The Soulful GP
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By Dr Rabia
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14 min read
You Have Options. Here Is Everything You Need to Know

The Soulful GP Perimenopause Series | Part Two

Welcome back.

If you read Part One and felt seen for the first time in years - that was the point. If you forwarded it to your sister, your best friend, your colleague who has been complaining about her frozen shoulder for six months - good. Keep doing that.

Now we go further.

Because understanding what is happening to your body is only the beginning. The real power comes from knowing what you can do about it. And I want to be very clear with you: you have more options than you have been told, and you deserve access to all of them.

This is the part where we talk about treatment. About medicine. About movement, food, sleep, your mind, your spirit - and about how to walk into a doctor’s office and refuse to leave without the care you need.

Let’s go.

First, let’s talk about the fear

Before we get into solutions, we need to address the elephant in the room: HRT.

For over two decades, Hormone Replacement Therapy has been surrounded by fear. Women were told it caused breast cancer. Doctors became reluctant to prescribe it. A generation of women suffered through perimenopause unnecessarily, their symptoms dismissed and their long-term health quietly eroding.

That fear came from one study. The Women’s Health Initiative (WHI), published in 2002, made international headlines with findings that HRT increased the risk of breast cancer and heart disease. Women stopped their prescriptions overnight. GPs stopped offering it.

Here is what the headlines did not tell you.

The women in that study were, on average, 63 years old - well past the optimal window for starting HRT. They were given older, synthetic hormones - not the body-identical hormones we use today. And the absolute risk increase for breast cancer was less than one additional case per 1,000 women per year - smaller than the risk associated with drinking two glasses of wine a day or being overweight.

The study was misreported. The early reporting of the WHI created long-lasting fear, and many women were left undertreated as a result.

The 2024 updated NICE guidelines are clear: for the majority of women who start HRT within ten years of their last period, or before the age of 60, the benefits are likely to outweigh the risks - and that assessment should be made through an individualised, informed conversation between you and your clinician.

The medicine: what modern HRT actually is

Modern HRT is not what your mother was offered. It has evolved significantly, and the version that is now widely considered the preferred approach is called body-identical HRT - hormones that are structurally identical to the ones your body produces naturally, derived from plant sources (usually yams).

There are two key components:

Oestradiol - the main form of oestrogen your body produces - is best delivered transdermally: through a patch, gel, or spray applied to the skin. This route bypasses the liver entirely, which means it does not increase the risk of blood clots the way oral oestrogen does. For many women with migraines, higher BMI, or certain other risk factors where oral HRT may not be suitable, transdermal oestradiol is often the preferred route - though suitability always depends on your individual clinical picture and should be discussed with your doctor.

Micronised progesterone (brand name Utrogestan in the UK) is the body-identical form of progesterone. Unlike older synthetic progestins, it has a more favourable safety profile, is associated with better sleep, and observational evidence suggests it carries a lower breast cancer risk than some synthetic alternatives - though as with all hormonal treatments, individual risk should be discussed with your clinician. It is taken orally at night - and many women find it genuinely improves their sleep quality.

What HRT protects

Heart health: HRT started within 10 years of menopause onset is associated with cardiovascular benefits in observational studies; timing matters and individual risk factors should be discussed.

Bones: HRT is among the most effective pharmacological options for preventing osteoporosis and fractures.

Brain: Early initiation may have benefits for brain health; research into cognitive protection is promising but still evolving.

Mood and sleep: HRT is well-evidenced for improving perimenopausal depression, anxiety, and insomnia.

Genitourinary health: Local vaginal oestrogen reverses GSM with minimal systemic absorption.

And for those who cannot or choose not to take HRT? There are evidence-based alternatives. SSRIs and SNRIs (antidepressants at low doses) have been shown to reduce vasomotor symptoms and improve mood. Gabapentin is effective for night sweats. Fezolinetant - a newly approved medication that directly targets the brain’s thermostat - is now recommended by NICE for moderate-to-severe hot flushes.

Some women have medical reasons why HRT is not appropriate for them, and for others it is simply not the right personal choice. That is entirely valid. The best treatment is always an informed decision made with your clinician - one that weighs your individual history, preferences, and priorities. What matters is that you are given the full picture and allowed to choose.

