Use low-dose local vaginal estrogen or DHEA products (e.g., Intrarosa) to reduce the risk of urinary tract infections by more than half, alleviate vaginal dryness, pain with sex, urinary frequency, urgency, and leakage, as these are safe for almost everyone, including those with a history of blood clots or breast cancer.
When measuring testosterone and estradiol levels, insist on using the sensitive LCMS (liquid chromatography-mass spectrometry) assay, as ELISA-based tests are prone to interference from supplements like biotin and can yield meaningless results.
If you have a uterus and are taking estrogen, you must also take progesterone to protect the endometrial lining from hyperplasia and potential cancer, even if you don’t feel its immediate effects.
Avoid testosterone pellets due to the risk of super physiologic levels and irreversible side effects like deepening voice or clitoromegaly; instead, opt for reasonably dosed topical formulations for better control and safety.
Prefer transdermal estrogen over oral estrogen, especially if you have risk factors for blood clots or prioritize sexual function, as oral estrogen can increase clotting proteins and sex hormone binding globulin.
Be aware that the Women’s Health Initiative (WHI) study, which caused widespread fear of HRT, was largely misinterpreted, leading to an entire generation of women being deprived of benefits and doctors being untrained in hormone therapy.
Understand that the misinterpreted WHI study actually showed HRT decreased risks of colon cancer, fractures, diabetes, and overall mortality, with no significant increase in cardiovascular disease or breast cancer mortality.
Recognize that declining hormones post-menopause, if left unaddressed, significantly increase risks for recurrent UTIs, osteoporosis, cardiovascular disease, dementia, and mental health issues.
Question the ’timing hypothesis’ that limits HRT initiation after age 60; instead, engage in shared decision-making to consider HRT at any age based on individual symptoms (vasomotor, osteoporosis prevention, genitourinary syndrome) and health goals.
Do not stop hormone therapy after 10 years or at an arbitrary age without a specific medical reason (e.g., active hormone-sensitive cancer), as stopping can reverse bone gains and potentially cause other health disruptions.
Consider testosterone therapy for women experiencing low libido, increased UTIs, pain with intercourse, pelvic pain, depression, or anxiety, as levels decline from the 30s and global consensus supports its efficacy for low libido in postmenopausal women.
For women, apply a small daily dose (e.g., 0.5 ml ‘blob’) of 1% testosterone gel (like Testim) to the calf, and consistently use it for 3-5 months to experience its full effects.
When starting hormone therapy, begin with a medium to medium-low dose and slowly titrate upwards as needed to avoid initial side effects like breast tenderness and improve tolerance.
When initiating HRT, introduce hormones sequentially (e.g., estrogen first, then progesterone, then testosterone) rather than all at once, to better understand individual responses and manage symptoms effectively.
While symptoms are paramount, use sensitive lab tests (like LCMS) to help guide hormone therapy, especially in perimenopause, as objective data can validate patient experiences and inform treatment adjustments.
Adjust estrogen dosage based on symptoms (e.g., breast tenderness indicates too much) and lab markers like FSH; if FSH is high and estradiol is low, and symptoms persist, consider increasing estrogen.
Educate yourself on the full spectrum of menopause symptoms beyond just hot flashes, as many doctors and patients are unaware of the wide-ranging whole-body effects due to hormone receptors throughout the body.
Consider hormone therapy to address brain fog, cognitive issues, and new-onset ADHD symptoms during perimenopause and menopause, as the brain’s estrogen receptors remain highly dense and even upregulate with age.
Consider hormone therapy to alleviate joint pain, stiffness, and improve recovery after exercise during menopause, as hormones act like ‘fluid’ or ’lubrication’ for the body, and their decline increases inflammation.
Consider using vaginal DHEA (e.g., Intrarosa) for genitourinary symptoms, as it converts to both estrogen and androgens in the vaginal tissue, benefiting areas with androgen receptors and reducing UTI risk.
For persistent pain with sex, UTI symptoms, or interstitial cystitis related to the vulvar vestibule, consider a compounded topical cream of 0.01% estradiol and 0.1% testosterone applied directly to the vulvar vestibule.
