PART 2: Understanding Hormone Therapy Options: A Woman's Guide to Menopause Treatment
This is Part 2 of a two-part series on menopause care. For the systemic issues in women's healthcare, read Part 1.
As I continue sharing what I've learned about menopause care, I want to emphasize that this journey has been deeply personal for me. In my work as a wellness professional, I constantly strive to bridge the gap between formal medical knowledge and real women's experiences. I'm not a physician, but I believe strongly that by sharing evidence-based information, particularly insights from respected experts like Dr. Rachel Rubin and Dr. Peter Attia, we can all make better decisions about our health.
What makes this particular podcast so valuable is how clearly and succinctly Dr. Rubin and Dr. Attia cut through the fog of misinformation surrounding women's hormonal health. In a field clouded by conflicting advice, outdated practices, and commercial interests, their evidence-based, nuanced discussion stands out as a beacon of clarity.
I believe strongly in thinking critically about all information sources—including this one. Throughout my journey learning about women's health, I've worked to recognize my own biases and those of the medical professionals I learn from. I'm drawn to voices like Dr. Rubin and Dr. Attia because they actively challenge their own assumptions, consider alternative viewpoints, and base their conclusions on quality evidence rather than dogma. Dr. Attia often discusses creating "steel man" arguments (the strongest possible version of opposing views) to test his own thinking, a practice I try to emulate.
After exploring the systemic failures in menopause care in Part 1, let's focus on what you can actually do about it. Knowledge is power, especially when navigating a medical system that often fails to provide adequate support for menopausal women.
As Dr. Rachel Rubin aptly says, "What are you afraid of?" This question frames her approach to hormone therapy—weighing actual risks against potential benefits rather than operating from a place of fear. It's a perspective worth adopting as we explore your options.
Understanding Your Hormone Therapy Options
When considering hormone therapy, it helps to understand your options in simple terms. Here's what you need to know about each hormone and how it can be delivered:
Estrogen: The Primary Female Hormone
Benefits: Relieves hot flashes, night sweats, brain fog, sleep issues; protects bones, heart, and overall health; improves urogenital symptoms
Available Forms:
Transdermal (through skin):
Patches (changed 1-2 times weekly)
Gels/creams (applied daily)
Sprays (applied daily)
Vaginal:
Creams
Rings (last 3 months)
Tablets
Oral pills:
Synthetic estrogens
Micronized estradiol
What to Know: Transdermal options bypass the liver, reducing clotting risks compared to oral forms. Vaginal options have minimal systemic absorption and primarily affect local tissues. Oral forms are familiar but carry slightly higher risks of blood clots and stroke, especially in women with risk factors or over 60.
Progesterone: The Protective Hormone
Benefits: Protects uterine lining (required for women with a uterus who are on systemic estrogen), can improve sleep and mood in some women
Available Forms:
Oral micronized progesterone (Prometrium): Natural form, often taken at bedtime
Progesterone-coated IUDs (Mirena, others): Deliver progesterone directly to uterus
Synthetic progestins: Found in birth control pills and some HRT formulations
Vaginal progesterone: For women who don't tolerate oral forms
What to Know: Women's responses to progesterone vary dramatically. Some experience improved sleep and reduced anxiety, while others may feel irritable, bloated, or notice no effects at all. Finding the right formulation and delivery method often requires some experimentation.
Testosterone: The Overlooked Hormone
Benefits: Improves energy, libido, muscle mass, joint pain, and cognitive function
Available Forms:
FDA-approved gels (prescribed off-label at 1/10th male dose): AndroGel, Testim
Compounded creams: Formulated specifically for women's dosing needs
Low-dose injections: Less commonly used but available
Implantable pellets: Inserted under the skin, last 3-6 months
What to Know: While not FDA-approved specifically for women, testosterone can be life-changing for many. Improvement in energy, libido, and joint pain is common. Effects may take 2-3 months to become noticeable. Dr. Rubin cautions that pellets often deliver supraphysiologic levels (too much hormone) and cannot be removed if side effects occur, despite their convenience.
Combination Therapies
Many women benefit from combinations of these hormones, tailored to their specific symptoms and needs. As you'll see in the next section, Dr. Rubin typically starts with one hormone, observes effects, then adds others as needed to create a personalized approach.
The "Start With One" Approach
Dr. Rubin emphasizes a methodical approach to HRT—start with one hormone, observe effects, then add others if needed. This helps you understand how each hormone affects you individually.
