More Than Hot Flashes: How Hormones Affect the Body
Estrogen influences multiple systems, including the musculoskeletal, neurological, urinary, and cardiovascular systems. There are hormone receptors in all parts of your body to include your joints, bones, skin, hair, nails, bladder, urethra, and more. The decline in estrogen, progesterone, and testosterone can lead to a variety of symptoms that affect multiple body systems. There are entire books dedicated to how hormones effects different body systems. Below you will find a few highlights.
Brain, Mind, and Mood
The brain has several different types of estrogen receptors, and, interestingly, the number of these estrogen receptors increase instead of decrease as a women ages. This increase is thought to be the brain’s way of trying to maintain estrogen signaling during a time when estrogen levels are naturally declining. Given this theory, it is not surprising that many perimenopause and menopause symptoms are neurological in nature to include hot flashes, night sweats, insomnia, and significant mood changes. One of the most common symptoms of perimenopause is “not feeling like myself” or NFLM. NFLM includes feelings of fatigue, overwhelm, anxiety, vigilance, nervousness, forgetfulness, tearfulness, increase worrying, difficulty with decision making, and harder time concentrating. The estrogen receptors in the brain are also a key point of data as researchers evaluate the emerging evidence on the decrease of incidence in Alzheimer’s disease among women on estrogen therapy.
There is also a 2-5 fold higher risk for a major depressive episode during perimenopause compared to women leading up to this time. Anxiety symptoms may peak during late perimenopause and then decline after the onset of menopause. A 2018 small, double blind study found that treating women with transdermal estrogen and oral progesterone with diagnosed mood disorders had a sustained anti-depressant effect. As early life stressors and current stressors often influence the level of depressive symptoms experienced in perimenopausal women, it is highly recommended to couple pharmacological care with psychotherapy such as cognitive behavioral therapy or trauma informed therapy such as Eye Movement Desensitization and Reprocessing (EMDR).
Bone and Muscle
Musculoskeletal syndrome of menopause is a lesser recognized condition associated with declines in estrogen and includes loss of mean muscle, musculoskeletal pain, joint pain, loss of bone density and associated fractures, increased tendon and ligament injuries, and progression of osteoarthritis. Joint pain is estimated to occur in over 50% of perimenopausal women. Estrogen regulates inflammation in joint health by inhibiting the release of inflammatory cytokines. As estrogen levels decline, this loss of anti-inflammatory support may contribute to joint pain. Estrogen also plays a key role in bone density and muscle mass. During perimenopause, women have an average reduction of 10% in bone mineral density. However, over half of women lose bone more rapidly than that, at an estimated 10-20% in the five to six years around menopause. The loss of bone density puts a woman at significant risk for fracture. Thus, estrogen therapy is an effective way to promote bone and muscle health as well as decrease the risk of osteoporosis and hip fractures which can have a profound effect on both quality and quantity of life.
Heart and Cardiovascular Health
Heart palpitations are another symptom of hormone deficiency that affects at least one in five women in perimenopause and menopause. It is more common in perimenopause and surgical menopause and may be more associated with fluctuations in hormones than in the general decline.
As previously mentioned, blood clots tend to be a topic of concern when discussing hormone replacement. Literature suggests that oral synthetic hormone therapy has an increased risk of clots as does oral bio-identical hormone therapy to a lesser extent. Thus far, research shows that transdermal bio-identical hormone therapy does not come with a measurable increase in clotting risk.
Lastly, the 2020 American Heart Association scientific statement on menopause transition and cardiovascular disease emphasized that research on menopausal hormone therapy and cardiovascular risk remains complex and, in many areas, inconsistent. The statement suggests that the cardiovascular effects of hormone therapy may depend on factors such as timing of initiation, route of administration, and treatment regimen. Current evidence does not support a blanket conclusion that hormone therapy increases cardiovascular disease risk in appropriately selected, recently menopausal women. Instead, hormone therapy may offer cardiovascular benefit when initiated early, particularly in women with premature or surgical menopause or within 10 years of natural menopause.
Genitourinary Symptoms of Menopause and Libido
Low libido is a complex physiological and psychological condition with a variety of causes. In perimenopause and menopause, one of those cause is that of declining estrogen and testosterone. In women interested in sex, hormone therapy to include transdermal estrogen and testosterone can help with low sexual desire. One 2019 meta-analysis of sexual desire and testosterone therapy found that compared to those on placebo, topical testosterone therapy was associated with a significant improvement in sexual desire, sexual satisfaction, arousal, and orgasm.
