and dealing with heavy, irregular, or unpredictable periods.
And the only answer you received was a prescription for birth control pills to regulate your cycle without any explanation of what is actually happening hormonally. That's worth a follow-up question. Hormonal contraception can absolutely be an appropriate option in perimenopause. And we will cover this even more in a future episode, but it should be a thoughtful, explained choice, not just a reflexive answer given without context.
I do want to mention faginal estrogen because I consider genital urinary syndrome of menopause to be one of the most undertreated conditions in women's health, in women's health. The genital urinary syndrome of menopause is something I just have to be very clear about. It's an entirely separate conversation from the systemic hormone therapy we've been discussing.
Two different decisions, two different risk profiles. Most women do not know this, and the lack of knowledge is costing them quality of life. Can I just say the name may be a problem? Genito urinary syndrome of menopause. Nobody's Googling that. They're Googling why does sex hurt? Why do I keep getting UTIs? Why does it burn when I sit down? The symptoms are real. The name is clinical, and the gap between the two is where women fall through. So.
GS genital urinary syndrome of menopause is can be explained by telling you that as estrogen declines, the tissues of the vagina, the vulva, the lower urinary tract, which are all estrogen dependent, begin to change. They become thinner, drier, less elastic, more vulnerable to irritation and infection. And unlike hot flashes, which often improve over time, for some, not all.
TSM progresses without treatment. It does not get better. It gets worse. The symptoms are are, there are a lot of symptoms, vaginal dryness, irritation, burning, painful intercourse, recurrent urinary tract infections, bladder spasms, urinary frequency and urgency, and in some women, significant pelvic discomfort with everyday activities.
These symptoms affect roughly half of postmedopausal women and the vast majority are never treated. Either because they don't know to bring it up or because they've never been asked. There's so much shame around this too. Women think that this is just about having sex. And so women who have symptoms but they're not sexually active specifically are not getting the help that they should be getting.
⁓ and these women may be getting UTIs every few months and just feeling like this is part of their life now. Vaginal estrogen is applied locally. I know we've talked about it before. It comes as a cream, as a ring, as a suppository, as a tablet, and it works locally on the tissue of the vagina, of the bladder. And there's no the systemic absorption is really negligible. I've actually in some of my patients measured using.
Serum testing, measure their blood to see if it increased their blood levels, and we've not found any increase in or change in their estrogen levels. So for those who want to make sure that they're not having systemic estrogen, there are ways that you can do this. As the bachinal estrogen also doesn't raise blood estrogen levels in a meaningful way. It's not raising blood pressure, it's not ⁓ carrying the same risk profile as systemic.
Therapy does it increase your risk for blood clots or stroke or heart attack. It's local. The effect is local, the risk profile is fundamentally different. So a woman who has been told that she can't take hormones can typically still use vaginal estrogen. And in many cases, this is also true for women that have had a history of hormone-sensitive breast cancer in consultation with their oncologist. This is not a blanket clearance.
Every woman's situation is individual, but it's not an automatic contraindication either. And far too many women are being told no without that nuanced conversation actually happening. Beyond vaginal estrogen, there are other options. There is something called intrarosa. It's a vaginal DHEA, which is a pro-hormone for testosterone and estrogen. There is
Osphina, it's an oral medication that acts as a selective estrogen receptor modulator, specifically for vaginal tissue, so it acts like an estrogen in the vagina, but not in other tissues of the body, which is exactly what many women with breast health concerns need to hear. There are options for women across a range of clinical situations. You do not have to be on systemic HRT to treat GSM.
Even my patients who are on systemic HRT are also on treatment for GSM. They are also using vaginal estrogen in some way. This is one of those areas that I get really passionate about. I think actually I'm really passionate about all of these areas. so I don't know who I'm kidding. I'm passionate about them all.
But you know, suffering is so preventable and a low dose vaginal estrogen used consistently can restore tissue integrity, eliminate dryness, eliminate pain, reduce UTIs or eliminate them, significantly improving your quality of life,
There is essentially one standard low dose, and the prescribing is really straightforward. Anyone can do it.
Jillian Woodruff, MD (22:38)
This is a long-term commitment to your own health and comfort. I always tell my patients, you brush your teeth every day without thinking about it. Your vaginal tissue deserves the same consideration. If you're gonna stop brushing your teeth, then we can stop with your vaginal estrogen.
Jillian Woodruff, MD (22:55)
That's it for today. I surely hope today's episode gave you something real, a framework, some language, maybe a little confidence to walk into the exam room and ask for what you deserve. I'll be honest with you, solo episodes are not my favorite way to do this show. I really like to have a day with me so we can bounce ideas off each other and have a real conversation.
But I know she'll be back next time and we'll return to our regular rhythm and cadence. If you have a question about today's show or any comments or feedback, or maybe a question that you want us to cover on a future episode, please email us at connect at modern midlife collective.com. We read everything, and your questions genuinely shape what we cover. This episode came directly from what you've been asking for.
And if you prefer to watch rather than listen to the podcast, each episode comes out one week later on my YouTube channel at Dr. Jillian Woodruff. So head over there and subscribe and you can watch this episode. If today resonated with you, please share it with a friend, a loved one, a woman in your life that was told it was too early to start estrogen or too early to be in perimenopause. This is exactly who the show is for. So please share it.
You can find us at modern midlife collective dot com and on Instagram at Modern Midlife Collective. Thank you so much for being here today, for listening to me talk, and I will see you next time. Goodbye.