Here's her typical approach:
Begin with estrogen to address vasomotor symptoms (hot flashes, night sweats)
For women with a uterus, Dr. Rubin notes it's reasonable to start estrogen alone for a short period (a few months) before adding progesterone
This lets you identify which effects come from estrogen alone
While progesterone is ultimately necessary for endometrial protection, a brief period of estrogen-only therapy for assessment purposes is acceptable
Add progesterone for women with a uterus
Typically 100mg daily or 200mg for 12-14 days monthly
About one-third of women feel dramatically better on progesterone (improved sleep, mood)
One-third notice no particular effects
One-third experience negative effects (irritability, mood changes)
For those who don't tolerate oral progesterone, options include progesterone-coated IUDs or vaginal progesterone
Consider testosterone if symptoms persist
Often helps with energy, joint pain, cognitive function, and libido
Women typically need about one-tenth the dose used for men
Can be life-changing for many women
This step-by-step approach helps you and your provider understand exactly how each hormone affects your body, allowing for truly personalized treatment.
The Powerful Benefits of Vaginal Hormones
Vaginal hormone therapy deserves special attention. As Dr. Rubin emphatically states, this may be one of the most underutilized, safest, and most effective treatments in medicine.
The condition these treatments address is called Genitourinary Syndrome of Menopause (GSM)—a mouthful, but an important term that replaced the outdated "vaginal atrophy." GSM recognizes that low hormones affect the entire urogenital system, causing:
Vaginal dryness and pain
Urinary frequency, urgency, and incontinence
Recurrent UTIs
Pelvic pain
Sexual dysfunction
Vaginal estrogen (in creams, rings, or tablets) is exceptionally safe and effective for these symptoms. The research shows it can reduce UTIs by over 50%—potentially saving billions in healthcare costs while preventing suffering and even deaths from urosepsis.
Importantly, Dr. Rubin advocates for considering both estrogen and androgen therapy (testosterone or DHEA) for the genitourinary tissues. Why? Because these tissues have both estrogen and androgen receptors. Some women need both to fully address symptoms.
The FDA-approved vaginal DHEA product Intrarosa works well for many women, particularly for vaginal pain conditions that don't fully respond to estrogen alone. For others, local testosterone may help.
Perhaps most crucial: The safety profile of vaginal hormones is excellent, with minimal systemic absorption. As Dr. Rubin points out, even women with a history of hormone-sensitive cancers may often use these products safely (though always in consultation with their oncology team).
The Hormone "Sweet Spot" and Finding Your Balance
When discussing approaches to hormone therapy, Dr. Rubin and Dr. Attia describe what could be considered a "sweet spot" for many women. But what makes their discussion so valuable is their emphasis on personalization and finding the right combination for each individual woman.
The ideal hormone approach varies significantly between women, but generally involves some combination of:
Estrogen (typically transdermal estradiol via patch or gel for systemic benefits)
Progesterone (either oral micronized progesterone or a progesterone-coated IUD like Mirena)
Testosterone (applied to the skin at approximately one-tenth the male dose)
Local vaginal therapy (estrogen cream/tablet/ring or DHEA)
What works beautifully for one woman might not work for another. Finding the right delivery method is just as important as the hormone itself. For example, some women get excellent results from progesterone-coated IUDs (which I personally use with great success), while others do better with oral options. Dr. Rubin specifically highlights the benefits of progesterone IUDs for women in perimenopause, as they can help manage the erratic, often heavy bleeding that characterizes this transition while simultaneously providing the necessary endometrial protection when using estrogen. As she colorfully describes it, perimenopause can be like a 'bloody murder hell scene' with unpredictable bleeding patterns, and an IUD can provide welcome relief while simplifying hormone therapy. These devices can remain in place for 5-7 years (depending on the type) and, contrary to common belief, are appropriate for women of all ages—not just those seeking contraception. There's no upper age limit for using progesterone IUDs, making them a viable long-term option for hormone therapy throughout menopause and beyond.
This is the art and science of hormone therapy—finding the right combination, delivery method, and dosage for your unique body and symptoms. The optimal approach isn't determined by a one-size-fits-all formula but through careful attention to how your body responds.
The Role of Lab Testing vs. Symptoms
One of the most interesting discussions between Dr. Attia and Dr. Rubin centered on the place of hormone testing in treatment decisions. Their insights provide a refreshing middle ground between those who say "never check labs" and those who overrely on testing.
