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This post is for educational purposes only and reflects personal opinion and interpretation of available science and history. It isn’t intended to diagnose, treat, or replace medical advice from a licensed healthcare provider. I’m a functional medicine certified nutrition and hormone coach, not a medical provider, and nothing here should be interpreted as personal medical guidance. Always consult a qualified healthcare professional before starting, ceasing, or adjusting any medication, including hormone therapy. I assume no liability for action—or inaction—taken based on this information.

This is likely going to ruffle some feathers. It may confuse you. It may relieve you. It may speak to that part of you that’s questioning. After thinking, researching, and talking about hormones for two decades, here’s how I really feel about HRT.

Most people think of “HRT” (hormone replacement therapy) as referring only to estrogen and progesterone replacement, but it encompasses the full endocrine system. My use of the term HRT includes not only sex hormones but also thyroid hormone replacement and other hormonal supports, reflecting a whole-system, integrative approach rather than a gynecology-only definition.

You’ll find an explanation of various types of HRT and their potential benefits and risks as you keep reading. I hope will be helpful in guiding you on your journey.

People ask me about hormone replacement therapy all the time. Clients and others ask what type they should take. How to dose it. Whether bioidentical is better. What the right delivery method is. How to best utilize and absorb it. How long to take it.

Other than explaining that liver and gut health are critical for metabolizing thyroid hormone replacement, briefly mentioning HRT delivery methods without suggesting one, and that you’re going to get the active and more bioavailable form of thyroid hormone (T3) with a naturally desiccated prescription like Armour (which could get banned in the blink of an eye), I don’t have hard answers for any of these questions. And even if I did, I’m not at liberty to give direct guidance and ask my clients to consult with a medical provider.

While hormone replacement therapy can be supportive for some, it’s also a complex, tissue-specific game of trade-offs. This post is not about telling anyone what to take or not take, but about informed consent, biological nuance, and why I’ve chosen a different path.

Here are the headings you’ll find below:

• Law of diminishing returns?
• Grandma didn’t need HRT
• Going into winter with no wood stacked
• Documented risks of HRT
• HRT and autoimmunity?
• Where to put your focus: bones, heart, and brain
• What about the FDA’s recent black box warning removal?
• Counterarguments: HRT benefits?
• The best testing
• A game of chutes and ladders?

Backing up for a second, I guess you could say that this post is 18 years in the making because in January of 2008, I refused thyroid hormone replacement after a Hashimoto’s (autoimmune hypothyroidism) diagnosis. My intuition said…why? After all, if Hashimoto’s is autoimmune in nature, why would I not address my immune system vs. replacing what’s missing? It made no sense whatsoever.

Additionally, I was barely symptomatic. And my thyroid hormone values were good, which was another layer of cognitive dissonance. I mean, why add more and throw myself into hyperthyroidism? I didn’t know much about the thyroid at the time, but common sense told me this was a bogus suggestion.

In short, I had not one, but two reasons to say…not today. The doctor wasn’t amused.

Then, at the age of 46 (10 years ago), I went through menopause. (So yes, even if I were to consider HRT at this point, which I’m not, there’s little to no benefit for me.)

Yes, menopause at 46 was a shock. Thankfully, it was mostly a blip on the radar—just a gentle cessation of cycling without hot flashes, night sweats, and all of the symptomology hell that so many women experience, although those couple of pre-menopausal years did leave me with a worsening of my alopecia that I’d had off and on since the age of 13.

Since these two “milestones,” I’ve gotten questions from countless clients and others…Did you start taking thyroid drugs when you got diagnosed with Hashimoto’s? Are you on them now? Are you taking estrogen or progesterone? Have you ever taken any HRT? No, no, no, and no.

Now that I’ve become such a nerd about hormones and natural approaches and have so much more personal and professional experience under my belt, including an understanding that all pharmaceuticals come with some level of risk, I can say with confidence that if I could go back to 2008 and 2016, I wouldn’t change anything.

And even if I were currently in the 10-year window, I wouldn’t take it for the “other benefits.”

My Hashimoto’s diagnosis led me to studying and understanding the endocrine system in a way that I didn’t necessarily see myself embarking on, which in the end, is probably why menopause left me relatively unscathed. I absolutely love what I do—it feels like an art just as much as a science.

