New UCLA research on menopause and cognition — see what Dr. Voskuhl's team found.
Getting Started
How do I know if I have brain fog?
Menopause brain fog usually shows up as difficulty concentrating, losing words mid-sentence, trouble holding several tasks at once, or forgetting things you would normally retain. Many women attribute these changes to stress, poor sleep, or aging before connecting them to hormonal changes.
If you are in perimenopause or menopause, take the Menopause Brain Fog Assessment. A CleopatraRX clinician can review your responses with you to determine whether PearlPAK may be appropriate.
Can a doctor evaluate brain fog remotely?
Yes. Cognitive symptoms are assessed based on what you report about your symptoms and medical history, which a clinician can do by telemedicine the same way they would in person.
After scheduling a consultation with a CleopatraRX clinician, you will be asked a series of questions about your symptoms and medical history. If you are a a candidate, your case is then reviewed by a consulting physician, who determines whether PearlPAK is appropriate for you.
Do I need a prescription for PearlPAK?
Yes. Estriol and progesterone are both prescription medications, so PearlPAK requires a prescription from a licensed clinician.
Where is PearlPAK available?
PearlPAK is available by prescription in the 48 contiguous United States. It is not currently available in Alaska or Hawaii. See our Availability of Services page for the current list.
Is my information safe?
Yes. CleopatraRX works with board-certified, licensed physicians who operate under HIPAA, the federal law protecting sensitive patient health information. We also maintain security protocols and access controls to protect the information you share with us.
You can read more in our Privacy Policy.
About PearlPAK
Who is CleopatraRX and what is PearlPAK?
CleopatraRX provides access to PearlPAK, a compounded hormone therapy developed at UCLA for women experiencing cognitive symptoms during perimenopause and menopause.
PearlPAK can be prescribed by a CleopatraRX consulting physician or your own physician, and is prepared by a partner compounding pharmacy. CleopatraRX is not a pharmaceutical company.
How does PearlPAK work?
Estrogen levels decline during perimenopause and menopause. Estrogen receptors are present throughout the body, including in regions of the brain involved in memory and attention, which is one reason cognitive symptoms are common during this transition.
PearlPAK combines estriol and micronized progesterone at a dose determined by your consulting physician, to address menopause-related symptoms including cognitive symptoms.
Is PearlPAK bioidentical?
Yes. PearlPAK contains estriol and micronized progesterone, both of which are structurally identical to hormones the human body produces.
“Bioidentical” describes chemical structure and does not by itself mean a medication is safer or more effective than other forms of hormone therapy. PearlPAK is compounded and has not been evaluated by the FDA for safety or effectiveness. Talk with a CleopatraRX consulting clinician or your physician about whether it is appropriate for you.
Is estriol the same as estradiol?
No. Estriol and estradiol are both estrogens, but they interact with estrogen receptors differently. Estradiol binds strongly to both ER-alpha and ER-beta receptors. Estriol is a weaker estrogen with relatively greater activity at ER-beta, the receptor subtype found in higher concentrations in regions of the brain involved in memory and attention.
PearlPAK uses estriol rather than estradiol because of this receptor profile and Dr. Voskuhl’s research on estriol and cognitive function in women.
If you have previously taken estradiol and had side effects, bring that history to your consultation. Your clinician will review what happened and determine whether PearlPAK is an appropriate option for you.
What is a compounded medication?
Compounding is the preparation of a medication by a licensed pharmacy to meet the specific needs of an individual patient, based on a prescription from a clinician. It allows a dose or combination to be tailored in a way that commercially manufactured products may not accommodate.
Why is PearlPAK not FDA approved?
Compounded medications do not go through the FDA’s premarket approval process. Because each prescription is prepared for an individual patient, the FDA does not review a compounded medication for safety, effectiveness, or quality the way it reviews a commercially manufactured drug.
Compounding pharmacies remain subject to applicable federal and state requirements, including oversight by state boards of pharmacy.
Where is PearlPAK made, and who regulates its quality?
PearlPAK is prepared at a licensed contracted pharmacy subject to annual inspection and review by the state Board of Pharmacy. Bulk compounding ingredients are purchased from FDA-registered facilities, and each batch is reviewed for quality by the pharmacist. Each prescription is compounded to the dose specified by your clinician.
Who is Dr. Rhonda Voskuhl?
Dr. Rhonda Voskuhl, M.D. is a Professor of Neurology at the University of California, Los Angeles and the founding neurologist of the UCLA Comprehensive Menopause Program. She received her M.D. from Vanderbilt Medical School, completed her neurology residency at UT Southwestern, and completed a fellowship at the National Institutes of Health. Her research on sex differences in neurological disease has been funded by the NIH.
Learn more about Dr. Voskuhl’s research.
Safety and side effects
What are the risks of estriol treatment?
Estriol is an estrogen, and it carries the risks associated with estrogen therapy generally. These include an increased risk of endometrial cancer if estrogen is taken without adequate progesterone, as well as blood clots, stroke, gallbladder disease, and, with long-term use in some women, breast cancer. The risk of heart disease is higher for women who begin hormone therapy more than 10 years after menopause starts.
More common side effects can include breast tenderness, headache, nausea, bloating, mood changes, and changes in menstrual bleeding.
Risks are generally lower for women who begin hormone therapy before age 60 or within 10 years of menopause, who take progesterone if they still have a uterus, and who stay current with gynecologic exams and mammograms. Your individual risk also depends on your health history and family history. Estriol has not been evaluated by the FDA for the treatment of any condition.
