What Your Friends & Neighbors Got Right About Perimenopause (and What It Left Out)
- Sital Bhargava DO, MS
- 3 days ago
- 4 min read
I finally started Season 2 of Your Friends & Neighbors last week.
Season 1 centered around Jon Hamm's character turning to burglary after losing his high-paying job as a hedge fund manager (don't worry—no spoilers here). I expected more of the same this season, so I was surprised when one of the major storylines quickly shifted to...perimenopause.
Honestly?
At first, it annoyed me.
Not because menopause was being discussed. Quite the opposite. The more we talk about menopause, the better. For decades, women were expected to quietly suffer through hot flashes, insomnia, mood swings, painful sex, and brain fog as if they were simply part of getting older.
The show actually did a nice job highlighting just how many symptoms women experience during perimenopause.
What frustrated me was that, at times, it felt like the show leaned into the drama without spending much time talking about treatment. (To be fair, I'm only on Episode 6, so maybe they'll prove me wrong.)
So I thought I'd do what I usually do—fill in a few of the gaps.
Let's talk about estrogen: what it's actually approved to treat, where the evidence is strong, and where we're still waiting for better data.
The Four FDA-Approved Uses for Estrogen in Perimenopause
1. Hot Flashes
If estrogen had a superpower, this would be it.
Studies show hormone therapy can reduce hot flashes by as much as 75%.
Seventy-five percent.
I still remember when hormone replacement therapy was almost taboo. We told women to sleep with cooling blankets, dress in layers, carry fans, and simply "wait it out."
Looking back...I'd like to personally thank every patient who resisted the urge to punch me.
One important thing to know is that about half of women will have their hot flashes return after stopping hormone therapy.
Bottom line: If hot flashes are affecting your quality of life, there's a very good chance estrogen will help.
2. Prevention of Osteoporosis
Notice I said prevention, not treatment.
Estrogen isn't used to treat established osteoporosis, but when started around menopause, it slows bone loss and reduces fractures in women both with and without osteoporosis.
The protective effect is dose-dependent—the higher the estrogen dose, the greater the benefit.
Think of it as investing in your bones now so they can continue carrying you around decades from now. (More on osteoporosis here https://www.rx4trauma.com/post/what-is-osteoporosis)
3. Genitourinary Syndrome of Menopause (GSM)
We talked about GSM a few weeks ago (https://www.rx4trauma.com/post/let-s-talk-about-sex-again-genitourinary-syndrome-of-menopause), so here's the condensed version
As estrogen declines, the tissues of the vulva, vagina, bladder, and urethra become thinner, drier, and more fragile.
Both local vaginal estrogen and systemic estrogen improve these tissues by:
lowering vaginal pH
increasing healthy vaginal cells
improving blood flow
reducing thinning of the vaginal walls
Which translates into less dryness, less painful sex, and fewer urinary symptoms for many women.
4. Premature or Surgical Menopause
Women who lose estrogen years—or even decades—before the average age of menopause benefit tremendously from hormone therapy.
This includes women with:
premature ovarian insufficiency (menopause before age 40)
surgical menopause following removal of the ovaries
For these women, estrogen isn't simply about symptom relief. It also helps protect bone health and may improve mood, cognition, and overall quality of life.
What Estrogen May Help...But Isn't FDA Approved For
This is where things become a little less straightforward.
There are several areas where the research is encouraging, but not strong enough for the FDA to approve estrogen specifically for these conditions.
Cognition
Hormone therapy should not be used to prevent or treat dementia .
In women over age 65, some studies have even suggested a small increase in dementia risk.
That said, women who begin estrogen immediately after surgical menopause appear to experience some cognitive benefits.
For women going through natural menopause, the evidence is mostly neutral—not clearly helpful, but not harmful either.
Depression
Hormone therapy is not approved to treat depression. (Find more here: https://www.rx4trauma.com/post/is-this-perimenopause-or-am-i-just-losing-it-understanding-mood-changes-during-perimenopause)
Some studies suggest estrogen may improve mood in women who are still in perimenopause, but those benefits haven't consistently been seen after menopause.
Interestingly, women whose mood improves while taking estrogen sometimes notice worsening symptoms when they stop it.
Diabetes
Hormone therapy isn't a diabetes treatment either.
However, the Women's Health Initiative found that women taking hormone therapy developed diabetes less often than those who did not.
Estrogen may also help reduce the amount of fat that accumulates around the abdomen, although it doesn't appear to prevent weight gain overall.
Joint Pain and Muscle Loss
Many women swear their joints feel better after starting estrogen.
(This author included.)
A handful of small studies support those experiences.
Unfortunately, we don't yet have enough evidence to recommend hormone therapy specifically for joint pain or preserving muscle mass.
So...Should You Take Estrogen?
As with most things in medicine, the answer is:
It depends.
It depends on your age, your symptoms, your medical history, your goals, and your
personal comfort with the risks and benefits.
Hormone therapy isn't right for everyone.
But neither is suffering through symptoms simply because you think you have to.
One of the things I appreciated about Your Friends & Neighbors is that it put perimenopause into a mainstream television show. Millions of women may watch those episodes and recognize themselves for the first time.
My hope is that they don't stop there.
I hope they ask questions.
I hope they find a doctor who is comfortable talking about menopause.
And I hope they realize there are options.
Because the conversation shouldn't end with, "This is just part of getting older."
It should continue with, "What can we do to help?"
Next week we'll tackle the question that makes almost everyone nervous: How does estrogen about breast cancer, uterine cancer, blood clots, heart disease, and stroke?
Let's separate the headlines from the evidence. I think you'll be pleasantly surprised.
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