When you consider that our hormones all play a part in a symphony, you can’t simply isolate the thyroid. Just like you can’t isolate progesterone and estrogen on a fertility journey, as hard as the conventional medical community tries. (And yes, when it comes to “treating” Hashimoto’s and infertility, they fail miserably most of the time.)

In other words, my hypothyroidism and early menopause forced me to learn about the endocrine system in depth—and in turn changed trajectory of my practice. And I’m so honored to have helped so many women improve their hormonal landscape—together, we’ve managed Hashimoto’s, adrenal burnout, PCOS, androgenic alopecia, infertility, and peri/menopause chaos. And in many cases, a combination thereof. Remember, they’re connected and the cellular level and it’s a symphony.

To highlight what I feel is the most critical endocrine relationship when it comes to supporting the thyroid, it’s unequivocally supporting the adrenals. And yes, my adrenals needed a fair bit of attention at the time of my Hashimoto’s diagnosis.

I wrote an ebook about this relationship called Hypothyroidism and Adrenal Health: The Often Misunderstood Link.

Law of diminishing returns?

Now that we’ve established my credentials (again, I’m not a licensed medical provider), let’s talk about the proven, substantiated, tangible, crazy-making side of HRT that many women experience, which is the impetus for this post.

For many years, I’ve witnessed countless women drive themselves absolutely bonkers with testing, overthinking, researching, tweaking, and spiraling about HRT.

Do I need it? Am I too young to start it? Am I too old to start it? I don’t think I’m on the right dose. I’m getting different opinions about what to take. I’m getting different opinions about how much to take. Should I take synthetic or bioidentical? I’m spending too much time on the internet looking for answers. My symptoms are worse. My symptoms haven’t improved—I feel the same. Can I get off of it? How can I get off of it? What are the risks of stopping? What are the risks of long-term use? Can I reduce my dose on my own? Can I increase my dose on my own? Should I test with blood, saliva, or urine? Or a combination thereof? Is there a delivery method I haven’t even heard of yet? How often should I be testing? Next year? Next week? My doctor said I have to be on this for the rest of my life and I’m not sure I believe them.

One of the most overlooked downsides of HRT isn’t just the risks in fine print (see more below)—it’s the headspace it consumes.

And I’m going to come out of the chute with three strong statements:

1. The psychological pressure to “get HRT right” can undo the very benefits it’s purported to provide.
2. The stress that swirls around taking HRT often becomes more physiologically disruptive than the HRT itself.
3. Speaking of those risks in fine print, many doctors aren’t in the practice of being educated about them, much less understanding or communicating it. Aka, informed consent.

Before we get into the risks…

HRT has been “a gift” to many of my clients and other women I know. I’m probably going to get a lot of pushback from those saying that it was a game-changer and they can’t imagine going without it. I understand.

But from where I sit, it’s only a gift when it’s a supportive backdrop, not the primary player.

Additionally, it’s not a cure-all or a fit for every woman. I’ve had way too many clients say, “I gotta get off of this…it’s making me crazy.” Or, “I can’t take HRT…it made me feel awful.”

If you’re relying on it—if it’s suppressing symptoms to the point that you’re ignoring the physiological mechanisms that made things uncomfortable in the first place, is that a good thing? I’m not so sure.

And my questions still stand…how long is this going to be a gift? And at what point could there be a law of diminishing returns, including side effects, known or unknown? How long do you plan on taking it? Into your 80s? What happens when your system is no longer receiving these exogenous hormones? Do you plan on continuing, feeling that you’ll “fall apart” without them?

My opinion is that women should only stay on HRT as long as it’s supportive, not subtractive, and as long as the individual risk profile remains low. For some women, that could mean years. For others, it could mean throughout their post-menopausal life with minor dose adjustments. Those determinations aren’t for me to make, but if things are going sideways, I agree that there’s no award for suffering through the symptoms of hormonal decline without some kind of support.

The problem is that from a medical perspective, “support” is propelled by a profit-driven industry built on the idea that you’re broken, perpetually “needing fixing,” and that the only fix comes in a pill, patch, or injection.

Let’s be honest here, Big Pharma isn’t in the business of making you whole. Their bottom line—not your long-term vitality—is what drives a highly dysfunctional system.

