Perimenopause and menopause
You are not too young,and it is not just stress.
“I was told I was too young for it to be perimenopause. I was forty-four, and it went on for another three years.”
Perimenopause can start in your late thirties and run for a decade, and it is diagnosed on your symptoms far more often than on a blood test — which is exactly why it gets missed. We take the whole picture seriously and say so plainly when hormone therapy is not the right answer.
- No referral needed
- No insurance needed
- Licensed in your state
What gets missed
Everybody knows about hot flashes.These are the ones nobody connects.
Perimenopause is not only vasomotor symptoms, and the rest of the list is where the years get lost. Each of these tends to be taken to a different clinician and treated entirely on its own.
Appointments. Nine separate answers. No diagnosis.
Nine symptoms, as many specialties, and nobody assembling them into a single picture. Women routinely spend years inside that pattern before anyone names it.Anxiety out of nowhere
New or sharply worse anxiety, often in women with no history of it. Frequently treated as a primary mental health problem on its own.
Heart palpitations
A fluttering or racing heart, often at night. Worth a cardiac look first — but when that comes back clean, this is a common finding.
Joint pain and stiff shoulders
Aching hands, hips and knees. Frozen shoulder is markedly more common in women in their late forties and fifties.
Waking at three in the morning
Falling asleep fine and then waking wide awake in the early hours, with or without a flash attached to it.
Recurrent UTIs and urgency
Repeat infections, urgency, or getting up at night. Thinning genitourinary tissue is a treatable cause that is rarely raised.
Losing the word you wanted
Word-finding trouble and short-term memory lapses. Distressing, common, and usually not the early dementia women fear it is.
Heavier, closer-together periods
Most women expect periods to taper. In perimenopause they often get heavier and less predictable first. Any new bleeding pattern needs checking.
Migraines that changed
New migraines, or long-standing ones changing in pattern or frequency as cycles become erratic.
Skin that itches or crawls
Dryness, itching, and the creeping or crawling sensation that has a clinical name and almost never gets one in the room.
What this list is, and what it is not
These are symptoms worth asking about, not proof of a cause. Thyroid disease, anaemia, sleep apnoea, depression and cardiac problems produce overlapping pictures, and hormones are a convenient answer that is sometimes the wrong one. We rule those out before we treat, which is why palpitations still get a cardiac workup here and not a patch.
What you are actually asking for
Not to feel young again.To feel like yourself again.
Nobody arrives wanting to be thirty. They arrive having quietly given up three or four ordinary things, and wanting them back.
Photographs are of models and are for illustration only. They do not depict Revani patients or treatment outcomes. Whether treatment is appropriate, and which kind, is a clinical decision made with you.
The part nobody explains
You were told noby a trial you were never in.
In 2002 one arm of the Women’s Health Initiative was stopped early and reported a raised breast cancer risk. It was front-page news everywhere. Almost nobody reported the correction.
A small risk explained to you is not the same thing as a small risk decided for you. You have spent twenty years on the wrong side of that difference.
Whether it is right for you
Small is not the same as safe,and some histories are a no.
The two things that move this decision most are your age and how long it has been since your last period. Starting within ten years of menopause is a different proposition from starting twenty years after it.
The four histories that mean we will not prescribe
Breast cancer, now or previously
Systemic hormone therapy is not something we will start. Local vaginal oestrogen is sometimes appropriate, but that is a conversation for you and your oncologist, not for us to open unilaterally.
Unexplained vaginal bleeding
This gets investigated before anything is prescribed. Bleeding that has not been explained is not a symptom to treat; it is a finding to work up.
A blood clot or stroke in your history
A previous DVT, pulmonary embolism, stroke or heart attack, or a known clotting disorder. Depending on the detail this may be an outright no or a specialist referral.
Active liver disease, or pregnancy
Both rule out systemic hormone therapy while they apply.
The four that change the plan rather than the answer
Migraine with aura
Not a bar, but it points firmly away from tablets and towards a patch or gel.
Blood pressure that is not yet controlled
We treat that first. It is a sequencing problem, not a refusal.
Smoking, or a higher BMI
Both raise clot risk enough to change the route of delivery, which is one of the levers we actually have.
