[00:00:00] Speaker 3: Welcome to Peri in Pause, the podcast where midlife women get real answers about their bodies, their health, and what's actually changing. Because every woman deserves this conversation

[00:00:18] Speaker: Welcome to Perimenopause, the podcast where we talk about all things midlife women's health, relationships, careers, family, changing bodies, changing priorities, and life in general. We talk about what it means to be a woman in this season of life, the challenges, the opportunities, the things we're figuring out as we go, and sometimes just the stuff women wanna talk about.

I'm Jamie Gallagher, nationally board-certified family nurse practitioner, a Menopause Society certified practitioner and owner of Perimenopause, a midlife women's healthcare practice serving women in North Carolina. I'm so glad you're here So today, I want to talk about estrogen, what it is, what it does, and why it's our bestie, then it feels like it fails us in midlife.

We tend to think of estrogen as a reproductive hormone only, a female hormone. Fun fact, in midlife, during perimenopause and menopause, our male counterparts have higher levels of estrogen than we do at times. It's not just a reproductive hormone. Most of us grew up thinking of estrogen as the hormone that, like, runs your period, and absolutely it does that.

But it's also talking to your brain, your bones, your blood vessels, your bladder, your skin, every part of you. So today, we're gonna go on a tour of everywhere estrogen actually works in your body, what happens as it starts to change during perimenopause and menopause, and then, because we can't talk about estrogen in 2026 without bringing this up, we're gonna talk about the black box, what that warning said, why it was there for so long, and what changed recently.

So let's get into it. Estrogen, one hormone with so many jobs, right? Here's the idea I want you to walk away with. Estrogen does not just have one job. It has so many, and we as midlife women probably already know this because when it begins changing and we're having highs and lows and chaotic levels of it, we feel it throughout our entire body.

It has receptors. Think of them like little docking stations everywhere, sitting in tissue all over your body. Your brain has them, bones, heart, blood vessels, bladder, skin, just to repeat that. Your gut has them. Your heart itself has them. Hello, palpitations. Um, when that gets chaotic, a lot of women will experience palpitations.

So wherever there's a docking station for estrogen, estrogen can show up and have an effect. That's why calling it just a reproductive hormone undersells it so much. It's more like a hormone that helps regulate your whole system, your temperature, mood, uh, strength, bone and muscle, skin health, heart health, and running your reproductive cycle is just one of its many jobs, not, by far not its only one.

So let's walk through what actually, what that actually looks like here, body part by body part. But before we do that, um, I, I wanna clarify we have different types of estrogen in our body. Estradiol, which is the most abundant, and if you're on a patch, a gel, a spray, a tablet, you know you're taking estradiol.

That's the most abundant estrogen in our body. There's another one called estrone. It's weaker, and it's more dominant in menopause. It's created from aromatization of, of other hormones, which means, you know, it, it aromatizes, that's a, a verb, um, from other hormones like a, like a androgen and converts to, um An estrogen.

But estrone is mostly created from the fat in our body that we acc- accumulate during, um, perimenopause because of course it is. Um, estriol is weak but higher during pregnancy, a very weak estrogen. And estetrol is only during pregnancy. So for the purpose of this podcast, we're just gonna call estrogen estrogen, and just meaning, you know, a general term.

So let's take that tour of where estrogen works. We'll start with your brain, your brain and your body's thermostat. So estrogen has a strong presence in the part of your brain that controls internal temperature, basically your body's thermostat. It also affects brain chemicals tied to mood and memory, like serotonin and dopamine.

So when estrogen starts swinging up and down instead of that natural wave we've had during our fertility years instead of staying steady, your internal thermostat gets more sensitive. That's what's actually happened during a hot flash. It's not that you're overheating, it's that your thermostat safe zone really got narrow, so you, instead of feeling fine between here and here, ooh, you only feel fine between here and here, and any, any increase in that feels like a profound surge of heat that also can trigger what's called cold flashes.

So if you've ever experienced that, so smaller changes now trigger a really big response, the flushing, the sweating, that wave of heat. That same brain chemistry shift is a big reason sleep gets disrupted, moods feel more unpredictable, and so many women describe that specific kind of brain fog, losing that word mid-sentence, walking into a room and forgetting why every day.