I’m not saying that all doctors are villains, but most are trained within that system. They’re taught that prescriptions are “the answer” for everything. I want to scream into a pillow when doctors claim that thyroid hormone replacement is “the treatment” for Hashimoto’s. It’s mind boggling.

Yes, some are wise enough to step outside if this deeply flawed framework. But in general, the culture of medicine still leans heavily toward writing a script instead of helping you build the habits that restore health—including endocrine health.

Personally, I don’t feel broken. I’m not perfect, but I don’t feel that I “need fixing.” And I’m sure not going to look to Big Pharma for any “assistance” with my hormones.

I’m 56 years old, feel good, sleep well, get excited about little stuff, keep up with my 12-year-old elite athlete’s schedule, and many people think I’m more than a decade younger than my age. I’ve been holding a little extra weight (I’m 5’10” and “carry it well”), but I’m down several pounds just this month. I say this because many post-menopausal women are weight loss resistant. If I were “broken,” I wouldn’t have these things going for me, which I’m very grateful for. I don’t feel “midlife.”

I’m not going to change my mind on what you read below—nothing will convince me to step into the full-blown mental project of a rolling cycle of labs, dosing tweaks from some “experts” who are mostly throwing darts with a blindfold on, symptom analysis, obsessiveness, micromanagement, catastrophizing potential risks, and fear that I won’t “age well” without the help of Big Pharma.

Some of these “experts” aren’t licensed medical providers and not only push HRT hard, but they even go so far as to recommend dosing, timing, and administration! It’s largely what some of their business models are based on…“helping women navigate the complexity of HRT” (i.e. estrogen and progesterone). In light of this unethical atrocity, I believe that this article is comparatively tame.

Anyway, the hamster wheel of hypervigilance is the exact opposite of what most women in midlife need. The hormonal transition is already destabilizing enough and adding a second job called “managing my HRT” rarely brings clarity or peace.

I’m choosing trust and collaboration with my intuition.

Do I believe in testing? Yes, definitely. But I don’t believe in becoming a lab rat. See more about testing below.

Grandma didn’t need HRT

The modern assumption that the menopausal female body is “broken” without synthetic hormones is historically new, commercially driven, and culturally conditioned.

For the vast majority of human history, women moved through menopause without pharmaceutical hormone replacement. Our grandmothers and women before them generally didn’t view the end of their monthly cycles as an identity crisis or pathology requiring lifelong medication—they adapted with food, rest, sunlight, physical labor, social support, and an acceptance of life stages as natural transitions rather than deficiencies to be “corrected.”

Call me old fashioned, but the above adaptations are what I’m personally focusing on, none of which requires a dissertation.

While some of our grandmothers experienced discomfort, the majority of these women functioned, worked, raised families (including grandchildren), and lived the final third of their lives with resilience, often gaining stability, authority, and clarity rather than becoming “an estrogen-deficient specimen.”

No doubt, the landscape changes during this time of life, turning more towards conservation, cellular repair, and immune and neurological health—not reproduction.

To that end, when we artificially maintain hormone levels into our 60s, 70s, 80s, and 90s, we’re overriding a mechanism that nature built for a reason. So to “prop up” reproductive hormones indefinitely assumes that aging is a defect, not a distinct biological phase with its own intelligence.

I understand that there are acceptable pre-menopausal and post-menopausal ranges (see section below on testing), but are our postmenopausal values supposed to remain the same from 51 (the average age of menopause) to 91? No. They’re not meant to be static for four decades because the endocrine system continues to adapt with aging. So what’s “normal” or optimal at 51 won’t be the same at 71 or 91 and dosing targets should reflect that biological trajectory. I believe this is challenging to manage—and for many women, stressful.

My burning question is— why do we not see the same historical prevalence of post-menopausal dementia, osteoporosis, stroke, and heart disease that we see today? If you’re using HRT to avoid these maladies, which this article concludes “has no net benefit,” you may be missing the forest for the trees.

Going into winter with no wood stacked

Many women today are entering their pre-menopausal years with nervous systems locked in chronic stress physiology—elevated (or depleted) cortisol, disrupted circadian rhythm and years of sleep deprivation, inflammatory burden, and dysregulated blood sugar, which are all conditions our grandmothers were far less exposed to.

All of these factors are a significant contributor to hypothyroidism. And we need our thyroid to be functioning as optimally as possible before and during menopause. Have you heard of the term, thyropause?

