GP & Sara Gottfried, M.D., on Perimenopause, Menopause & Hormone Resets

Written by: the Editors of goop


Updated: April 5, 2018


Reviewed by: Dr. Sara Gottfried

GP sat down with hormone expert Dr. Sara Gottfried to get the answers that elude women in hormonal transitions: Is it advisable to take hormones during perimenopause or menopause? What kind? Are there nonprescription alternatives that help with symptoms like mood swings and hot flashes?

Educated at MIT and Harvard Medical School, Gottfried is a board-certified ob-gyn physician-scientist, which means she is a practicing doctor who focuses on research. Gottfried takes a holistic approach to restoring hormonal balance. She has developed a three-step protocol for addressing the symptoms of perimenopause and menopause (like drops in libido, increased inches around the waist, and other unwelcome physiological changes). She starts with food and lifestyle interventions and has found that a majority of women don’t need anything else to feel like themselves again. (To simplify things, Gottfried formulated a powdered shake that checks off a lot nutritional boxes. Her favorite is chocolate, which she wrote a guide about on goop.) For women who need more support, Gottfried recommends herbal remedies next and is open to hormone therapy: “Why shouldn’t women consider replacing the hormones their bodies are missing, especially if their quality of life is miserable and they are good candidates?”

This is what you’ll find distilled in Gottfried’s books (like The Hormone Cure and The Hormone Reset Diet) and online protocols (like the Hormone Reset Detox): Her arsenal of research and proven strategies serves as a guide for women looking to make the choices (in partnership with their doctors) that work best for their fluctuating hormones. For a crash course in rebalancing hormones, watch her in conversation with GP and listen to Gottfried delve into how she unexpectedly turned around her own out-of-whack hormones on The goop Podcast.

A Q&A with Sara Gottfried, M.D.


How do hormones get thrown off around perimenopause and menopause?


Women have it tough. Once we hit thirty-five to forty, hormonal balance becomes elusive as estrogen, progesterone, testosterone, cortisol, thyroid, insulin, and leptin may become out of whack. It’s gradual for some and dramatic for others. But perimenopause and menopause need not be a torturous slog through hormonal hell. Your body prefers to be in hormonal homeostasis, a state of equilibrium. A few tweaks are often all that’s needed to restore balance. Some of us need more support, and there are strategies that work for both camps and everyone in between.

Perimenopause refers to the years of hormonal upheaval before your last menstrual period, which occurs on average around age fifty-one. However perimenopause is a state of body and mind, not a chronological destination. It begins with dropping progesterone levels and ends with dropping estrogen levels in the year or two before your final period. Some women will notice the start of this shift as their periods become closer together and perhaps heavier. For some women, perimenopause is a time when mood becomes unpredictable, weight climbs, or energy wanes—and most commonly, women experience a combination of all three symptoms.

Women in perimenopause may experience low progesterone as sleep disruption, night sweats, heavier and shortened menstrual cycles, and anxiety—i.e., fretting over work and field trip permission slips in the middle of the night. Low estrogen may add mild depression to the mix, along with wrinkles, poor memory, hot flashes/night sweats, vaginal dryness, droopy breasts, achy joints, and more sun damage, especially on the chest and shoulders. In your forties, gene variants, like the short serotonin transporter gene (5-HTTLPR, or SLC6A4), can cause you to feel more stress, anxiety, and depression as estrogen drops. [Editor’s note: Read more in The Hormone Cure, pages 62 to 63.]

Menopause is when you officially cease menstruation for one year. Women in menopause commonly have low cortisol during the day, which may make them feel tired, and high cortisol at night, which may make them worry about everything from the stock market to whether or not their kids will get decent jobs.

At any time, a woman can experience low thyroid function, but this is more common after age fifty. Thyroid-related symptoms include lethargy, weight gain, loss of the outer third of the eyebrows, dry skin, strawlike hair that tangles easily, thin/brittle fingernails, fluid retention, high cholesterol, constipation, decreased sweating, cold hands and feet, and cold sensitivity (i.e., skiing sounds miserable but a trip to Hawaii sounds just right).

Testosterone starts declining 1 to 2 percent per year starting in your thirties, and it may lead to decreased confidence, feelings of helplessness, low or no sex drive, loss of muscle mass or less of a muscle response to resistance training, and loss of pubic hair and clitoral size. No bueno—but there is help.


Is there a greater emotional component to periods of hormonal transition—and any upside?


