The two HRT stories we’re being sold—and why you’re probably stuck in the middle
If you've spent any time in the perimenopausal wellness space recently, you've probably encountered two very distinct voices , two very different answers to the same question: what should I do about my hormones?
On one side, there's the narrative that says: lift heavy, fuel your training, eat enough protein, push harder — and your body will adapt. Hormones are declining, yes, but the right external stressors can replicate the signalling that estrogen used to provide. You don't necessarily need HRT.
On the other, there's the narrative that says: declining estrogen isn't just about hot flashes. It's a whole-body event — your heart, your brain, your bones, your metabolism — and lifestyle changes, as powerful as they are, cannot fully compensate for what those hormones were doing. HRT is not optional for many women. It's the foundation that makes everything else work.
Both camps are populated by brilliant, evidence-driven voices who genuinely care about your health. Both are right in important ways. And both leave something critical out of the conversation — which is why so many of you are sitting in the middle, doing all the things, and still feeling like something isn't quite landing.
Let me unpack this properly as a women who has also been confused in the past about this exact thing.
HRT vs. exercise in perimenopause: the training-first narrative
This perspective is rooted in exercise physiology and female-specific sports science. The central argument being: when estrogen begins its erratic decline in perimenopause, we lose the hormonal signalling that maintained our muscle fibres, our bone density, our glucose metabolism, and our neuromuscular strength. But the body is adaptable. The right exercise stimulus — specifically heavy resistance training and high-intensity interval work — can replicate much of that signalling from the outside in. Sounds simple right?
The science behind this is solid. A 2023 meta-analysis of 80 studies involving more than 5,500 postmenopausal women confirmed that exercise positively affects bone mineral density at the lumbar spine, femoral neck, and total hip — with early postmenopausal women, those closest to the transition, responding best (Mohebbi et al., Osteoporosis International, 2023). The message: the earlier you start training intelligently, the better your outcomes.
This narrative also addresses nutrition and importantly, it does so through a performance and recovery lens. The argument is well-made that training fasted or under-fuelled in perimenopause is counterproductive: perimenopausal women who don't fuel adequately before training miss 2–5% of their top training load, simply because they can't generate the intensity needed to drive adaptation. Protein timing, pre-training fuelling, and adequate energy intake are all part of this framework. This is true for women in this camp.
It's worth noting, however, that this approach is largely built for and around active women — those who are already training, already body-literate, and looking to optimise around their hormonal changes. The nutritional guidance assumes a woman who is moving, recovering, and asking how to do it better. That is a critically important distinction, and we'll come back to it.
The training-first narrative is empowering, practical, and genuinely backed by evidence. It also carries an important cultural message, you don't have to wait for a prescription to start protecting your future self. Your gym, your kitchen, your sleep, these are your first line of defence which is true.
Is HRT necessary during perimenopause? The hormone-first narrative
The other narrative comes largely from the clinical world — from gynaecologists, menopause practitioners, and women's health advocates who watched a generation of women be undertreated, dismissed, or denied access to hormone therapy. Their frustration is entirely warranted.
For decades, the Women's Health Initiative (WHI) study — flawed in its design, misrepresented in its conclusions — caused a generation of clinicians to stop offering HRT to women who genuinely needed it. The current evidence tells a very different story. When menopausal hormone therapy (MHT) is initiated in women under 60 and within 10 years of menopause — what researchers call the "timing hypothesis" — the outcomes are striking. A landmark study showed a 52% reduction in cardiovascular disease after 10 years of randomised HRT, with benefits persisting at 16 years of follow-up (Hodis & Mack, Cancer Journal, 2022). A 2024 retrospective cohort study of over 6,500 participants found that HRT was associated with significantly lower diabetes incidence over 20 years, most pronounced in women aged 46–60 (Harper-Harrison et al., StatPearls, 2024).
Sleep, mood, bone protection, cardiovascular health, cognitive function, the evidence for timely, appropriately-dosed hormone therapy across all of these domains continues to strengthen. A 2025 narrative review synthesising contemporary MHT literature concluded that transdermal estradiol at low-to-moderate doses, initiated within the timing window, is both effective and carries a favourable risk profile for the vast majority of perimenopausal women (IJMS, 2025).
This narrative advocates for informed consent, clinical access, and patient empowerment. Its message is clear: know your options, find a provider who listens, and make a decision based on evidence — not on decades-old fear.
What both HRT narratives are missing — and why it’s crucial to understand
Here's where I need to step in as your nutritional scientist and a woman in this season with you, because both of these stories, as powerful as they are, leave a critical piece of the puzzle on the table.
The training-first narrative speaks beautifully to the woman who is already active, already fuelling, already asking how to refine her approach. But what about the woman who isn't there yet? The one who is symptomatic, possibly deconditioned or metabolically compromised, whose gut health is suboptimal, whose energy intake has been chronically too low for years? She picks up the training-first advice and can't execute it, why? because her metabolic foundation simply isn't in place. The guidance was never built for her starting point.
The hormone-first narrative addresses nutrition broadly , anti-inflammatory eating, fibre, protein — but not at the level of precision that determines how well a woman actually absorbs, utilises, and responds to everything she's doing. Gut function, liver detoxification pathways, individual food responses, inflammatory load, these are the variables that determine whether your HRT lands the way it should, or whether it feels like it's doing very little.
And there's a mechanism that both narratives underaddress, which I think is genuinely important.