Additionally, the constant vigilance associated with “perfect delivery method, perfect dose, perfect timing” tends to raise cortisol (even if you’re depleted, it can still spike), which sends the body into a fight or flight response when what we need most is down-regulation. It disrupts all the systems that need attention, especially in midlife. Talk about having one foot on the gas and one on the brakes! It can be a self-perpetuating and counterproductive cycle.

Constant blue light, endocrine-disrupting chemicals, ultra-processed food, psychological hypervigilance, dehydration, comparison culture, and the expectation to perform at full capacity create an environment where hormonal transitions feel more chaotic and symptomatic. In this context, menopause is not inherently “worse,” but it’s unfolding in a system that’s often dysregulated and inflamed, making a normal life stage feel like a crisis rather than a joyful rite of passage.

Then comes the HRT, which, if it’s not administered carefully and correctly, can add fuel to this fire, ramping up instability rather than addressing the underlying dysregulation that made the transition so difficult in the first place.

Documented risks of HRT

The section after this is called, “Where to put your focus: bones, heart, and brain,” where I explain some alternatives to HRT. It’s not medical advice. And I’m not telling you to not take HRT. Everything in life has risk.

Based on my research and experience with countless women on HRT, the vast majority of whom have wanted off, I’m personally taking the road less traveled. That doesn’t mean that you should, too.

Again, I know I’m going to get pushback on this post. That’s okay. Some may call me “irresponsible” or a fear monger. But fear mongering isn’t the goal—the goal is to share some semblance of informed consent, even though I’m not a medical provider and no one will be “consenting” to my scripts.

Please use discernment. Ask hard questions of your medical provider. And take advice (mine included) as data points, not commandments.

While HRT risks exist:

1. Delivery method matters enormously
2. Dosing matters enormously
3. Personal history and age determine a woman’s true risk profile

I don’t want to make these decisions more difficult than they need to be for anyone.

Again, if you’re 10 years or more post-menopause and wondering about HRT for “prevention,” the evidence doesn’t support it. You’re not missing some golden ticket by saying no and there are plenty of ways to protect your brain, bones, and heart without rewiring your hormones. See the next section, which everyone needs to read, pre- or post-menopause.

And if you’re on HRT and it’s working for you, as they say, if it ain’t broke, don’t fix it. But for the love of all things holy, keep monitoring. And for what it’s worth, I don’t like serum testing, although it’s all we have for thyroid testing.

I’m going to be relatively brief with this list—it’s not meant to be a thesis and I don’t claim that it’s an exhaustive list of risks.

And I’m not covering several tightly restricted, off label hormones, just the most common.

With minor exceptions, I’m largely not distinguishing among delivery routes (oral, transdermal, injectable, implantable), nor between synthetic, bioidentical, or naturally desiccated formulations. All are being referenced collectively as exogenous hormone exposure and signaling.

Additionally, absorption, tissue distribution, and downstream biological effects of HRT can vary substantially by formulation, dose, and metabolic environment and can produce markedly different levels, receptor exposure, and physiologic responses due to gastrointestinal absorption, liver metabolism, skin permeability, storage in fat tissue, binding protein levels, enzymatic conversion rates, and clearance.

As this article states, “Current evidence indicates that different estrogens and progestogens are not recognized in the same way in all cells and tissues. In addition, doses, routes of administration (oral, transdermal, injectable), and the pattern and timing (cyclic versus continuous; interval from menopause to initiation of ET/HT) are all critical determinants of whether a particular woman should receive MHT.” (MHT = menopausal hormone therapy)

I’m encouraging you to research all of this further and speak with a trusted medical provider.

The one that gets me fired up the most is thyroid hormone replacement. I guess it’s because I’ve been in that world since 2008, I’ve seen how it fails on a large scale, and I’ve witnessed how many of my clients have ended up with bone loss from long-term use and highly disruptive heart palpitations right out of the chute.

The following is a systems-level risk overview, not a recommendation for or against HRT, and not a claim that all individuals will experience these effects. Please re-read the disclaimer at the top of this post.