How to walk into your GP’s office and get what you need

This section might be the most important thing I write today.

Because even if you know everything about perimenopause, even if you have read every study and tracked every symptom - if you cannot communicate effectively with your healthcare provider, the knowledge stays theoretical.

Here is how to advocate for yourself.

Before the appointment: Keep a symptom diary for at least two weeks before you go. Write down every symptom - physical, psychological, sleep-related, menstrual. Note the dates, the severity, and how each symptom affects your daily life. This transforms your experience from a subjective complaint into objective clinical data. It is much harder to dismiss a documented pattern.

In the appointment: Use direct, specific language. Do not say “I’ve been feeling a bit off.” Say: “I believe I am in perimenopause. I have been experiencing [specific symptoms] for [length of time] and they are significantly affecting my quality of life. I would like to discuss my options, including HRT.”

If you are dismissed: If your GP tells you that you are “too young,” that your symptoms are “just stress,” or that HRT is “too risky,” you are entitled to push back. You can say: “I have read the 2024 NICE guidelines, which recommend that HRT should be discussed and offered where appropriate as part of an individualised risk-benefit conversation. I would like to have that conversation.”

You can ask for a referral to a menopause specialist. The British Menopause Society maintains a directory of accredited specialists across the UK. You are entitled to that referral.

If you are a woman of colour, I want to say this plainly: the data shows that Black and South Asian women are significantly less likely to be prescribed HRT, more likely to experience delayed diagnosis, and more likely to have their symptoms attributed to stress or mental health conditions. This is a systemic failure, not a personal one. You are not being dramatic. You are not being difficult. You are being underserved. Know your rights. Bring your symptom diary. Bring the NICE guidelines if you need to. And if one GP does not listen, find another.

Move your body like your life depends on it

I know that when you are exhausted, in pain, and barely sleeping, the last thing you want to hear is “exercise more.” So let me reframe this.

This is not about losing weight. This is not about fitting into a dress. This is about protecting your heart, your bones, your brain, and your metabolic health during the most significant hormonal shift of your adult life.

If there is one form of exercise to prioritise during perimenopause, it is strength training.

Here is why. When oestrogen declines, you begin to lose muscle mass - a process called sarcopenia. You also begin to lose bone density at an accelerated rate. Resistance training - lifting weights, using resistance bands, bodyweight exercises - directly counteracts both of these processes. It also improves insulin sensitivity, reduces visceral fat, and has been shown to reduce the frequency and severity of vasomotor symptoms.

You do not need to become a powerlifter. Two to three sessions per week, with weights that genuinely challenge you, is enough to make a significant difference.

Aerobic exercise - 150 minutes per week of moderate activity - supports cardiovascular health, mood, and weight management. High-Intensity Interval Training (HIIT) has shown particular benefits for fat loss during perimenopause specifically.

Yoga deserves a special mention. It is not just stretching. Yoga combines physical movement, controlled breathing, and mindfulness - addressing perimenopause at multiple levels simultaneously. Multiple studies show it reduces vasomotor symptoms, improves mood, lowers anxiety, and enhances quality of life. For women whose cultural background includes yoga as a spiritual practice, it carries additional meaning and power.

Feed your body what it needs now

Your nutritional needs have changed. The diet that served you in your 30s may not be serving you now, and that is not a failure - it is biology.

Protein is your best friend. Declining oestrogen accelerates muscle loss, and adequate protein intake (aim for 1.2-1.6g per kilogram of body weight per day) is essential for maintaining muscle mass, supporting bone health, and keeping your metabolism functioning well.

Calcium and Vitamin D are critical for bone protection. Aim for 1,000-1,200mg of calcium daily through food (dairy, fortified plant milks, leafy greens, sardines) and supplement vitamin D if you are deficient - which is particularly common in South Asian women who cover their skin, and in anyone living in the UK where sunlight is limited.