Many women in their forties and fifties reach a point of reckoning and can no longer tolerate toxic or codependent relationships—or even friendly neighbors who now just seem annoying and nosy. Since hormones drive what you’re interested in, there’s certainly a hormonal component in the shift from the reproductive years to perimenopause. In our reproductive years, hormones fluctuate predictably every day, and women typically accommodate, accommodate, accommodate other people’s needs—often at the expense of their own—and roll with the punches. In perimenopause, estrogen fluctuates wildly, and we tend to care less about pleasing others and become more comfortable with who we are. Being able to speak your truth and stand your ground happens earlier for some wise women, but for me, it began around forty-five. Dr. Christiane Northrup first spoke about how you pierce the hormonal veil starting in your forties and move into what I would call your wiser, more grounded years with greater faith in yourself and personal power.

“Many women in their forties and fifties reach a point of reckoning and can no longer tolerate toxic or codependent relationships—or even friendly neighbors who now just seem annoying and nosy.”


How does gut health fluctuate with hormonal changes?


It’s bidirectional: Your gut controls your hormone levels, and your hormones strongly influence your gut function. For instance, not eating enough fiber or consuming excess red meat can raise estrogen levels unfavorably by stimulating the estrobolome—the aggregate microbes in your gut that affect estrogen levels and risk of estrogen-dependent conditions, like breast and endometrial cancer, diabetes, and obesity. The gut-brain axis puts your gut function at the center of any mood, weight, and energy issue that a woman faces. For example, excess stress and cortisol can poke holes in the gut, leading to symptoms like constipation, gas, bloating, loose stool, diarrhea, and feeling tired and foggy. Nutrient deficiencies can show up, leading to moodiness, weight gain, even autoimmunity, like Hashimoto’s thyroiditis.


Where do stress and cortisol come into play?


High stress strongly affects the control system of most hormones, which is the brain-body system known as the hypothalamic-pituitary-adrenal-thyroid-gonadal (HPATG) axis. It’s a mouthful. When a woman comes to my functional medicine office asking me to just write a prescription for bioidentical hormones so she can feel like her old self again, we have to look upstream at why her hormones are out of whack. And 99 percent of the time, the HPATG is in disarray. That’s the primary reason for hormone imbalance: wayward feedback loops in a woman’s control system. And fixing it begins with unlocking the most important hormone first—cortisol. Nearly all other hormones depend on it.

“When a woman comes to my functional medicine office asking me to just write a prescription for bioidentical hormones so she can feel like her old self again, we have to look upstream at why her hormones are out of whack.”

Unlocking cortisol isn’t a matter of meditating more or better (although that helps), but it requires measuring your cortisol (which I do via dried urine, at four points during the day) and how your body metabolizes it. This wear-and-tear hormone is in charge of blood sugar, blood pressure, gut, and immunity, so rebalancing cortisol involves extensive lifestyle medicine adjustments, personalized for your life situation and root cause. A forty-seven-year-old runner who sleeps six hours per night, travels 50 percent of the time, and has high cortisol and low progesterone might need more B vitamins, vitamin C, and magnesium; adaptive exercise (yoga, Pilates); and maybe a botanical, like chasteberry, for progesterone and Cortisol Manager to help her sleep. An overweight forty-two-year-old with carb cravings, weight loss resistance, and gas might need gut and blood testing, a detox, and a carb blocker. So the approach involves an integrated model of biology, psychosocial context, hormones, gut health, cell energy, even genetic study.


What’s the foundation of the Gottfried Protocol and what does your three-step protocol for resetting hormones look like?


It’s based on decades of research, my time at Harvard Medical School, my experiences with my own hormonal imbalances, peer-reviewed and well-performed randomized trials, and what I’ve learned from patients over the past twenty-plus years of practicing medicine. When I dealt with my own hormone imbalances, my goal was to discover the root causes, to formulate a customized and rigorous fix, and to track my progress. I drew upon many sources, including traditional Chinese and Ayurvedic medicine. In the Gottfried Protocol, I combine the latest medical advances and cutting-edge techniques with ancient treatments validated by modern research and scores of women in my practice.

“Even if you’re genetically programmed to develop depression or cancer, the way you eat, move, and supplement can alter how your genes express themselves.”

