Why Menopause Medicine Is Stuck in the Past—And How We Fix It

Earlier this week I had the opportunity to be  part of an intimate panel discussion in NYC on perimenopause and menopause. Predictably, one of the fellow panel members stated “we must only treat with the lowest effective dose of hormones,” and it made me shift in my seat. 

This phrase has been repeated for years, rooted in long-standing medical guidance. But as I listened, I couldn’t help but reflect on how much more we’ve learned—and how much more we need to do to truly support women’s health.

Because here’s the truth: treating menopause with the lowest effective dose isn’t enough. We need to recognize the loss of hormones as a major risk factor for women’s health, one that deserves thoughtful, proactive care.

The WHI Study: A Turning Point

In 2001, the Women’s Health Initiative (WHI) Study released preliminary findings that sent shockwaves through the medical community. The study incorrectly concluded that hormone replacement therapy (HRT) increased the risk of cardiovascular events and breast cancer. Practitioners and institutions scrambled to adjust their recommendations, erring on the side of extreme caution.

By the time I was in graduate school, the message was clear:

• HRT was only to be used for severe hot flashes.

• Antidepressants should be the first-line treatment instead.

• If hormones were prescribed, they had to be discontinued after five years.

• The goal was to use the lowest effective dose—always.

But we now know the WHI data was deeply flawed. The majority of participants were over 60 and had gone more than ten years without estrogen. For women who started hormone therapy earlier—within ten years of menopause—the risks were entirely different.

We also know that the only group in the WHI study that showed a slightly increased risk of breast cancer were those taking medroxyprogesterone acetate (Provera), a synthetic progestin. Women who took estrogen-only therapy (Premarin) actually had a lower risk of breast cancer compared to those taking the combined regimen.

And yet, the damage was done.

The Gaps in Menopause Care: Where the System Falls Short

Some providers still operate under the assumption that estrogen and progesterone are potential threats to a woman’s long-term health. But what we know now is quite the opposite: the loss of these hormones is the real threat.

Estrogen loss is the catalyst for a cascade of health problems in women in their 40s and 50s—chronic inflammation, metabolic dysfunction, muscle loss, increased fat mass, cognitive decline, bone degradation, and arterial stiffening. These aren’t just inconvenient symptoms of aging. They are signs of systemic deterioration that demand attention.

And yet, our healthcare system continues to minimize hormone loss as a key risk factor.

Currently, the only officially recognized benefit of hormone therapy is slowing bone loss. That’s it. Not brain health. Not cardiovascular protection. Not metabolic stability.

Even within this narrow scope, the guidance is frustratingly contradictory: if preventing bone loss is the goal, how do we determine the “lowest effective dose”? When should treatment begin? What level of estradiol is sufficient for bone protection?

The truth is, that insurance companies make it nearly impossible for women to get the answers they need. Most won’t cover a bone density scan until age 65—long past the recommended window to start HRT. Many providers won’t even test hormone levels, because professional medical societies don’t recommend it.

This isn’t healthcare. This is a system designed to delay, minimize, and deny.

A Smarter Approach to Menopause Care

In every other endocrine disorder, we treat hormone loss, not just symptoms.

Diabetes, for example, is often asymptomatic in its early stages, yet we proactively screen and treat elevated glucose levels to prevent long-term damage. The same should be true for menopause.

Yet, because large-scale drug trials take years and require substantial funding, menopause medicine remains stuck in outdated paradigms. Until we recognize aging through the lens of hormone deficiency, the standard of care will remain inadequate.

But there is a better way.

Some providers will continue prescribing the lowest dose of hormones necessary to suppress symptoms without tracking deeper health markers—bone density, metabolic shifts, and vascular changes.

But others, like myself, take a different approach.

There are providers, like myself, who are keen to utilize hormone replacement therapy to maintain and sustain health. And that approach is much more elegant than the lowest-effective-dose model. 

Many of my patients will be in their seventies, or older, by the time we have the most disease-preventive guidelines established for the use of hormone replacement therapy. 

So, for now, I will replace hormones with the most physiologic approach, in accordance with each woman’s goals and personal desires. 

My desires are: to have my wits and brain functioning optimally for years to come, to avoid metabolic disease at all costs, to have satisfying sex for a lifetime, and to feel as good as I possibly can. In my experience, this requires a commitment to a healthy lifestyle regimen, and a physiologic approach to hormone replacement—meaning I aim to dose my hormones to optimal levels, in a physiologic rhythm. 

Because real primary care for women means acknowledging the truth: menopause is a major health transition, and hormone loss is a major risk factor.

It’s time to stop treating menopause like a minor inconvenience—and start treating women like the long-term health investment they are.

Every patient I treat gets a highly individualized approach—and to me, that’s the best version of the art and science of medicine.