A family history of breast cancer
It belongs in the conversation and it is rarely decisive on its own. It changes how closely we screen, more often than whether we treat.
If the risks outweigh the benefits for you, we will tell you so and we will not prescribe. There are non-hormonal options, and we would rather offer you one of those than a prescription you should not have.
What treatment actually is
Four hormones and one routethat involves no hormones at all.
This is not one product. It is a small set of decisions about which hormone, by what route, at what dose and for how long — and the answers differ enough between two women the same age that the plan is worth explaining rather than assuming.
Estradiol, through the skinUsually first
Patch, gel or spray. Best-evidenced, and a lower clot risk than the tablet.
Micronised progesteroneRequired if you have a uterus
Protects the lining of the uterus. Not optional, and not an upsell.
Vaginal oestrogenUnder-prescribed
The single most commonly missed treatment in menopause care. Usable by many women who cannot take systemic hormones.
Testosterone, sometimesOff-label, and rationed
For low desire, which has evidence. Not for energy or mood, which do not.
The non-hormonal routeA real option, not a consolation
Newer non-hormonal drugs, low-dose alternatives and CBT. Where we go if hormones are ruled out.
The full detail on all five, including the off-label one
Estradiol, through the skinUsually first
A patch, gel or spray rather than a tablet. It is the best-evidenced treatment for flashes and night sweats, and going through the skin instead of the stomach carries a lower clot risk than the oral form. Which one you use is mostly a question of what you will actually remember to do.
Micronised progesteroneRequired if you have a uterus
Oestrogen on its own thickens the lining of the uterus over time, and progesterone is what protects it. This is not optional and it is not an upsell. Taken at night, because it tends to make people drowsy, which for a lot of women turns out to be the part they like most.
Vaginal oestrogenUnder-prescribed
A low-dose cream, tablet or ring acting locally, with very little reaching the bloodstream. It treats dryness, painful sex, urgency and recurrent urinary infections, and it can be used on its own or alongside systemic treatment. Many women who cannot take systemic hormones can still use this. It is the single most commonly missed treatment in menopause care.
Testosterone, sometimesOff-label, and rationed
There is reasonable evidence for testosterone improving low sexual desire in postmenopausal women, and there is not good evidence for it improving energy, mood, or the general sense of being a better version of yourself. We prescribe it for the first thing. There is no product approved for women in the United States, so this is off-label and compounded, and we will say so in writing before you agree to it.
The non-hormonal routeA real option, not a consolation
Certain antidepressants at low dose, gabapentin for night-time symptoms, the newer non-hormonal drugs developed specifically for hot flashes, and cognitive behavioural therapy, which has better evidence for menopausal symptoms than its reputation suggests. If hormones are ruled out for you, this is where we go, and it is not us giving up.
Before you compare us to anyone
Four things sold in this categorythat we will not do.
If you have been shopping for a while, you have already been offered at least two of these.
Hormone pellets
The dose cannot be adjusted once it is in, and it cannot be removed.
Saliva hormone testing
A panel that cannot change a decision is not a test, it is a receipt.
“Hormone balancing”
There is no balanced state being restored and no number we are aiming at.
Treating the lab instead of you
A normal result on the wrong day is how women get told nothing is happening.
The evidence on all four, in full
Hormone pellets
Implanted under the skin and marketed as convenient. They routinely produce hormone levels well above the normal range, the dose cannot be adjusted once it is in, and it cannot be removed if you react badly. The major menopause societies advise against them. We do not place them and we will help you come off them.
Saliva hormone testing
Sold as a personalised map of your hormones. Saliva levels swing through the day and correlate poorly with what is actually circulating, so the results cannot be acted on responsibly. A panel that cannot change a decision is not a test, it is a receipt.
“Hormone balancing”
There is no balanced state being restored and no number we are aiming at. Custom-compounded blends marketed as more natural or inherently safer than approved products have no evidence behind that claim, and FDA-approved estradiol and micronised progesterone are already chemically identical to your own. Natural is a marketing word here, not a clinical one.
