Unlike men who produce a fair amount of testosterone throughout their lives, women lose most of their estrogen around age 50 when they reach menopause. It seems logical that it would be a good idea to start taking something to replace those missing hormones, but for a lot of reasons this is a very controversial subject. Why? Because certain medical problems such as blood clots and breast cancer have been associated with estrogen use, and women, as well as their doctors, don’t want to take any risk. However, taking estrogen also brings many benefits, such as relief of hot flashes, and preventing bone loss and fractures. It comes down to whether taking them causes more risks than benefits.
Recently, studies are finding that there are many more benefits from taking estrogen than we’ve ever realized – mainly in that they can prevent heart attacks and strokes and actually decrease the risk of certain cancers, and even appear to prolong lifespan. We also are realizing that the type of hormones, how they are taken, and when they are started have a huge impact on the how they behave in the body. Times are changing and the attitude about hormone replacement therapy for menopause is shifting and women need to know about the latest research and studies.
I believe, as do many experts, that most women going through menopause should consider taking estrogen. I’m excited to share the latest information about this in future blogs and welcome any questions and comments to get the discussion going.
I wonder if there is any update about decreasing libido in older women?
Hi Laura. As a matter of fact this is a topic that seems to be finally coming out of the closet and your timing is great. October 18 is World Menopause Day, an annual day to raise awareness of midlife women’s health issues. The theme this year concentrates on sexual wellbeing after menopause. The International Menopause Society recently put out information on this topic, and the North American Menopause Society has its annual conference this month, and sections are dedicated to this subject. I plan to review the presentations and post a blog summarizing their findings next month. In the meantime, you can find some information by goggling the websites of each of these organizations where they have lots of helpful information on this and other topics. Sandy
Hi, I just found you thru the NYTimes article comments. Thank you for having this resource. My questions are; As a 46 year old woman with no history of cancer, I am experiencing some lack of sleep, extreme irritability, lack of sex drive and serious brain fog. I wonder if you could advise about the over the counter supplements? In particular the DIM supplement, Now progesterone creme and Calcium D-glucarate? I take these during the week or so before my period. The CDG gets rid of my cystic acne and I think helps me sleep. The P cream helps me sleep and moods, DIM the same. Nothing really helps the brain fog or the sex drive.
Second, is it better to wait until your late 40’s to get on HRT? I don’t have hot flashes and do sleep better than some, but read that HRT could help you NOT get Alzheimer’s later. My father has Alzheimers, so I feel especially worried.
And third (thank you thank you!) what is your advice on diet? Should we eat more estrogen friendly foods like soy, fish oil, wheat germ etc? Thank you again for any info you can give on any of these topics
Hi Jenny, thank you for your comments. While this site is not intended to give personal medical advice, I am happy to try to respond to readers’ questions with objective information that may be helpful. According to the North American Menopause Society (NAMS) – there are not enough clinical studies to really determine if any alternative medicine supplements will help your symptoms. Research is being done on DIM and calcium D glucarate and these agents do have some effects on estrogen metabolism. The problem with these is that dietary supplements are not monitored by the FDA so women can never be sure of their purity. Same with OTC progesterone cream. Progesterone can be helpful for some perimenopausal symptoms, but again we don’t have definitive data – and progesterone cream is not consistently absorbed. The NAMS website has helpful information. They comment on SAMe and melatonin as agents that possibly may help symptoms like you are experiencing. Women should always discuss taking supplements with their primary care providers. NAMS does have a referral service based on zip code to connect women to providers with expertise in menopause. Women who are not having hot flashes and having regular menstrual periods are generally not advised to start HRT prematurely and there is no data that starting HRT before needed helps prevent Alzheimer’s. There is a lot of research that estrogens are good for the brain when taken after menopause, but unfortunately there are not enough conclusive studies to be able to definitely advise women to take them as preventative therapy of Alzheimer’s. Soy and other phytoestrogens have estrogen properties and may be helpful and not harmful. Diets high in fruits, vegetables, low fat dairy products, whole grains, nuts and fish are ideal. Good luck! Sandra
Hello I am 45 and started having hot flashes and irregular periods at 44, I had other strange perimenopause symptoms before then. What are your thoughts on HRT in perimenopause if one’s periods are irregular (more often late or skipped) and one has mild hot flashes and heart palpitations and insomnia and other painful symptoms? Or should one wait a long hard 12 months of symptoms to see if they are really in menopause yet, first?
