“A wonderful time to reinvest in yourself”: Understanding menopause, perimenopause and hormone therapy

Menopause isn't a single event. It's a complex process with three distinct stages, each with its own experiences and challenges. 

According to a recent Sun Life study, three in four women (aged 40 and over) said that their perimenopausal and menopausal symptoms interfere with their daily lives – including their work lives.

The good news? “The landscape of women's health is evolving rapidly,” says Dr. Shafeena Premji. “Women can approach menopause armed with insight, which leads to an improved quality of life in the chapters that follow.” 

To learn about perimenopause, menopause and hormone therapy, we spoke with Dr. Premji. She is a family physician, a Menopause Society Certified Practitioner, and the Founder and Director of Milestone Menopause Centre of Southern Alberta.

There are three stages of natural menopause:

1. Perimenopause: This is the time when hormone levels start to fluctuate and decline, and menstrual cycles may become irregular. You may start to experience other symptoms as well, like hot flashes and trouble with sleep.
2. Menopause: This milestone occurs when you’ve gone without a period 12 months in a row, due to loss of ovarian function.  
3. Post-menopause: This is the time after menopause has happened. You’re in post-menopause for the rest of your life.

As Dr. Premji explains, perimenopause often starts in our 40s, but it can begin in the late 30s. It lasts anywhere from four to 10 years.

Menopause usually occurs between the ages of 45 and 55; the average age in Canada is 51.

Dr. Premji believes that preparation is key to embracing these years with confidence. She urges us to educate ourselves before reaching perimenopause: “With increased knowledge comes reduced fear, enhanced decision-making capabilities and overall, a more positive transition.”

She also emphasizes that we must be prepared to advocate for our own health and start the conversation with our primary care clinician. 

(A report from the Menopause Foundation of Canada shows that only 27% of women say their family physician proactively started a discussion about menopause.)

“The hormonal changes you experience during perimenopause are mostly caused by declining estrogen levels,” says Dr. Premji. 

She explains that:

• Your ovaries make estrogen, which plays a key role in maintaining the reproductive system.
• Once you start perimenopause, your estrogen levels start to lower. 
• As estrogen decreases, so do the levels of progesterone, another hormone produced by the ovaries. 
• Together, these two hormones are responsible for ovulation and menstruation. 
• It’s common for hormone levels to fluctuate during perimenopause. 
• By the time you reach menopause, your ovaries stop releasing eggs and estrogen levels decline. This leads to the end of your menstrual cycles.

Dr. Premji says everyone experiences perimenopause differently. 

Perimenopause doesn’t have a set sequence of symptoms, but it may include:

• Irregular periods
• Hot flashes and night sweats 
• Periods that are heavier or lighter than normal
• Worse premenstrual syndrome (PMS) 
• Hair changes
• Problems with memory or concentration (brain fog)
• Weight gain
• Mood disturbances including anxiety and depression
• Sleep disturbances
• Vaginal dryness
• Joint and muscle aches
• Changes in sexual desire
• Urinary tract infections (UTIs)
• Dry skin
• Frequent urination
• Fatigue

These symptoms can also occur during menopause.

Dr. Premji explains that “today, health-care providers recognize the interconnectedness of the different symptoms associated with perimenopause and menopause.” 

For example, hot flashes and night sweats can seriously disrupt sleep. This lack of good quality sleep then affects mood, which can lead to anxiety and depression. It can also cause brain fog and irritability. 

The good news? “Once we treat hot flashes and night sweats, sleep often improves, which then improves brain fog and irritability,” Dr. Premji says.

Many women worry about dementia when experiencing brain fog. But Dr. Premji says while the two conditions may appear similar at first glance, there are key differences.

“Brain fog primarily affects memory recall – the ability to retrieve specific pieces of information,” says Dr. Premji. 

“Women may struggle to remember a word or why they walked into a room. But it doesn’t affect their executive functioning – which includes skills like problem-solving, planning and completing tasks. And it doesn’t affect their long-term memory. 

“Dementia, however, affects a broad range of cognitive abilities and progressively worsens over time. The memory recall issues associated with brain fog during perimenopause are usually temporary.”

There's no specific test for perimenopause.

“The best approach to figure out if you’re in perimenopause is to track your symptoms and your period,” says Dr. Premji. “Share the information with your health-care provider so they can investigate whether it’s perimenopause or another condition.”

Menopause hormone therapy (MHT) – sometimes called hormone replacement therapy (HRT) – involves taking hormones to relieve symptoms.

“MHT typically refers to treatment for symptoms of menopause, while HRT is used for treatment of premature or early menopause, under the age of 40 and 45, respectively,” says Dr. Premji. “MHT can include estrogen alone or combined with progesterone.”

The decision to use estrogen alone or in combination with progesterone during perimenopause and menopause depends on whether a woman has a uterus. 