Genitourinary symptoms of menopause include symptoms such as genital dryness, decreased lubrication with sexual activity, pain with sex, decreased arousal, decreased orgasm, decreased sexual desire, vaginal itching or burning, urinary frequency or burning, and recurrent urinary tract infections. Important to note, genitourinary symptoms of menopause is an imperfect term as these conditions can also be caused by perimenopause, hormonal contraception, laction, and disordered eating. In addition to pelvic floor therapy, the American Urological Association recommends that local low dose vaginal estrogen should be offered to women to improve vulvovaginal discomfort and irritation as well as vaginal dryness and pain with sex. A 2026 electronic health record database analysis of nearly 2 million women with recurrent UTIs found that local vaginal estrogen therapy in women of all ages was associated with a decreased rate of sepsis, hospital admission, and death associated with UTIs. Of note, a woman can be on systemic and vaginal estrogen therapy at the same time.
Health Beyond Hormone Therapy
Hormone therapy can be an important and effective tool for many women, but it does not replace the foundations of health. As women move through perimenopause, menopause, and beyond, the cornerstones of long-term wellness remain nutrition, movement, sleep, and stress reduction. This season of life is an opportunity to shift the focus from simply managing symptoms to building strength, resilience, and vitality.
Nutrition plays a central role in supporting the body through this transition. Rather than focusing only on calories, many women are better served by prioritizing nutrient-dense foods that support muscle, bone, cardiovascular, metabolic, and brain health. This includes adequate protein, fiber, omega-3 fatty acids, and antioxidant-rich foods. Protein is especially important because it supports satiety, helps preserve lean muscle mass, and contributes to bone health. Maintaining muscle and bone strength is not just about appearance; it is directly tied to mobility, independence, injury prevention, and quality of life.
Movement is equally important and should be viewed as a form of long-term investment in the body. During perimenopause and menopause, declining estrogen can contribute to changes in muscle mass, bone density, body composition, and insulin sensitivity. Strength training is one of the most effective ways to counter these changes. Ideally, women should aim for at least two strength-training sessions per week, focusing on exercises that build and maintain muscle across the major muscle groups.
Aerobic movement also remains essential. Activities such as brisk walking, swimming, cycling, or other moderate-intensity exercise can support cardiovascular health, improve insulin sensitivity, boost mood, and increase energy. Flexibility, mobility, stability, and balance training are also valuable parts of a well-rounded routine, especially as they help reduce fall risk, improve posture, and support comfortable movement over time.
One of the most important parts of building an exercise routine is giving yourself grace. This is especially true if you have not been exercising consistently or if your body feels different than it used to. Start slowly, choose activities you enjoy, and allow the routine to grow over time. The goal is not punishment, restriction, or chasing a number on the scale. The goal is to feel strong, capable, and energized in a body that can carry you comfortably through the next several decades.
Health during midlife and beyond is not about becoming smaller. It is about becoming stronger, more supported, and more connected to the body you live in every day.
Hormone Therapy at the Coit House
Each visit begins with a thorough review of your health history, current symptoms, goals, and priority concerns. This conversation is an important part of the process because hormone changes can affect multiple body systems, and symptoms may overlap with other medical conditions. Lab work may also be obtained to evaluate current hormone levels and to help rule out other possible causes for symptoms beyond hormones alone.
Once your symptoms, health history, and lab results have been reviewed, we will have a detailed discussion about whether hormone therapy is appropriate for you. This includes reviewing potential benefits, risks, treatment options, and your personal goals for care.
At The Coit House, hormone therapy is typically started low and slow. This approach allows the body time to adjust while helping minimize side effects. Many women who are interested in hormone therapy begin with a very low dose of estrogen, which can then be gradually increased over the course of several weeks based on symptom response, tolerability, and individual needs.
For individuals with a uterus, estrogen therapy must be paired with progesterone therapy. Progesterone helps protect the uterine lining and reduces the risk of endometrial overgrowth, which can increase the risk of uterine cancer when estrogen is used alone. In some cases, progesterone may also be used by itself, especially for women who are earlier in perimenopause or whose primary concerns include heavy or irregular bleeding, sleep disruption, or insomnia.
Progesterone is often taken at night because it may cause drowsiness and can support sleep. For some women, this nighttime effect is helpful, particularly when insomnia is a major concern. Progesterone is also a highly fat-soluble hormone and some women report that they tolerate it better when taken with a small amount of fat, such as almond butter or peanut butter.
Testosterone therapy may also be an option for some women, particularly when symptoms include low sexual desire, reduced motivation, low energy, or changes in strength and muscle recovery. As with estrogen and progesterone, testosterone therapy is individualized and started cautiously, with ongoing monitoring for both benefit and side effects.
Overall, the goal is not simply to “replace hormones,” but to create a thoughtful, individualized plan that supports symptom relief, safety, and long-term health.
Authored by Megan Heimerl, FNP.
Schedule an appointment for Hormone Health & Wellness at The Coit House
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