Phytoestrogens - plant compounds that mimic a mild oestrogenic effect in the body - are found in soy, flaxseed, chickpeas, and lentils. Some research suggests that regular soy consumption may help reduce hot flush frequency, which may partly explain why East Asian women, whose traditional diets are rich in soy, tend to report fewer severe vasomotor symptoms - though the evidence varies across studies.

What to reduce: Alcohol worsens hot flushes and disrupts sleep. Caffeine can trigger vasomotor symptoms and exacerbate anxiety. Processed sugar and refined carbohydrates worsen insulin resistance. None of this means deprivation - it means being strategic about what you put in your body during a time when your body is working harder than usual.

The mind: your most powerful tool

The psychological symptoms of perimenopause - anxiety, depression, brain fog, emotional volatility - are among the most debilitating and the least discussed. They are also among the most treatable.

Cognitive Behavioral Therapy (CBT) is the most extensively researched psychological intervention for perimenopause. A 2024 meta-analysis of 30 studies involving over 3,500 women found that CBT significantly improved anxiety, depression, and cognitive function. CBT for Insomnia (CBT-I) is now a strongly recommended first-line treatment for menopause-related sleep problems, with evidence suggesting it outperforms sleeping tablets in the long term and carries no dependency risk.

Mindfulness reduces the reactivity to symptoms. It does not necessarily reduce the frequency of hot flushes, but it changes your relationship to them - reducing the fear, the anticipation, the sense of being at the mercy of your own body. Research shows medium effect sizes for anxiety reduction in menopausal women who practise mindfulness regularly.

Hypnotherapy - and I say this as a doctor who respects the evidence - has shown consistently strong results in clinical trials. Five sessions of clinical hypnosis reduced hot flush frequency by 74% in one major study. It is recommended by the North American Menopause Society. It is not woo. It is neuroscience.

And perhaps most importantly: community. The research on social support and menopause is clear. Women who have people to talk to - who feel seen, validated, and not alone - report significantly lower levels of distress during the transition. If your community does not yet have that conversation, be the one who starts it.

The spirit: reclaiming this transition

The evidence can guide treatment. What comes next is something medicine often overlooks - and something I believe matters just as much.

I want to share something the medical literature rarely says, but that I believe deeply.

Perimenopause is not just a hormonal event. It is a threshold. A turning point. And across many of the world’s wisdom traditions, it has been understood as such.

In Japan, the word for menopause is konenki - meaning “renewal energy.” In many African traditions, older women are honoured as queens, as keepers of wisdom, as the ones who have earned the right to speak truth. In Ayurvedic medicine, this phase is understood as a time to turn inward, to nourish the self, to cultivate the wisdom that comes from having lived.

These are not naive sentiments. They are alternative frameworks - ones that position this transition not as a loss but as a becoming.

The chronic stress that many women carry through this period - the stress of being everything to everyone, of managing the household and the career and the ageing parents and the growing children while quietly falling apart inside - is itself a physiological problem. Elevated cortisol suppresses oestrogen production, worsens insulin resistance, disrupts sleep, and accelerates bone loss. Stress is not just uncomfortable. In perimenopause, it is biologically costly.

Practices that reduce stress - prayer, meditation, yoga, time in nature, creative expression, rest - are not indulgences. They are medicine. They are, in the most literal sense, health-protective.

Give yourself permission to receive care, not just give it.

You are not at the end of something. You are at the beginning.

I want to leave you with this.

The women who come through perimenopause with their health, their vitality, and their sense of self intact are not the ones who suffered in silence. They are the ones who got informed, got supported, and got the care they deserved.

They are the ones who stopped apologising for their symptoms and started treating them as the medical signals they are.

They are the ones who walked into the GP’s office with their symptom diary and their NICE guidelines and refused to leave without a plan.

They are the ones who started lifting weights, eating protein, sleeping with intention, and building the communities where these conversations could finally happen.

That woman can be you.

You are not going mad. You are not weak. You are not too young, too old, too dramatic, or too much.

You are a woman in perimenopause. And you deserve every tool, every treatment, and every conversation that will help you not just survive this - but thrive through it.

The Soulful GP | Mind · Body · Soul

If this series has helped you, share it. Print it. Read it to your mother. Send it to your GP. The more women who know, the more women who get the care they deserve.

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