A 2023 paper published in BJOG: An International Journal of Obstetrics and Gynaecology identified that during the menopausal transition, two interacting mechanisms drive net protein breakdown in the body: enhanced protein catabolism, which is acutely reversible with estrogen replacement and anabolic resistance, a blunted ability to synthesise muscle protein from dietary protein (Simpson et al., BJOG, 2023). Together, these can trigger what researchers called the Protein Leverage Effect: when the body's appetite for protein rises but dietary protein concentration doesn't increase to match it, excess non-protein energy is consumed — and stored as fat.
In other words your body is asking for more protein. If it doesn't get it at the right amount and at the right times, it compensates in ways that make fat gain and muscle loss feel inevitable and yes even when you're training consistently and doing everything you've been told is right.
A 2024 narrative review confirmed that perimenopausal and postmenopausal women experience significantly higher anabolic resistance than younger women, requiring more dietary protein at each meal to maximally stimulate muscle protein synthesis — a threshold that most women are simply not reaching (Mackay et al., Physiologia, 2024).
This is not a minor detail. This is the mechanism. And it sits underneath both narratives, largely unaddressed.
Why perimenopausal women feel stuck in the middle
If you're reading this and recognising yourself , training consistently, maybe already on HRT, eating reasonably well, and still wondering why you're not feeling or looking the way you expected, this is likely why.
Because both narratives, as valuable as they are, can create a false sense that choosing one approach is enough. That if you just train hard and fuel your sessions, you won't need hormones. Or that if you just start HRT, your body will do the rest. Neither is the full picture.
What the research tells us ,when you read across it honestly is that these interventions are synergistic, not competing. Estrogen replacement enhances muscle protein synthesis. Resistance training enhances hormonal sensitivity and metabolic flexibility. Adequate protein provides the raw material for both to work. Anti-inflammatory, whole-food nutrition supports the gut, the liver, and the hormonal detoxification pathways that determine how well you metabolise and respond to everything you're putting in.
And critically your individual biology matters enormously. Your symptom burden, your stress history, your gut function, your genetics, your cardiovascular risk profile, your relationship with food. All of these shape which intervention you need first, how much of each you need, and in what order.
This is why personalisation is the only option. It's the scientific reality of women's metabolic health in midlife.
A personalised approach to HRT and nutrition in perimenopause
Rather than choosing a camp, here's how I guide the women I work with to think about this:
Nutrition comes first — always. Not as a diet, but as a precision framework. Protein adequacy (1.6–2.0g per kg of body weight daily, distributed across meals), anti-inflammatory whole foods, stable blood sugar, and adequate energy intake are non-negotiable. Without these, both exercise and HRT are working against a metabolic headwind. It's the right food, in the right amounts, for your biochemistry.
Training is medicine. Three sessions of heavy compound resistance training per week, alongside one to two high-intensity intervals, is the evidence-based minimum in perimenopause. Not because you need to earn your body, but because your muscle and bone require that mechanical loading signal now that estrogen is no longer providing it consistently. And if you're not yet at that starting point — that's where we begin. It doesn’t need to be difficult or massive heavy sessions.
HRT is a clinical decision — and an informed one. For many women, particularly those with moderate-to-severe symptoms or entering perimenopause in their early-to-mid forties, timely initiation of appropriately-dosed hormone therapy can be genuinely transformative. It's not a sign of failure. It's not a shortcut. And for most healthy women initiated within the timing window, the evidence strongly supports its safety and long-term benefit. I opted for it as I wanted all the benefits for a healthy long life.
Personalisation determines the sequence. Some women need their nutrition stabilised before their body can respond to training. Some need their hormones addressed before their sleep is functional enough to support recovery. Some need gut healing before they can even absorb the protein they're consuming. There is no universal starting point only your starting point.
The bottom line on HRT, exercise, and nutrition in perimenopause
The two narratives you're being sold aren't wrong but they do need to be nuanced and adapted for YOUR life and body and sustainable.
The training-first perspective is right that exercise is profoundly powerful medicine for the perimenopausal body — and that most women are not training hard enough, fuelling consistently enough, or recovering intentionally enough. The hormone-first perspective is right that declining estrogen is a whole-body event, that HRT has been unjustly withheld from women who needed it, and that timely, evidence-based hormone therapy is a legitimate and often essential part of navigating this transition.
But neither replaces the other. And neither replaces the foundational, individualised nutritional work that makes both of them work, for the woman in front of me, with her specific biology, her specific history, and her specific starting point.
You deserve to have all the cards on the table. You deserve a framework that honours your biology, your symptoms, your lifestyle, and your goals not one that fits you into a philosophy built for someone else (there is enough pressure in daily living for that).
References:
Mohebbi R, et al. Exercise training and bone mineral density in postmenopausal women. Osteoporosis International, 2023.
Hodis HN & Mack WJ. Menopausal hormone replacement therapy and reduction of all-cause mortality and cardiovascular disease. Cancer Journal, 2022.
Harper-Harrison G, et al. Hormone replacement therapy. StatPearls, 2024.
Simpson SJ, et al. Weight gain during the menopause transition: evidence for a mechanism dependent on protein leverage. BJOG, 2023.
Mackay H, et al. The impact of protein in post-menopausal women on muscle mass and strength. Physiologia, 2024.
Davis SR, et al. The 2023 practitioner's toolkit for managing menopause. Climacteric, 2023.
Menopausal hormone therapy — risks, benefits and emerging options: a narrative review. International Journal of Molecular Sciences, 2025.
Mikaela Deats is a BSc (Hons) Nutritional Scientist and Women's Metabolic Health Specialist based in Christchurch, New Zealand. She is the founder of M Deats Wellness and creator of the Sérenité Women's Wellness Programme — a personalised, science-based metabolic health programme for perimenopausal women.