Dr. Rubin acknowledges that there's controversy about hormone testing, with some providers strictly following symptoms and others meticulously tracking levels. Her approach is balanced:
Lab tests can provide useful information, particularly when using liquid chromatography/mass spectrometry (LC/MS) methods for accuracy
However, symptoms ultimately matter more than specific numbers
High estradiol levels with ongoing symptoms might suggest the need for more hormone, regardless of what the lab says
Low estradiol but high FSH can help confirm that more estrogen would likely help
Dr. Attia describes himself as a "minimalist essentialist" on labs—using them strategically to guide decisions without overreliance. He finds them especially helpful in perimenopause when levels fluctuate dramatically.
Both agree that watching for patterns can be more valuable than fixating on specific numbers. For instance, if a woman's FSH is 78 and her estradiol is 40, while she reports some improvement but ongoing symptoms, this suggests she likely needs more estrogen despite having "some" in her system.
The most important indicator of proper treatment? How you feel.
The Black Box Warning Issue: "Killing Women By Trying to Protect Them"
One of the most problematic aspects of hormone therapy today is the black box warning that appears on all estrogen products—even vaginal estrogen with minimal systemic absorption.
This warning stems from the WHI study and states that estrogen can increase risks of stroke, blood clots, heart attacks, and more. For vaginal estrogen preparations, this is simply not supported by evidence, yet the FDA maintains the warning.
Dr. Rubin's powerful statement—"We're killing women by trying to protect them"—underscores how this inappropriate warning prevents women from receiving treatment that could prevent serious conditions like UTIs while posing virtually no risk.
This affects all of us. Dr. Rubin shared a heartbreaking story about her own mother, who was in the ICU for months. Despite Dr. Rubin being a leading expert in the field, she had to fight hospital staff repeatedly to continue her mother's vaginal estrogen treatment to prevent UTIs while hospitalized. The staff's resistance was based entirely on misunderstanding and fear from these inaccurate black box warnings.
Is It Too Late? HRT for Women Years Past Menopause
A question that frequently comes up is whether women who are ten or more years post-menopause can still benefit from hormone therapy. Dr. Rubin addresses this directly, challenging the outdated "timing hypothesis" that suggested a narrow window for starting HRT. While there was once concern about starting hormones "too late," newer research questions this limitation. As Dr. Rubin explains, the benefits of hormone therapy—particularly for bone health, sexual function, and quality of life—can apply to women many years past menopause. The key is personalized assessment and careful consideration of individual health factors. There is no arbitrary cutoff date where hormones suddenly become more dangerous than beneficial. What matters most is your overall health profile, your symptoms, and the type of hormone therapy being considered. For many women who have gone a decade or more without hormone therapy but are experiencing significant symptoms or health concerns, appropriately prescribed HRT may still be an excellent option worth discussing with a knowledgeable provider.
A Note About Breast Cancer and Hormone Therapy
The relationship between hormone therapy and breast cancer is complex and nuanced. Dr. Rubin challenges conventional thinking by drawing a powerful parallel to prostate cancer treatment.
"All prostate cancer is testosterone-sensitive prostate cancer," she explains, "but we don't cut off testicles for the fear that an abnormal cell will develop in a prostate."
Similarly, while many breast cancers are estrogen-receptor positive, that doesn't mean estrogen causes cancer. This is a crucial distinction.
Dr. Rubin points out the double standard: "We castrate women with the mere thought that they may develop an abnormal cell in their body, and completely ignore their quality of life."
Here's what the research actually tells us:
Women who used estrogen-only therapy in the WHI study had a decreased risk of breast cancer
The risk-benefit calculation changes depending on many factors including age, years since menopause, personal and family history
Some women with BRCA mutations or ductal carcinoma in situ (DCIS) may still be candidates for hormone therapy after careful consideration
For women with a history of breast cancer, individualized decisions should be made considering quality of life and overall risk
The core philosophy here: "Women are more than breast tissue." A woman's wellbeing encompasses bone health, cardiovascular health, brain health, urogenital health, and overall quality of life—all of which may benefit from appropriate hormone therapy.
Red Flags in Hormone Therapy: What to Watch For
While I advocate for appropriate hormone therapy, it's important to recognize warning signs that may indicate problematic approaches. Dr. Rubin highlights several concerning practices to be aware of:
Provider Red Flags:
Dismissing symptoms or concerns with statements like "HRT is dangerous" or "there's nothing we can do"
Telling women in their late 30s or early 40s they're "too young for perimenopause" (which can actually begin up to 10 years before menopause)
Refusing to consider HRT options or relying on outdated information from the WHI study
Insisting on expensive pellet insertion every 3-4 months as the only option
Requiring costly specialized testing (especially saliva hormone tests) without clear justification
Making claims that their compounded formulation is "safer" or "more natural" without evidence
Being unable to explain the differences between FDA-approved products and compounded options
Using the term "bioidentical" as if it's a specific type of hormone (it simply means the hormone has the same molecular structure as what your body produces—many FDA-approved products are bioidentical)
Dr. Rubin emphasizes that FDA-approved products provide consistent, tested doses with proven efficacy. While compounding has its place (especially for testosterone in women, where FDA options are limited), be wary of claims about superiority without evidence. Any provider who categorically dismisses your concerns or fails to thoroughly evaluate your individual situation is likely not the right partner for your menopause journey.