Across all types of HRT, general risks include:

• The body slows or stops making its own hormones because it senses enough coming from the outside (exogenous)
• Cells become less sensitive over time, so higher doses may be needed to get the same effect
• The brain’s “thermostat” for hormone balance can reset, changing what your body now considers “normal”
• Gene signaling can be altered, affecting how cells behave long-term, even after the hormone is stopped
• The body can become reliant and stopping may cause withdrawal symptoms
• Tissues that grow in response to hormones (breast, uterine) may be more likely to develop abnormally or even cancerous
• The immune system can shift, sometimes dampened and thrown out of balance rather than strengthened (see heading below, “HRT and autoimmunity?”)

I’m specifically choosing not to clutter the lists below with links and studies. These high-level risk categories reflect well-documented findings in the endocrinology and epidemiology literature and are widely accepted. Any board-certified endocrinologist should recognize them as established and real.

Again, with a couple of exceptions, I’m largely not distinguishing among delivery routes (oral, transdermal, injectable, implantable), nor between synthetic, bioidentical, or naturally desiccated formulations. All are being referenced collectively as exogenous hormone exposure and signaling. 

I can’t say it enough: these risks are highly dependent on dose, type, route of administration, individual health status, and age. This is nuanced, so do your own research and consult with your medical provider on the best plan.

Thyroid:

• Cardiac: atrial fibrillation, tachycardia, palpitations, angina, arrhythmia, myocardial infarction (heart attack) in those with pre-existing coronary artery disease
• Skeletal: accelerated bone loss and increased fracture risk
• Neuropsychiatric: anxiety, insomnia, agitation, cognitive over-stimulation, burnout
• Metabolic: reduced muscle mass (sarcopenia), joint issues, increased cortisol demand and adrenal strain
• Nutrient depletion: the very nutrients your thyroid (and adrenals, gut, and mitochondria) needs to recover

Estrogen:

• Thromboembolic: venous thromboembolism (highest with oral forms), ischemic stroke
• Oncologic: breast cancer (duration-dependent, synergistic with progestins), endometrial hyperplasia and cancer if unopposed in women with a uterus, possible ovarian cancer signal with long-term use *
• Cardiovascular: increased triglycerides (oral), hypertension, arrhythmia, tachycardia
• Metabolic and other: gallbladder disease, fluid retention/edema, migraines, prolactin elevation

Progesterone:

• Neuropsychiatric: depression, anxiety, emotional blunting, mood swings, sedation, cognitive slowing
• Oncologic: when combined with estrogen: higher breast cancer risk than estrogen alone (notably with synthetic progestins) *
• Cardiovascular: adverse lipid changes, increased coronary risk depending on formulation
• Metabolic: insulin resistance, fluid retention, bloating
• Other: headaches, weight gain (via fluid and insulin signaling)

* The estrogen-alone vs. estrogen-with-progesterone conversations are confusing for many. Estrogen without progesterone raises uterine cancer risk. (See section below, “What about the FDA’s black box warning removal?”) Estrogen with some synthetic progestins appears to raise breast cancer risk more than estrogen alone. These are different tissues with different biology and different risk patterns.

So yes, welcome to the HRT paradox. Estrogen alone can overstimulate the uterus and raise uterine cancer risk, which is why progesterone is added as the “safety brake.” But then, in a plot twist that some don’t know how to explain clearly, adding certain synthetic progestins seems to raise breast cancer risk more than estrogen alone. One tissue says, “Thank you for the protection,” while another says, “Hold on a sec.” This biology is complex and the messaging is usually oversimplified to the point of being misleading. How is it that I understand this, but so many women I’ve worked with have never been given informed consent from their medical provider?

Moving on…

Testosterone:

• Cardiovascular: stroke, hypertension, dyslipidemia (unhealthy lipid profile)
• Endocrine: HPT axis suppression (hypothalamic, pituitary, thyroid), infertility, anovulatory cycles, amenorrhea (missed cycles)
• Neuropsychiatric: aggression, emotional volatility, impulsivity
• Androgenic: facial/body hair (hirsutism), abnormal enlargement of the clitoris, voice deepening, acne, scalp hair loss (androgenic alopecia)
• Oncologic: breast and ovarian tissue effects

DHEA:

• Androgenic: acne, facial/body hair (hirsutism), voice deepening, scalp hair loss (androgenic alopecia)
• Oncologic: breast and ovarian tissue effects
• Neuropsychiatric: irritability, hypomania
• Cardiovascular: dyslipidemia (unhealthy lipid profile)

For DHEA and pregnenolone (see below), you can get both over the counter. In full disclosure, I’ve suggested (not prescribed) DHEA many times and pregnenolone far fewer times (not prescribed) through my professional Fullscript account. Never in a blanket, “Here, take this” manner.