“Women with a uterus typically use a combination of estrogen and progesterone. This approach is used to prevent endometrial cancer, which can be a risk when estrogen is used alone. Women who’ve had a hysterectomy (removal of the uterus) may use estrogen alone because the risk of endometrial cancer is no longer a concern.”

MHT refers to the use of hormones to treat menopause and menopausal symptoms including:

• Hot flashes and night sweats 
• Vaginal dryness

Hormone therapy may improve sleep, mood changes, and other symptoms; however, this often requires a more nuanced and individualized discussion with your healthcare provider.

Dr. Premji says the benefits include relief from menopausal hot flashes, night sweats, mood disturbances and vaginal dryness.

There are also secondary benefits. These include a reduced risk of osteoporosis.

In general, MHT is considered very safe. 

As Dr. Premji explains, there is a slight increased risk of breast cancer for women on estrogen and progesterone if used for over five years; however, no more than 1-2 women in every 1,000 are affected. 

“Breast density poses a greater risk than hormone therapy. And women who take estrogen alone, typically those without a uterus, have a decreased risk of breast cancer. It’s the combined use of estrogen and progesterone that is associated with a slight increase in breast cancer risk after five years of use.”

While MHT can be highly effective, it's not suitable for everyone. Dr. Premji says, for women over the age of 60 or who started menopause more than 10 years ago, the risks may outweigh the benefits. 

Dr. Premji says that, in general, women with a history of the following should avoid MHT:

• Estrogen sensitive cancer (breast, uterine or ovarian)
• Blood clots
• Active liver or gallbladder disease
• Heart attack
• Stroke
• Unexpected vaginal bleeding that hasn't been evaluated by a doctor

“With your health-care provider, it's key to discuss your personal and family medical history to weigh the benefits and risks. Every woman should feel empowered and informed to make her own decisions regarding personal healthcare.”

Bioidentical hormones are hormones that are chemically identical to those the human body produces. 

Dr. Premji says that Health Canada has approved forms of hormone therapy that include both bioidentical and synthetic hormones. 

“These hormones are safe and have been proven to show effectiveness with well-designed studies and are the recommended form of hormone therapy.”

However, Dr. Premji advises people to avoid compounded bioidentical hormones. “These are custom-made formulations prepared by pharmacists. The safety and effectiveness of compounded bioidentical hormones isn’t regulated and hasn’t been extensively studied.”

If you’re seeking advice on menopause hormone therapy, Dr. Premji says you have several options for professional guidance. 

“You can start by speaking to your family physician or a gynecologist. They can provide personalized information and treatment options based on individual health needs.”

For more specialized assistance, the Menopause Foundation of Canada offers resources, including a directory of Menopause Specialists in Canada. To ensure quality care, Dr. Premji says it's essential to choose health-care providers who are up to date with the current guidelines and treatments, as recommended by The Menopause Society (TMS).

To understand your treatment plan, Dr. Premji says to have your provider explain:

• The dose – how much of each hormone you’re to take
• The regimen – how often you have to take it
• The route – whether it’s topical or oral

Forms of hormone therapy approved by Health Canada are generally covered under group benefit plans.

Besides MHT, lifestyle adjustments can be quite effective. And Dr. Premji says that there are also other, non-hormonal medications that may work to treat hot flashes.

They include:

• Antidepressants
• Gabapentin, which is typically used to treat migraines and seizures
• Oxybutynin, which is used to treat an overactive bladder 

“Researchers have now developed new treatments,”  Dr. Premji explains. “We now have targeted, non-hormonal therapies available that act on specific brain pathways involved in hot flashes and night sweats. These therapies target specialized brain cells called KNDY (K-N-D-Y) neurons, which play an important role in regulating the body's temperature control system and are thought to be central to the development of vasomotor symptoms.”

Dr. Premji says these medications have been available in Canada since March 2025 and have been well received as an option for women who cannot use hormone therapy due to medical contraindications, who prefer not to use hormones, or who have experienced side effects or intolerance with hormone-based treatments.

Perimenopause and menopause are not merely physiological transitions; they can also mark a period of empowerment and opportunity.

According to Dr. Premji, while there are significant hormonal changes throughout all three stages, there are also benefits at each milestone each stage brings changes, but also opportunities.

“Despite the emotional complexities tied to the loss of fertility, this life phase presents a unique chance – a chance to focus on personal health and well-being.”

Menopause can open a liberating chapter for many of us. 

“It’s a prime time to reestablish yourself as a priority,” says Dr. Premji. “Positive lifestyle changes often become more possible, and for many, the journey towards self-improvement and self-care begins. It is a wonderful time to rediscover and reinvest in yourself.

“With the average lifespan now reaching 80 years, postmenopausal women can anticipate over three decades of active and engaged living. This time is rich with potential.” 

Written in consultation with Dr. Shafeena Premji, BSc MHA MD CCFP FCFP MSCP.