Hi Jessica your situation brings up a lot of issues to discuss, but primarily the pros and cons of starting hormone therapy before menopause, which by definition is 12 months after a woman’s final menstrual period. Many women do take hormones during the perimenopause. Women who are having heavy or unpredictable bleeding are frequently placed on low dose birth control pills. These control the bleeding as well as the hot flashes and other menopause issues. If a woman is not having adverse bleeding problems, but hot flashes, night sweats and other bothersome symptoms, many menopause experts recommend HRT hormones during the perimenopause (as long as they don’t need contraception, which would require birth control pills or other measures). There is very little down side to doing this (as long as a woman does not have breast cancer, blood clots, or other contraindications). And, there is the benefit that taking hormones during the perimenopausal period will prevent the rapid bone loss that occurs during this time. It really comes down to assessing how the perimenopausal symptoms are impacting one’s life and choosing the appropriate hormones.
Hello, thank you for this informative site.
I have been without my period for approximately 2 years now and am still experiencing hot flashes, sleep disruption, loss of hair, no libido and word search problems.
I have been fairly healthy, with regular blood work conducted, good diet and regular exercise.
Is it too late to consider effective HRT given that it has been 2 years already? I had been anti hormone in the past, but reading up on this topic has made me rethink this as an option for me.
Recently, my primary physician, who was so diligent in requesting bloodwork has retired.
Who is this discussion best suited for, my new primary care physician, or a gynecologist ( I currently have neither). Is it necessary to see a gynecologist post menopause?
THANK YOU FOR THIS BLOG! I discovered you through the NYT comments section and already find your words super helpful. This is obviously very needed.
With much appreciation…
Hello Margaret. The current thinking about HRT is that women who take them around the time they go through menopause reap more benefits than risks – primarily in that studies are showing that taking HRT at this time decreases a woman’s risk of developing heart disease and diabetes, plus it prevents the rapid loss of bone that occurs when we lose our estrogens. The data seems to point to transdermal estradiol (which is available as the estrogen patches) and oral or vaginal natural progesterone as the forms of HRT that offer the most benefits. Women who start taking HRT 10 years after menopause may experience more risks than benefits, and this may primarily apply to women who have preexisting heart disease. So most experts consider that taking them within 5 years of menopause is well within the window.
Many primary care physicians keep up to date on treating menopause, but I have found that many don’t. Some still feel reluctant to prescribe hormone treatment. Gynecologists tend to stay more up to date on menopause treatment, but having said that, many focus their practices on caring for younger women who need birth control and pregnancy management.
The North American Menopause Society is dedicated to educating women and their providers with up-to-date recommendations for menopause treatment. They have a very informative web site and also provide a referral list of doctors in the U.S. Hope this is helpful. Sandra
Thank you!
HI there, Dr. Rice,
I have read your book. Thank you. In my experience, there is nothing (an my friends all concur) in which doctors are less interested than menopause. This includes multiple ob-gyns I have seen. Be that as it may, I have started taking estrogen and natural progesterone. However, what I don’t understand is what constitutes a therapeutic dose. I am not taking it for hot flashes but for all the long-term health benefits. Can you help me determine this?
Thank you.
Hi Nikki, thank you for your comments. This is an excellent question and there are no hard and fast rules. Generally, the lower the dose of estrogen, the less potent any effects, either positive or negative. The best studies are from assessing hormone effects on the bones where the optimal benefit is from the following doses: transdermal estradiol 0.05 patch, oral estradiol 1 mg. or conjugated estrogen like Premarin 0.625. However, since progesterone appears also to help the bones, lower doses of estrogen along with progesterone are almost as effective as these doses listed. So, in general my opinion is that women will get long term benefits using the doses listed above, but going down to the 0.0375 patch, 0.5 mg estradiol or 0.45 mg conjugated estrogen is likely to provide long-term benefits, although perhaps not as much. I wish we had more research in this area. It is important to match the progesterone dose with the estrogen dose. Generally 100 mg daily of natural progesterone or 200 mg. progesterone taken 12 to 14 days per month cyclically is the recommended dose of progesterone to go along with the 0.05 patch. I too find it unfortunate that so many doctors are not more concerned about women in menopause. Have you looked at the North American Menopause Society’s website? They list doctors that are updated in menopause treatment by zip code. Perhaps there is someone in your area on the list. Good luck. Sandra
Hi Sandra,
Thank you very much. It is very generous of you to reply. I apologize for my late reply.
I am on 100 mg progesterone daily with 0.025 patch. So based on your response, am I correct in thinking that I should go up to the 0.05 patch? I had, indeed, already checked, and there is an NMS practitioner a few hours away. However, I do not yet know if she is taking patients, I will check. Until then, I have no choice but to work with the practitioner I have.