Below is my disclaimer on all of my materials referencing DHEA and what I tell my clients and students.

DHEA is an adrenal hormone and I recommend supplementation with caution. Never supplement with DHEA unless you know that you’re deficient. Don’t blindly take DHEA. Even when you’re known to be deficient, supplementation should be low dose. Otherwise, you risk excess androgens including aggression, facial hair, and acne. Both of these products offer a mere 5 mg/spray. As with all supplements, talk with your doctor about proper dosing.

For comparison, the majority of DHEA supplements I’ve seen at Whole Foods and my co-op are a whopping 25 mg per dose. Some are 50 mg per dose. Even 25 is nothing short of astronomical for most women, in my opinion. My belief is that any woman taking this much DHEA is going to experience the above issues, to some degree.

Pregnenolone

• Endocrine: can push production toward androgens or estrogens depending on enzyme activity, may worsen estrogen dominance or androgen excess—see two points below
• Androgenic (via conversion to DHEA/testosterone): acne, oily skin, androgenic alopecia, hirsutism
• Estrogenic (via aromatization): breast tenderness, water retention, cycle disruption, stimulation of estrogen-sensitive tissues
• Neuropsychiatric: anxiety, agitation, irritability, brain fog, mood swings
• Adrenal: increase in cortisol production (“pregnenolone steal”), blunting of normal stress signaling, dysregulation of circadian rhythm

Pregnenolone is a central upstream hormone that can push you down multiple biochemical pathways at once. This is why testing is so important. Which pathway depends on genetics, enzyme activity, age, stress load, liver function, and existing hormone balance.

Again, it’s been pretty rare that I’ve suggested (not prescribed) pregnenolone. I mean, it’s called “the mother of all hormones” and it makes sense when you consider that we literally make downstream hormones from pregnenolone. This chart is rather impressive. It’s also printed on page 329 of my Essential Thyroid Cookbook: Over 100 Nourishing Recipes for Thriving with Hypothyroidism and Hashimoto’s.

As one doctor explained it several years ago, why plug the leaks (HRT or trying to “fix” low hormone status) when you can take pregnenolone that converts into these hormones? Aka “going upstream.” I now understand that this is an oversimplification.

I’ve never suggested that anyone take it long-term and it’s mostly in the context of women with a history of not enough healthy dietary fat, which, by the way is an utter travesty in light of the “no fat” or “low fat” movement that gripped us for way, way too long. This is one of the single reasons that I believe that we see so much hormonal chaos in women. This is deserving of another post.

HRT and autoimmunity?

This also has me fired up. As an autoimmunity practitioner since 2008…this has me very fired up.

This article, from October of 2025, states, “A new large-scale study involving nearly 1.8 million women with a mean age of 60.5 years aimed to investigate the association between hormone therapy use and the incidence of autoimmune diseases among postmenopausal women. Compared to non-users, hormone therapy users had a higher incidence of autoimmune diseases at 5 years, 10 years, and across the full postmenopausal period. When evaluating 17 individual autoimmune conditions over the full postmenopausal period, statistically significant increases in risk were observed for all autoimmune diseases except Graves’ disease and autoimmune hepatitis.”

This page, also published in October of 2025 and which is clearly referencing the same study as above (1.8 million women) states, “…hormone users had a 28% higher risk of developing a broad range of autoimmune diseases in the next 10 years.” It references this paper.

This article, from December of 2024, states, “Combined estrogen and progesterone therapy is associated with an increased risk of several autoimmune conditions.”

PREGNANT PAUSE.

Where to put your focus: bones, heart, and brain

These are the three most defensible, clinically relevant priorities for the post-menopausal woman. And I’d argue, the pre-menopausal woman, so you’re not playing “catch up.”

They’re not separate systems and preserving one helps to preserve the others. It’s how we age with structural and cognitive clarity and cardiovascular resilience—not just “normal labs.”