Discuss your full medical history with your prescribing clinician. Contact them promptly if you experience unusual vaginal bleeding, chest pain, shortness of breath, leg swelling or pain, severe headache, or vision changes.
What are the risks of progesterone treatment?
Micronized progesterone is generally well tolerated. Commonly reported side effects include drowsiness, dizziness, headache, breast tenderness, bloating, mood changes, and changes in menstrual bleeding. Because progesterone can cause drowsiness, it is typically taken at bedtime. Know how it affects you before driving or operating machinery.
Progesterone should not be used by women with a history of blood clots, certain hormone-sensitive cancers, liver disease, or undiagnosed vaginal bleeding. When taken with estrogen as part of combined hormone therapy, the risks of the combination apply, including those related to breast cancer and cardiovascular events.
What side effects might I experience?
If you are not yet fully menopausal, you may notice changes in menstrual bleeding after starting hormone therapy. Note any symptoms in your follow-up survey so your consulting physician can determine whether your prescription needs adjustment.
If you have not had a period for several years and experience vaginal bleeding after starting PearlPAK, contact your consulting physician promptly.
For a fuller list, see the estriol and progesterone risk answers above.
Are there other medications I should avoid while taking PearlPAK?
Taking other hormone therapy while taking PearlPAK is not recommended. Tell your consulting physician about all medications and supplements you take, including over-the-counter products, so they can identify potential interactions.
Does PearlPAK prevent pregnancy?
No. PearlPAK is not a contraceptive and should not be used to prevent pregnancy. Hormone therapy for menopause does not reliably prevent ovulation. If you are still able to become pregnant, use an appropriate form of contraception and talk with your healthcare provider about the best option for you.
Will PearlPAK help with brain fog caused by dementia or Alzheimer's disease?
No. PearlPAK is intended for women experiencing cognitive symptoms related to perimenopause and menopause. It is not a treatment for dementia, Alzheimer’s disease, or other neurological conditions, and it is not intended for individuals with advanced cognitive or memory impairment.
If you are concerned that your symptoms may reflect a neurological condition, talk with your primary care physician or a neurologist. Evaluating that possibility requires an in-person workup that an online visit cannot provide.
Cost and billing
How much does PearlPAK cost?
PearlPAK is $147 per 28-day cycle. That price includes your medication, shipping, and ongoing support from the CleopatraRX care team.
PearlPAK ships every 12 weeks in a quantity covering three 28-day cycles. Billing follows the three-cycle schedule, so your payment dates will not always line up with calendar months or with the day a shipment arrives.
Is PearlPAK covered by insurance?
No. PearlPAK is a compounded medication, and compounded prescriptions are generally not covered by insurance plans. PearlPAK is cash-pay at $147 per 28-day cycle, which includes your medication and ongoing support through CleopatraRX.
Why am I being billed if I am not getting a shipment this month?
PearlPAK ships every 12 weeks in a quantity covering three 28-day medication cycles. Your subscription is billed according to those three cycles rather than according to when a shipment goes out.
Because three 28-day cycles equal 84 days, your billing dates will gradually drift relative to calendar months and will not always align with your shipment date.
If you have questions about your billing or shipment schedule, contact CleopatraRX Support and we will review your account with you.
Taking PearlPAK
What do I do if I miss a dose?
If you miss a dose, take it when you remember, unless it is almost time for your next scheduled dose. Do not take two doses at once to make up for a missed one.
If you are unsure what to do based on your specific PearlPAK dosing schedule, contact your CleopatraRX care team.
My hot flashes are not going away. Why?
Everyone responds to hormone therapy differently. Estrogen therapy is among the most effective treatments available for menopausal hot flashes, but it does not eliminate symptoms completely for everyone.
Hot flashes may persist because your dose needs adjustment, because you have not been on a therapeutic dose long enough, or because other factors are contributing. It can take up to three months at a therapeutic dose to see the full benefit for hot flash control.
Even after symptoms improve, hot flashes can still be triggered by heat, hot drinks, spicy food, alcohol, caffeine, nicotine, stress, intense exercise, hot baths, or heavy clothing. A symptom diary can help you identify your own patterns.
Do not change your PearlPAK dose on your own. If hot flashes continue, contact your prescribing clinician so your treatment can be reviewed.
I still have brain fog. Why?
Cognitive symptoms such as changes in memory, attention, and cognitive function can take time to respond to treatment. If you are still experiencing brain fog early in treatment, this does not necessarily mean that PearlPAK is not working. Cognitive symptoms take approximately 9–12 months to fully appreciate improvement.
Other factors can also contribute to brain fog, including poor sleep, stress, anxiety, fatigue, medications, and other health conditions.
How long can I stay on PearlPAK?
There is no single maximum duration that applies to every patient. The decision to continue should be individualized based on your symptoms, health history, risk factors, and response to treatment.
The benefits of PearlPAK are not expected to persist after treatment stops. PearlPAK addresses menopause-related symptoms while you are taking it; if you discontinue, symptoms may return as the effects of the hormones wear off.
Your prescribing clinician will periodically reassess whether continuing PearlPAK remains appropriate for you and can help determine the appropriate duration of treatment based on your individual needs.
Can I refill PearlPAK at my local pharmacy?
Not at this time. PearlPAK is compounded by a partner pharmacy and shipped directly to you.
Your consulting physician may adjust your prescription over time based on how you respond to treatment, which is why maintaining your follow-up appointments matters.
Is PearlPAK® Right for You?
Find out if you have menopause related brain fog.