Treating the lab instead of you
FSH and oestrogen levels fluctuate wildly in perimenopause, and a normal result on the wrong day is how women get told nothing is happening. Menopause is usually diagnosed on your symptoms and your history. We run the labs that change what we would do, and we do not run the ones that only produce a chart.
What you get
Enough time to say all of it,and someone who has heard it before.
Included in the program
- An unhurried evaluation, with room for the whole list rather than one symptom
- A clinician licensed in your state who has treated menopause before
- Bloods where they change the plan — thyroid and iron especially — and not where they only produce a chart
- A clear answer on whether hormone therapy is right for you, including when it is not
- FDA-approved estradiol and micronised progesterone where indicated, from a licensed U.S. pharmacy
- Vaginal oestrogen considered on its own merits, not only as an afterthought
- Non-hormonal options if hormones are ruled out, prescribed properly rather than suggested
- Dose adjusted as symptoms change, with review at least annually for as long as you continue
- Direct messaging with your care team between check-ins
What it costs
Quoted in writing after your evaluation, and before you commit to anything.
The figure depends on whether hormone therapy is prescribed, which route suits you, and whether you need one preparation or two, so naming it before a clinician has read your history would be a guess. The evaluation costs nothing to complete and no insurance is required at any point.
Start my evaluationEstradiol and micronised progesterone are available as FDA-approved products and that is what we prescribe wherever possible. Where something compounded is used, it is prepared by a licensed U.S. pharmacy, it is not FDA-approved, and your clinician will tell you so and explain why it was chosen.
Straight answers
The questions that comeafter you have decided.
If yours is not here, a clinician answers it during your consultation rather than after you have paid for something.
Safety and side effectsI still have periods. Am I too early for this?
Almost certainly not. Perimenopause is the stretch before periods stop, it can run for eight to ten years, and it is when symptoms are often at their worst because hormone levels are swinging rather than simply low. Treatment during perimenopause is normal and well established. Being told to come back when your periods stop is how a decade gets wasted.
Will a blood test tell me whether I am in perimenopause?
Usually not, and this is the single most common source of a wrong answer. Hormone levels fluctuate so much month to month that a normal result proves very little. Over forty-five, the diagnosis is made on your symptoms and your cycle pattern. We run bloods to rule out the conditions that mimic it, particularly thyroid disease and anaemia, rather than to confirm menopause itself.
How long can I stay on it?
There is no longer a fixed stopping date, and the old advice to get off within five years no matter what has not held up. It is reviewed at least annually against your symptoms, your age and your current risks, and plenty of women continue well past their fifties with that review in place. What we will not do is keep renewing a prescription without seeing you.
Will it make me put on weight?
Hormone therapy itself is not shown to cause weight gain. The redistribution towards the middle that most women notice in their forties and fifties happens with or without it. If weight is your main concern we will say so honestly and talk about whether the weight program is the more direct answer, on its own or alongside this.
Is hormone therapy contraception?
No, and this catches people out. You can still conceive during perimenopause, and menopausal hormone therapy will not prevent it. If you need contraception as well, that needs planning into your regimen rather than assuming one covers the other.
Will I bleed on it?
Some irregular bleeding in the first three to six months is common depending on the regimen. Bleeding that starts later, gets heavier, or continues past that window needs investigating rather than tolerating, and we would rather you message us about it early. Please do not wait to mention bleeding.
What about my bones?
Oestrogen protects bone, and hormone therapy reduces fracture risk while you are taking it. For most women that is a welcome secondary benefit rather than the reason to start. If bone loss is your primary concern there are treatments aimed specifically at it, and that may be the better conversation.
What if I only have vaginal dryness and pain?
Then you may not need systemic hormones at all. Local vaginal oestrogen treats dryness, painful sex, urgency and recurrent urinary infections directly, with very little absorbed into the bloodstream, and it is appropriate for many women who cannot take systemic treatment. It is the most under-prescribed treatment in this field and it is worth asking about specifically.
Do you need my insurance?
No. No insurance is required at any point, and nothing is charged to complete the evaluation and find out where you stand.
You have already raised this with someone
You should not have to arrive with research and a printout to be taken seriously,and here you do not.
About three minutes. Nothing is prescribed at this step and nothing is charged.