It is very disappointing to see how little practitioners know. My GP, whom I like very much and is going through menopause herself, doesn’t even bring it up during my annual physical. When I have tried to discuss it with her, she basically says that I know more about it than she does and that it is a personal choice. I feel that I should be able to look to my doctor for partnership in making the decision. My friends (those who admit being in this accursed state) have all agreed that their physicians have zero interest in discussing it and that they have been told to suck it up. In addition, you may be interested to know, although again hardly a scientific sample, that I have tried to have a conversation with my friends on the subject of taking HRT and with the exception of one who had become educated from having a hysterectomy, none was interested in thinking about it in any serious way. Several did not even know what HRT is!
Please let me know if I followed you. Many thanks, Nick
Hi Nikki, I will respond to your question, but want to be sure that you realize that my website is not intended to take the place of a patient-doctor relationship, but intended solely to educate women about menopause and hormones. So, I really cannot give direct medical advice to an individual. If you were my patient, there are many things that I would need to know (such as your medical history, bone density test results, risk factors for various diseases, etc.) that would play into my medical advice. Based on one’s medical situation, what I advise one person may be different than to another. That is why it would be great if you can find a practitioner interested in menopause that can assess your situation and give you personal advice. Having said all of that, if a person is having hot flashes uncontrolled on the 0.025 patch, we would generally not hesitate going up to either the 0.0375 patch or 0.05 patch if needed. It’s trickier when a woman is not having hot flashes, because the US guidelines basically limit HRT to only women with hot flashes (which is something I personally think is absurd, but it is what it is right now). The 0.025 patch plus 100 mg progesterone should be helping the bones almost as much as the 0.05 patch. In my practice, when I want to assess if a medication is working to protect the bones, I order a test called the NTX test. It is a simple test performed on a urine sample that estimates how fast a woman’s bones are being broken down. If the test comes back high, then I generally adjust the woman’s medications to see if we can slow down the bone loss process.
We just don’t have enough research about how effective the 0.025 patch is for the heart, but likely has some benefit. Most of the articles I have read are based on what is considered a standard dose, which is equivalent to the 0.05 patch.
There is controversy about whether or not estrogen truly increases breast cancer, but it likely does slightly increase the risk and the more estrogen a woman takes over her lifetime, the higher the risk. So, the 0.05 patch may slightly increase the risk compared to the 0.025 patch, but probably only if it is taken for more than five or ten years.
It must be very frustrating to not find doctors more concerned about menopause. I think that much of this is because when the WHI study came out in 2002, medical school curricula changed and menopause was either not emphasized, or the message simply was not to treat it with anything. So a lot of doctors haven’t had a lot of training in menopause. In addition, the guidelines haven’t changed since 2002 because there haven’t been any further big studies like the WHI. I truly believe the guidelines will be changing in the future, but that doesn’t help women going though menopause now.
Another resource for information is the International Medical Society (IMS). They have some very good YouTube videos designed for women. I hope this is helpful. Sandra
Hi Sandra.
It is helpful. I do appreciate it very much. It is very, very generous of you. However, I am pretty much exhausted trying to figure out what to do. I do not have terrible hot flashes. I would never take HRT for that reason given that they aren’t fun, but mine can certainly be lived with. This leaves me given the guidelines and the medical professionals I am dealing with having to make my own decision based on my reading and my background to the extent that I understand either and having to be cautious with what I tell the practitioner–or even to misinform the practitioner. That is, with mild hot flashes, what is the point in talking to any practitioner if everyone is going to adhere to the guidelines based on me saying “I have mild hot flashes”? The risks and benefits in such a situation are not a consideration! I am so tired of trying to work out what to do. I will reach out to the NMS practitioner in the area, as you suggest. But I am starting to feel that there isn’t any point!! Again, thank you. I really do appreciate you and your book.