Some studies suggest that your genes directly control only about 10 to 15 percent of your biology. They are a blueprint only. As a general rule, your environment controls the remainder. A rather simple formula of nutrient-rich food, targeted supplements to address missing precursors, and lifestyle changes can keep your genes in “repair” mode. Even if you’re genetically programmed to develop depression or cancer, the way you eat, move, and supplement can alter how your genes express themselves. This fascinating field of epigenomics examines how genes are modified without changing the DNA sequence—that is, how a gene for obesity, for instance, is modified by eating nonstarchy vegetables versus cupcakes. Your genes are a template; you can often leverage epigenetics to overrule genetic predispositions.

Epigenomics is the foundation of the Gottfried Protocol. Creating a reproducible methodology to assess, support, and maintain hormonal balance for myself and my clients took more than ten years. I defined, tested, and refined a systematic three-step approach:

Step 1. Lifestyle design—food and nutraceuticals fill in the missing precursors to proper brain-hormone communication, along with targeted exercise

Step 2. Herbal therapies

Step 3. Bioidentical hormones

Most of my recommendations are available without prescription. When women put an earnest effort into step 1 of the protocol, they find most of their symptoms of hormone imbalance disappear. If they don’t, we shift to step 2—proven botanical therapies. After completing steps 1 and 2, few women need bioidentical hormones, but for those who do, the doses and duration of treatment are often lower than if they’d skipped the lifestyle design and herbal therapies.

Sometimes a small adjustment creates big changes. I love it when a patient realizes that she can alter her presumed life sentence of low sex drive with a particular form of meditation (like OM), a natural plant-based supplement like phosphatidylserine, and a maca smoothie.


What should you consider before taking hormones?


I have a food-first philosophy, so I prescribe lifestyle medicine prior to bioidentical hormone therapy. In perimenopause, I recommend The Hormone Reset Diet as a start. In our experience with 25,000 women, this protocol resolves 80 percent of hormonal symptoms, based on quantitative surveys conducted pre and post-protocol. If it doesn’t address your concerns within four to six weeks, move on to proven botanicals, like chasteberry for PMS, ashwagandha for sleep, or Lavela for anxiety. It takes four to six weeks to reach a new equilibrium with hormones, so be patient. If your symptoms persist, it’s reasonable to discuss bioidentical hormones.

Before taking hormones, it’s important to consider genetic and environmental risks. I ask my patients about contraindications, including blood clots, pregnancy, moderate to severe endometriosis, enlarging fibroids associated with heavy bleeding, gallbladder disease, liver disease (because the liver processes estrogen and sends it to the gut via bile), unexplained vaginal bleeding, atypical hyperplasia of the breast, and some types of estrogen-sensitive breast, endometrial, and ovarian cancer. To look for genetic contraindications or further issues to discuss, I run two different genomic profiles, 23andMe and the Genova Estrogenomic Profile, to make sure a patient is a good candidate. This conversation should include extensive informed consent of risks, benefits, and alternatives, all in a nonrushed context, i.e., no hand on the door.

It may sound like an obstacle course that few complete, but many of my patients safely choose bioidentical hormone therapy. Often it’s a quality of life decision, or a commitment for three to six months followed by a reevaluation. When they’ve done the first two steps of the Gottfried Protocol, I find that my patients need the lowest hormone doses for the shortest durations, making the risk lower. I negotiate with my patients every three to twelve months as we determine whether the benefits outweigh the risks, and I stop most treatment ten years postmenopause (around age sixty to sixty-five), if not earlier.

To be more complete, risks include a greater chance of blood clots (venous thromboembolism), heart disease, stroke, gallbladder disease, and possibly breast cancer and dementia. Potential benefits include better mood and sleep, improvement in hot flashes and night sweats, increased lean body mass, less anxiety, higher sex drive, fewer clinical bone fractures, and possibly lower rates of colorectal cancer.


What kind of hormones do you prescribe? Can you explain bioidentical versus synthetic?


There’s a popular movement to favor bioidentical hormones over synthetic hormones. Bioidentical hormones are exact replicas of the hormones your body makes during your fertile years, including estradiol and progesterone, which are the two hormones commonly referred to as “bioidenticals.” Synthetic hormones have a different chemical structure, which allows them to be patented by pharmaceutical companies. It’s important to recognize that bioidentical hormones include both FDA-approved forms as well as non-FDA-approved forms made by compounding pharmacies, such as Biest, which contains both estradiol and estriol.

