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 answering the same question: what should I do about my hormones?
One 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.
The other says declining estrogen is a whole-body event. Your heart, your brain, your bones, your metabolism. 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 women are sitting in the middle, doing all the things, and still feeling like something isn't quite landing.
I've been confused by this exact debate myself. Let me unpack it properly.
The training-first narrative
This perspective is rooted in exercise physiology and female-specific sports science. When estrogen begins its erratic decline in perimenopause, we lose the hormonal signalling that maintained our muscle fibres, bone density, glucose metabolism, and neuromuscular strength. The argument is that the body is adaptable, and that the right exercise stimulus (specifically heavy resistance training and high-intensity interval work) can replicate much of that signalling from the outside in.
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 responding best (Mohebbi et al., Osteoporosis International, 2023). The earlier you start training intelligently, the better your outcomes.
This narrative also addresses nutrition through a performance and recovery lens. Perimenopausal women who don't fuel adequately before training miss 2 to 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.
What's worth noting is that this approach is largely built for and around women who are already active, already body-literate, and looking to refine what they're doing. The nutritional guidance assumes a woman who is moving, recovering, and asking how to do it better. That is a critically important distinction, and I'll come back to it.
The training-first narrative is empowering 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 training, 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: gynaecologists, menopause practitioners, and women's health advocates who watched a generation of women be undertreated, dismissed, and denied access to hormone therapy. Their frustration is entirely warranted.
For decades, the Women's Health Initiative (WHI) study (flawed in its design and widely misrepresented in its conclusions) caused a generation of clinicians to stop offering HRT to women who genuinely needed it. The current evidence tells a different story. When menopausal hormone therapy 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 and 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 to 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. Know your options, find a provider who listens, and make a decision based on current evidence.
What both narratives are missing
Here is where I need to step in as your nutritional scientist, and as a woman in this season alongside you. Both of these stories, as powerful as they are, leave a critical piece of the puzzle on the table.
The training-first narrative speaks well to the woman who is already active, already fuelling, already asking how to refine her approach. But what about the woman 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 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.
There is a mechanism that both narratives consistently underaddress, and it matters.
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. The first is enhanced protein catabolism, which is acutely reversible with estrogen replacement. The second is 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.
Your body is asking for more protein. When 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, even when you're training consistently and doing everything you've been told is correct.
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 so many 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.
Both narratives can create the impression that choosing one approach is enough. That training hard and fuelling your sessions means you won't need hormones. Or that starting HRT means your body will do the rest. Neither is the full picture.
When you read across the research honestly, these interventions are synergistic. 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.
Your individual biology matters enormously here. 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.
Personalisation is the only scientifically sound approach to women's metabolic health in midlife. That's not a philosophy. It's what the evidence requires.
A personalised approach to HRT, training, and nutrition in perimenopause
Nutrition comes first, always. Not as a diet but as a precision framework. Protein adequacy (1.6 to 2.0g per kilogram of body weight daily, distributed across meals), anti-inflammatory whole foods, stable blood sugar, and adequate energy intake are non-negotiable. Both exercise and HRT perform better when the metabolic foundation is solid. 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 interval sessions, is the evidence-based minimum in perimenopause. 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 is where we begin. It doesn't need to be dramatic or heavy from the outset.
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. For most healthy women initiated within the timing window, the evidence strongly supports its safety and long-term benefit. I opted for it because I wanted all the long-term protective benefits, and I don't hesitate to say so.
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 yours.
The bottom line
The two narratives you're being sold are not wrong perse. They are incomplete, and they need to be adapted to your life, your body, and your starting point.
Exercise is profoundly powerful medicine for the perimenopausal body, and most women are not training hard enough, fuelling consistently enough, or recovering intentionally enough. Declining estrogen is a whole-body event, HRT has been unjustly withheld from women who needed it, and timely, evidence-based hormone therapy is a legitimate and often essential part of this transition.
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. That, my darlings, is the standard worth working toward.
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.