Hi Nikki, I sense your frustration and feel badly for you. Try to stay positive. One other option would be to check out a menopause resource website called Gennev. I have no affiliation with this group, nor do I endorse any of their products, but I did hear a lecture by one of the physicians in the group and was very impressed. They employ dozens of doctors and it appears they are all board certified, reputable physicians, from all over the country and most appear to have certification from the North American Menopause Society. Perhaps one of them is in your area. They also are doing telemedicine appointments, which is becoming more popular during this Covid era we are in. Sandra
Hello Dr. Rice, I came across you in a comments section in the NY Times. It prompted me to buy your book, which I have just started reading. Thanks so much for all you do and your advocacy around menopause. I had a complete hysterectomy at age 43 (16 years ago). I am now 59. My GYN had me on Estrogen for about 3 years after my hysterectomy. I remember all the discussions we had about risks/benefits using Estrogen and your book helped me understand that thinking related to WHI. Dr. Google wasn’t used as much 16 years ago. So, getting information was more limited. We made a decision to stop using Estrogen because of what experts said about the risks and my symptoms were very mild. You mention in the introduction about why you should read this book. My heart kind of sank because I am many years beyond menopause (surgical menopause). You stated “waiting for a period of years beyond menopause may not be advisable because we are learning that our bodies don’t react to hormones in the same way after prolonged estrogen deprivation.” I do have some health issues I am dealing with, i.e., recently diagnosed with Hypothyroidism (Sub-Clinical), struggle with insomnia, and interstitial cystitis. I had a full cardio assessment 4 years ago and everything was fine. My URO/GYN has me on Estradial .01 cream. Can you recommend any course of action for me? The 16 years seems like such a long time ago and I feel like this has all caught up with me and the times were not on my side. I am really concerned about the amount of time that has gone by.
Hello Katherine, thank you for sharing your situation. I am sorry that your gynecologist took you off your hormones. Today the standard of care is to have women take HRT following surgical menopause at least until the age of normal menopause which is 52. Continuing them after that time is a decision based on a woman’s symptoms and personal preferences and goals. The WHI really led us astray because it is clear that taking HRT at the time of menopause brings more benefits than risks for the majority of women. The results of the WHI should only apply to women who start HRT many years beyond menopause. Some of the women were as old as 79! The WHI did conclude that starting HRT ten or more years beyond menopause increases the risk of heart disease and breast cancer. However this applied only to women over the age of 59 and those taking both an estrogen and a progestogen and not for women on estrogen alone. The main risk for women on estrogen alone was blood clots, and this now is believed to only occur on oral estrogen and not the estrogen applied to the skin.
In your situation, you would be considered someone who went through menopause at age 46 and now has been off estrogen for 13 years. So technically you would fit into the group of women who are more than 10 years beyond menopause – putting you in the higher risk group. However, even these women had a less than one in 1,000 risk of having an event like a heart attack. And it is also suspected that the women who did develop heart complications already had underlying heart problems such as plaque buildup on their arteries. If a woman is older and has not developed underlying heart problems, she is likely at even a lower risk.
So it’s really complicated. I think that the risk/benefit balance of resuming transdermal estrogen alone is even in your situation assuming you have no heart disease, no history of blood clots, no indication of breast cancer or at high risk of breast cancer and otherwise are healthy. I don’t believe the medical problems you list would be affected by taking hormones. Finding a doctor to sit down with you and carefully go over your situation in detail and discuss your symptoms and preferences is the best advice I can give you. You may want to go to the North American Menopause Society’s (NAMS) website and see if they list a provider in your zip code. Members of NAMS tend to be the most up-to-date on the current data on the benefits and risks of HRT.
Finally, since you have been off estrogen for this length of time, a baseline DEXA scan would be a good idea. And I think it is important to be sure and exercise, keep the cholesterol and blood pressure in the normal ranges, and maintain a normal weight with BMI less than 30.
If your are interested, the link below is a good article that critiques why the WHI has led many doctors astray.
WHI article
Hello Dr. Rice,
Thank you very much for your response. Yes, it is complicated and I certainly plan on setting an appt. with a local NAMS provider. I had a DEXA in July and came out with flying colors. I’m 5’10”, 150 lbs and have excellent blood pressure and BMI. I work hard on keeping this way. It doesn’t come easy. I watch my diet very carefully. I walk 45 minutes a day with my pooch and do two days of weights and two days of spin bike per week. We were able to install a nice, small gym during COVID that took the place of our regular gym that closed. Therefore, I feel I am fairly healthy.
I am slowly digesting your book. I am learning so much. Lots of times I get lost in medical books and find they are too much like an academic medical book. You write it in such a way that it is written to understand for the lay person. It boggles my mind that I am 59 years old and I am now having this conversation (about menopause). My partner teaches a Women’s Studies course at a local university and one of the students commented “No one ever talks about Menopause.” My daughter and I had a nice long conversation about Menopause and Estrogen. I will have many more with her, my friends, and sisters. Finally, thanks for all you do and thanks for writing this book. I am grateful for all your advocacy around Estrogen/Menopause (“MenoStop”..lol). You have helped me more than you can ever imagine!! I feel very hopeful and very good because I understand more.