They’re foundational across the entire female lifespan, not “emergency repairs” after estrogen starts to decline. That way, you enter menopause from a position of physiological reserve, not deficit. Then the transition is an adaptation and in that context, aging isn’t a “sudden state of loss.”

These systems are deeply interlinked through inflammation, the lack of mitochondrial function, blood sugar mismanagement, and nervous system dysregulation. This isn’t about ovarian output and midlife estrogen deficiency (or progesterone, androgen, or thyroid deficiency for that matter), but a system that now depends more on metabolic health, circadian rhythm, micronutrient sufficiency, and stress regulation.

In short, they map directly to the primary long-term risks after our reproductive years.

I don’t claim that they’re a “fix-all” or a “cure” for post-menopausal symptomology and aging, but they’re extremely powerful levers that can indeed, keep us out of the weeds.

In my non-medical opinion, this is where you have more control and predictability—where you’re not obsessing over micro-adjusting your chemistry and worrying that every minor sensation means that something is “off.”

You’ll see that there’s some overlap in these suggestions—again, they’re not separate. For example, blood sugar dysregulation and insulin resistance are upstream from osteoporosis, Alzheimer’s, and atherosclerosis.

Bone health (bones are an endocrine organ):

• Get your minerals (All minerals are important for a wide array of biological systems, but go here for a one-click guide on the most thyroid- and immune-supportive minerals—and other nutrients.)
• One mineral that’s not often discussed is boron, which helps not only with steroid hormone signaling, but also bone density and cognition
• Lift heavy enough weights that you get stronger, not just “toned,” and add safe impact like step-ups or light hops
• Consider weighted walking, which stimulates osteoblasts (and improves insulin sensitivity)
• Do single-leg exercises, like light jumping, which helps with fall prevention and bone remodeling
• Get plenty of protein, distributed throughout the day (I like to think of this in terms of blood sugar management, which is also critical. You can go here for my ebook, Balance Your Blood Sugar, Balance Your Life.)
• Get calcium and Vitamin D—from food sources and from the sun (Vitamin D)
• Consider a DEXA scan—the radiation is biologically negligible and orders of magnitude below levels associated with DNA damage or cancer risk
• For additional bone support suggestions, read my post, The Risk: Thyroid Hormone Replacement and Osteoporosis

Heart health (and vascular system):

• Get cardio conditioning throughout the week—even brisk walking is highly beneficial
• Keep tabs on blood pressure, cholesterol, and blood sugar (Do you want “low cholesterol?” It depends on what reference ranges you’re comparing your values to, but in general, no.)
• Get your healthy fats
• Consider taking omega-3 fatty acids in the form of molecularly-distilled fish oil
• Greatly reduce processed food intake
• Get your polyphenols (darkly pigmented berries, cocoa, olive oil, pomegranate, green tea), which help to reduce oxidative stress on vascular lining
• Manage your weight—central belly fat is a stronger heart risk than BMI
• For additional heart support suggestions, read my post, Hearty-y Nourishment

Brain:

• Move your body—aerobic exercise boosts blood flow and neuroplasticity and strength training support executive function
• Do brief, high-intensity bursts (stairs, hills, short sprints), which drives BDNF (brain-derived neurotrophic factor) and nitric oxide
• Consider creatine, which is not only neuroprotective, but improves musculature (bone loading) and supports cardiac health
• Get morning light, even in the winter (10-20 min.), which not only helps with circadian rhythm, but also bone turnover and cardiovascular repair
• Sleep like it matters—poor sleep accelerates cognitive decline and deep sleep clears glymphatics (brain lymph) and clears plaque
• Focus on nasal breathing, which improves oxygen to the brain
• Brain reserve is built, not inherited, and you can build cognitive resilience by challenging yourself: learn something new, do puzzles, study a new subject
• Play music
• For more information on hormones and the brain, read my post, Hormones and Their Effect on the Brain

For this last link, I’m not discounting that hormones affect brain health—but you’ll see that the post mentions nothing of HRT and references many of the same supportive strategies shared in this post.

I still go back to the same question…why did we not see the same historical prevalence or medicalization of post-menopausal dementia, osteoporosis, stroke, and heart disease that we see today? I understand that our grandmothers may have had a shorter lifespan and were possibly underdiagnosed, but I’m not in favor of using HRT to prevent cognitive decline when there are so many other methods.