Um, that's where that comes into play. For your bones, um, estrogen normally puts the brakes on cells that break down bone. We have cells, osteoblasts, osteoclasts, fun word, right? Um, that build bone and break down bone. So estrogen helps balance that. But when estrogen drops, the brakes come off and bones start breaking down faster than your body can rebuild the bone tissue.

That's why the few years right around your final menstrual period, so late peri, and right after are the fastest bone loss period of a woman's entire life, faster than any other time. This isn't a vague connection between hormones and bones. It is very direct and a well-understood mechanism. This can cause osteoporosis, which is where our bones thin to the point they're easily breakable.

I mean, it's to the point sometimes that a sneeze can cause a rib fracture or one of the bones in our spines, uh, spine breaks simply because it's carrying the weight of our upper body. It, it will crush. I've seen that in clinic even y- you know, years past. In older age, having a fracture related to osteoporosis increases your risk of death within one year to about one in two out of every five people who experience this, and that's profound to me.

Like osteoporosis being life-threatening, it absolutely is, and those 12 months after an osteoporotic fracture, that's a critical time. Those are huge stats related to s- simply to bone loss. So vaginal and urinary tissue. The vulva, vagina, and bladder area are all tissues that depend on estrogen to stay thick, well-lubricated, and healthy.

So when estrogen drops, that tissue gets thinner and drier, and the natural balance of our normal bacteria shifts, and that's what leads to dryness, discomfort with sex, and more frequent urinary tract infections or, uh, m- more feeling that you need to urinate more frequently. So here's the important part about that.

Unlike hot flashes, which often get better over time on their own, this tends to get worse, not better, if it's left untreated because that tissue doesn't have the estrogen it needs to maintain itself, and we aren't making any more post-menopause. So let's move to skin and joints. Estrogen helps your body make collagen, the protein that keeps skin firm and joints cushioned.

Women lose a surprising amount of skin collagen the first few years after their final period, faster than any other point in their life. So this is, like, just all kinds of great things we're talking about today, huh? Um, that's also part of why so many women no-notice new joint aches or stiffness during perimenopause.

It's real, and there's a clear reason behind it. Estrogen acts like an anti-inflammatory also. So let's keep going to your heart and our metabolism. This is a system tangled up in the fear of what we're talking about. So let's be clear here. Estrogen keeps blood vessels flexible, stretchy. It supports healthy cholesterol levels and helps your body respond well to insulin.

So as estrogen drops, women often see weight shift toward the belly, it's your little friend here, cholesterol numbers moving in the wrong direction, and blood vessels getting stiffer. This is a big reason why heart disease risk climbs noticeably after menopause. Heart disease, number one killer of women, hands down.

So brain, bones, vaginal urinary tissue, skin, heart, and that's not even the full list. Estrogen also touches mood, digestion, and immune function. There's really no part of the body it doesn't reach in some way. So what are we noticing as midlife women and when? So what does all of that feel like in real life? Here's the general order most women will go through, though everyone's timeline looks a little different. Early on, in early perimenopause, when estrogen is still bouncing up and down rather than just dropping, um, it can be chaotic at times.

Women often notice mood swings, trouble sleeping, heavier unpredictable periods. "I just had a period two weeks ago. Wait, where is my period? It's been six weeks." Um, they experience a new kind of anxiety that feels different from anything they've felt before. This is the rollercoaster phase, chaos, and it gets misread as a mood disorder more often than it should.

I know some of you have been there Here's something for an- for anxiety, or here's something for depression, when that's not the root cause of this problem, so we're fixing a problem the wrong way. And we, as women who are experiencing this, we typically know that that's not going to help because it's something very different.

As estrogen starts trending downward more steadily, the hot flashes, night sweats, brain fog, joint aches, vaginal dryness, and changes in libido tend to show up. Later, once you're fully post-menopausal and estrogen has settled at a low, steady level, the vaginal urinary symptoms often get worse instead of better.