If oral or vaginal progesterone causes severe mood issues (e.g., irritability, anger), consider a progesterone-coated IUD as an alternative to protect the uterus while avoiding systemic progesterone side effects.
For progesterone, consider starting with 100mg daily, or 200mg for 12-14 days cyclically; daily dosing often helps with sleep and anxiety reduction.
Be aware that progesterone, especially at higher doses like 200mg, can significantly improve sleep quality, thicken hair, and enhance mood for many women.
If experiencing sedating side effects from oral micronized progesterone, consider taking it vaginally to potentially reduce brain exposure and mitigate these effects.
For BRCA patients undergoing surgical menopause without active cancer, offer hormone therapy to prevent shortened lifespan due to bone health and cardiovascular disease risks, as withholding it trades one problem for another.
For women who have completed treatment for DCIS (Ductal Carcinoma In Situ) and are not on endocrine therapy, there is no reason why they cannot take hormone therapy.
When considering HRT, understand that the absolute risk increase for breast cancer incidence, even from the WHI study, was only 0.1% (1 additional case per 1,000 women), with no increased mortality.
Question the outdated and inaccurate box labeling on estrogen products that warns of stroke, blood clots, heart attacks, and dementia, as these claims are not supported by current data and may deter beneficial use.
Do not routinely seek endometrial surveillance (e.g., ultrasound, biopsy) for women on HRT unless they experience abnormal bleeding, as unnecessary procedures carry their own risks and discomfort.
Prefer FDA-approved hormone therapy products, which are well-studied and often covered by insurance, over compounded formulations like ‘biest’ due to lack of robust data on safety and efficacy.
Be wary of doctors who dismiss HRT outright, push expensive or compounded products as ‘safer’ without evidence, or require costly, non-validated saliva testing, as these are red flags for exploitative practices.
Be very suspicious of doctors who directly sell hormones or operate their own compounding pharmacy within their practice, especially if they profit from these sales, as this can indicate exploitative practices.
Demand that testosterone pellet companies conduct FDA-approved studies to prove safety and efficacy for women, rather than relying on unproven claims or off-label use.
To find qualified menopause practitioners, consult websites like menopause.org (The Menopause Society) and isswsh.org (International Society for the Study of Women’s Sexual Health), and educate yourself through books and podcasts to advocate for your health.
Conduct your own research on hormone therapy, including resources like ‘Estrogen Matters’ by Avram Blooming, to make informed decisions about your health rather than relying solely on a doctor’s recommendation.
View your healthcare as assembling a ‘pit crew’ of specialists (e.g., sexual health, menopause, bone, heart doctors) rather than relying on a single physician, and make informed decisions based on comprehensive advice.
Men should support women in seeking appropriate menopause care, as maintaining healthy partnerships through perimenopause and menopause can significantly impact male longevity and health outcomes by reducing divorce rates.
When making medical decisions, consider not only the risks of taking a medication but also the significant risks associated with not taking it, as these are often overlooked.
Recognize that women typically have 10 times more testosterone than estradiol in their bodies (when normalized to the same units), underscoring testosterone’s significant, often overlooked, role in female health.
Do not assume your hormones are normal just because you have regular periods, as testosterone levels, which decline with age, are not reflected in the menstrual cycle curve and can still be problematic.
Understand the difference between systemic (Femring, high dose, requires progesterone if uterus present) and local (Estring, low dose, no progesterone needed) vaginal estrogen rings to ensure correct treatment and avoid pharmacist errors.
If using a 3-month estrogen ring and symptoms return in the last month, consider changing it earlier (e.g., every two months) or supplementing with a patch or gel during that period, despite potential cost implications.
Select your HRT delivery method (patches, gels, rings, oral) based on personal preference, lifestyle (e.g., activity level, sauna use), and potential allergies to adhesives, as compliance is key for effectiveness.
Explore sublingual estrogen (placing an oral tablet under the tongue to dissolve) as a potentially cheap and effective method to increase estrogen levels without liver metabolism or driving up SHBG, similar to vaginal absorption.