Some alternative providers insist that bioidenticals solve every problem a menopausal woman has and are vastly superior to their synthetic and animal-derived counterparts. Academic and mainstream thought leaders think you’re being taken for a ride. Where’s the truth? I suspect it’s somewhere in the middle. When I counsel a woman about taking hormone therapy, I recommend bioidentical estrogen and progesterone, including transdermal estradiol and oral progesterone, but with an important caveat: I assume that the risks of bioidentical hormone therapy are the same as synthetic until proven otherwise.

Overall, compounded bioidentical hormones often lack the regulatory oversight and rigorous testing that I believe women deserve. Based on current data, I prefer to prescribe FDA-approved forms of bioidentical hormones, particularly the estradiol skin patch and oral micronized progesterone (Prometrium) pills.

Bioidentical Progesterone

Some women are at the point in their ovarian lives where an herb like chasteberry isn’t an option: Because they are in late perimenopause or menopause, their ovaries can no longer respond. Time for option B.

For a woman with the perimenopausal symptoms of shorter cycles, heavier bleeding, or difficulty sleeping, I prescribe bioidentical progesterone. You could start with a small dose of progesterone cream. Bioidentical progesterone is biochemically the same as the progesterone you make in your ovaries. In most over-the-counter creams, twenty milligrams equals about a quarter teaspoon. Rubbing a quarter teaspoon (about the size of a dime) into your arms where they’re hairless and the skin is thin for fourteen to twenty-five nights per month, is often enough to relieve the symptoms of low progesterone.

There are three randomized trials demonstrating the efficacy of progesterone cream for women with symptoms of low progesterone, such as hot flashes. One examined a dose of twenty milligrams a day, and when it came to hot flashes, 83 percent in the cream group experienced fewer flashes (versus 19 percent in the placebo group), but several of the women experienced vaginal bleeding. If you have bleeding, consult a doctor immediately. Another trial looked at a dosage of thirty-two milligrams per day and found that the progesterone cream raised serum levels but did not affect hot flashes, mood, or sexual drive. One trial of progesterone cream at various doses showed no change in hot flashes—this time using progesterone cream at doses of sixty, forty, twenty, and five milligrams or placebo. Another review found no benefit, so the data are not concordant. It’s possible that the different formulations of progesterone cream are responsible for the inconsistent results; anecdotally, many of my patients find it to be helpful.

Bioidentical Estrogen

I am confident recommending estradiol patches to appropriate patients, provided they do not have issues that make using the patches unsafe, such as a history of blood clots, and they are not ten years past menopause (beyond ten years from menopause, the risk of heart disease rises). Because these patches are approved by the FDA, there is excellent regulatory oversight. Examples are Vivelle-Dot and Climara, taken at the lowest doses that relieve symptoms. I’ve found that, for most of my patients, doses of 0.025 milligrams or 0.0375 milligrams work effectively.

Estrogen’s ability to raise serotonin, which is associated with improved mood, sleep, and appetite, is well proven. At the latter half of perimenopause, which normally begins around age forty-three to forty-seven, estrogen withdraws from the daily hormonal menu. Many women find that estrogen withdrawal causes serious mood changes, which may relate to genetic vulnerability combined with environmental factors—the so-called GxE interface. Data from a randomized trial that examined perimenopausal women ages forty to fifty-five who had either major or minor depression showed that the estrogen patch caused a remission of symptoms in 68 percent of women assigned to the patch, compared with 20 percent in the placebo group. In short, estrogen has an antidepressant role, particularly with mood disorders affecting women over forty.

Any woman with a uterus who takes systemic estrogen of any type, such as a cream, patch, or pill, must counterbalance the estrogen with progesterone, delivered orally as a pill, to prevent a buildup of excess tissue in the uterine lining, which may turn into precancer or cancer—which is why I believe in the lowest possible doses of FDA-approved and regulated transdermal estrogen balanced with oral progesterone.

Sara Gottfried, M.D., is the New York Times bestselling author of Younger, The Hormone Reset Diet, and The Hormone Cure. She’s a graduate of Harvard Medical School and MIT. You can read more of her articles on hormones and weight-loss resistance on goop, and learn more about her online programs and supplements here.

The views expressed in this article intend to highlight alternative studies and induce conversation. They are the views of the author and do not necessarily represent the views of goop, and are for informational purposes only, even if and to the extent that this article features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment, and should never be relied upon for specific medical advice.

Related: Female Hormones