Bone loss continues quietly in the background. The heart and metabolism changes become more visible on labs, and, and we feel it as well in our bodies. So the big takeaway, declining estrogen doesn't just cause one symptom. It causes a whole rolling wave of changes across your body, and the order and intensity, they're different for everyone.

That's exactly why menopause care needs to be personalized to you, not a one-size-fits-all checklist. So now let's talk about the black box. If you've heard this term before, it usually comes up alongside a study called the Women's Health Initiative, and I've talked about this on podcasts here before. Back in 2002, early results from that study came out, and by 2003, the FDA had placed a black box warning, the strongest warning label the FDA can put on a medication, on estrogen-containing hormone therapy. It warned about increased risk of heart disease, breast cancer, dementia.

What followed was more than two decades of fear and confusion, and that's not just my read. That's how the FDA itself has described it as well. Doctors, um, and clinicians stopped prescribing hormone therapy. Millions of women went without treatment for these symptoms that had good, effective option available.

And a lot of fear traced back to how that original study got interpreted and applied to everyone. The average woman in that study was 63 years old, more than a decade past when most women actually go through menopause, and she was on, on an older hormone formula that isn't even the one most commonly used today.

Starting hormone therapy at 63, years after menopause, carries a different risk picture than starting at 52 or 48, closer to when your body's own estrogen is dropping. The nuance got lost. Warning label never reflected that. That finally started to shift. The FDA convened an expert panel mid last year, took on public comment, and did a deep review of everything they've learned since 2002.

And on November 10th, whoop, day in infamy, uh, 2025, the FDA and Health and Human Services announced they were beginning to remove the broad black box warnings from estrogen-containing hormone therapy, specifically the language about the heart disease, breast cancer, and dementia. Those were even applied to vaginal estradiol creams.

You would get the side effect list on a vaginal estradiol cream, cream that says breast cancer, DVT, probable dementia. That is not true. They also approved a couple of new treatment options at that same announcement. On February 12th, 2026, the first actual label changes were approved. Six products covering all the major types of hormone therapy, estrogen only, combination estrogen and progesterone, progesterone only, and vaginal estrogen.

Those specific warnings about the heart disease, breast cancer, dementia were taken off those labels. The FDA pointed to research showing that starting hormone therapy within about 10 years of menopause or around age 60-ish is linked to lower rates of death and fewer fractures, and this was just the first batch.

Dozens more products are expected to follow. So here's the part I really want you to hear. This does not mean the FDA decided estrogen has zero risk. What it means is the FDA decided that old one-size-fits-all warning, same scary label slapped on every product was not giving women an accurate picture. It was just too broad, and in a lot of cases, definitely misleading.

One warning that didn't get removed, by the way, is the one about uterine cancer with estrogen-only therapy in women. If you still have a uterus, that risk is real and needs to be managed. We manage that by adding a form of progesterone, and we'll talk about progesterone in the next podcast. So the message isn't hormone has no-- hormone therapy has no risks.

Just take it. The message is the blanket scare label was overstating and misapplying risk in a way that frightened an entire generation of women and doctors, clinicians away from treatment that for the right person at the right time does more good than harm.

Your own personal risk factors, heart history, family history, your timing relative to menopause, that still matters and still needs a real conversation with a very good clinician who truly understands this. That conversation didn't get simpler. It just finally got more honest. So that's estrogen, not just the period hormone, but something your whole body relies on, your brain, bones, bladder, skin, heart, all that, all shifting together as the signal changes.

And after more than 20 years of one study shaping how an entire field practiced, we're finally getting a warning label that reflects what a lot of us have understood for quite a long time. Thanks so much for joining in and listening. I hope this helps you understand estrogen and what it does.

If you found this episode helpful, please share it with a friend, a sister, a coworker, a partner, anyone you think would find this helpful. Our next show, we're gonna discuss progesterone, another hormone that contributes to the changes we experience in midlife. It's not just a pregnancy hormone.

So we'll see you on our next show. 

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Until next time, take good care of yourself. The information shared on the Perry and Pause podcast is intended for informational and educational purposes only and should not be considered medical advice, diagnosis, or treatment.