The "No One Owns It" Problem
One of the most profound insights from Dr. Rubin and Peter Attia's conversation is identifying the root of our broken menopause care system: "When it's nobody's problem, nobody takes ownership of it."
Gynecologists focus primarily on reproductive years. Internal medicine doctors receive virtually no training on menopause. Endocrinologists typically focus on diabetes and thyroid conditions. Psychiatrists treat depression but aren't trained in its hormonal causes. Cardiologists address heart disease but rarely connect it to estrogen loss.
The result? A whole-body health transition affecting every woman falls through the cracks between specialties.
This is a marketing problem as much as a medical one. As Dr. Rubin points out, "We have a product that is better than Viagra for women, it's been around longer than Viagra, it's inexpensive. What are we missing? It's marketing."
Navigating This Broken System: Practical Steps
Given everything we've discussed, how can you actually get the care you need? Here are practical steps:
Do your research
Listen to reputable and trusted medical sources who follow evidence based data
Look for menopause-certified practitioners through organizations dedicated to women's health, such as The North American Menopause Society (NAMS) and The International Society for the Study of Women's Sexual Health (ISSWSH) – both offer online provider directories that Dr. Rubin specifically recommends as excellent resources for finding knowledgeable specialists.
Be wary of those making absolute statements without acknowledging complexity
Ask specific questions of potential providers
"How often do you treat women in perimenopause/menopause?"
"What's your approach to starting hormone therapy?"
"What types of hormones do you typically prescribe and why?"
"How do you monitor for effectiveness?"
"What's your philosophy on the WHI study?"
Consider the hormone "sweet spot"
Transdermal estrogen, oral progesterone (if needed), appropriate testosterone, and vaginal estrogen or DHEA
But remember that individualization is key—what works for one woman may not work for another
Trust your body's response
Lab tests provide useful information but your symptom improvement is equally important
Regular follow-up and adjustment are often necessary
Stay informed about emerging research
Our understanding of hormone therapy continues to evolve
What we know today may change as better research emerges
My Personal Approach and Final Thoughts
Throughout this journey of learning about hormone therapy, I've adopted a philosophy of informed experimentation guided by the best available evidence. Like many women, I've had to piece together my own approach to menopause care. Currently, I use a combination of transdermal estradiol patches, a Mirena IUD for progesterone, and a compounded testosterone cream. I'm planning to try FDA-approved testosterone gel at my next appointment to compare results, and will incorporate vaginal estrogen when urogenital symptoms present themselves.
This personalized approach has evolved through research, conversations with knowledgeable providers, and careful attention to how my body responds. I share this not as a recommendation, but as an illustration of how individualized hormone therapy can be.
This is where critical thinking becomes essential. Throughout my health journey, I've learned to question everything—not from a place of cynicism, but from a commitment to finding what's true and what works. I recognize that our healthcare system operates within capitalism, where profit motives can influence regulations, research funding, and treatment recommendations. The FDA, pharmaceutical companies, compounding pharmacies, and even individual providers all have their own biases and incentives. Being aware of these realities doesn't mean rejecting the system entirely—it means engaging with it thoughtfully, weighing evidence carefully, and making informed choices.
What made this particular podcast episode so activating for me was how brilliantly Dr. Rubin and Dr. Attia cut through layers of misinformation and disinformation. They didn't just present facts—they explained how we arrived at this crisis of women's health care, naming the systemic failures while offering practical solutions.
The most valuable resource we have right now may be our collective experience. When the medical system fails us, learning from each other becomes crucial. I share this information not as medical advice, but as part of our necessary community of knowledge-sharing in a system that has failed women so profoundly.
As Rachel Rubin aptly puts it: "When you give women information about how their bodies work, they make great decisions for themselves."
That's the goal of this two-part blog—not to tell you what to do, but to empower you with information that has been systematically withheld from us.
I encourage you to listen to the full conversation between Dr. Rachel Rubin and Peter Attia. At over two hours, it's comprehensive, but the information is invaluable. The more we understand, the better equipped we are to advocate for ourselves and others.
And please, share this information widely. The system will only change when enough of us demand better—loudly, persistently, and together.