Is it possible to feel grounded, resilient, and at home in your body? Yes. And for many women, focusing on these lifestyle factors brings about great peace of mind and permission to relax.

[For any of the nutraceuticals mentioned above, you can go here to set up a Fullscript account, where you’ll receive 15% off suggested retail on the highest quality supplements. U.S. only.]

What about the FDA’s recent black box warning removal?

I had the idea for this post before November 10, 2025, when the FDA announced its plan to remove the black box warning on HRT.

I know many who celebrated this announcement. And I get it. The removal of “broad warnings” referencing risks of cardiovascular disease, breast cancer, and probable dementia led to a collective exhale for both users and practitioners who recommend HRT.

I’ve seen several of these practitioners say things along the lines of, “This is HUGE for women because for decades, hormones have gotten a bad rap.”

But the FDA isn’t removing the warning for endometrial cancer stating, “The FDA is not seeking to remove the boxed warning for endometrial cancer for systemic estrogen-alone products.”

Yes, I learned about the risks of estrogen alone (without opposing progesterone) in multiple lectures at the Institute for Functional Medicine’s Annual Conference in 2018. The theme of the entire conference was…hormones.

In other words, while the FDA is rolling back several of the strongest warnings on HRT for menopause and reframing risk information based on more recent evidence, the specific risk related to endometrial cancer with systemic unopposed estrogen remains in place per the current regulatory action.

In my non-medical opinion, whether any warning is printed in black ink or removed after 20 years, one of the problems women face isn’t just the “official” risks. It’s the psychological load of trying to “do HRT perfectly.” It’s the dread of making a wrong move and the decision fatigue.

So yes, the black box news is interesting and again, for many women, a relief. But my point still stands, which is the stress about HRT often becomes more disruptive than the HRT itself.

This is my opinion, based largely on what I’ve witnessed in my practice for nearly 20 years.

To be balanced about this, the FDA’s announcement states:

“Randomized studies show that women who initiate HRT within 10 years of the onset of menopause (generally before age 60) have a reduction in all-cause mortality and fractures. Women may also reduce their risk of cardiovascular diseases by as much as 50%, Alzheimer’s disease by 35%, and bone fractures by 50 to 60%.”

See!…bones, heart, and brain.

It continues, “Though the starting time of HRT and duration of use are decisions made between the prescriber and the individual patient, the FDA’s labeled recommendation will be to start HRT within 10 years of menopause onset or before 60 years of age for systemic HRT.”

Counterarguments: HRT benefits?

Remember, I’m not giving medical advice. I’m not telling you, “Don’t take HRT.”

One non-licensed “women’s health influencer” recently said: “The bottom line is that if you take HRT within 10 years of menopause, it’s considered safe.” 

Yes, I’m paying attention to what’s being said out there, not indiscriminately throwing my opinions around. And this sweeping statement about safety is a massive oversimplification based on the factors explained above.

I understand that there’s a current backlash on the “flawed” Women’s Health Initiative (WHI) study from 2002 linking HRT to breast cancer, heart disease, and stroke.

Thus, here’s a final attempt at being balanced about this. There are many, many more where these came from:

Use of menopausal hormone therapy beyond age 65 years and its effects on women’s health outcomes by types, routes, and doses > (It says, “Among senior Medicare women, the implications of menopausal hormone therapy use beyond age 65 years vary by types, routes, and strengths.” Yep, envision me beating a drum. Types, routes, and strengths (dosing).)

This MarketWatch article is certainly making the rounds. It’s behind a paywall.

Here’s FDA Commissioner, Marty Makary, espousing the benefits of HRT, wherein he states that the symptoms of menopause can last 8-10 years and that they occur in 80% of women.

Why? Why? This isn’t how it’s meant to be. This isn’t what our grandmothers experienced. I can understand why today’s women are desperate, but we have to look under the hood.

The best testing

The goal isn’t to engineer the “perfect” hormone protocol. The goal is to feel grounded, resilient, and at home in your body. This is the goal. As I’ve said for many, many years, how you feel is a better indicator of your overall health than any panel can convey to you. Do not make your labs your identity.

But I’m highly in favor of hormone testing, no matter what age or stage.

This post isn’t a “promo” for testing. That’s not why I’m including this section. That said, it can be a useful piece in a bigger picture when it comes to handling hormones. It’s not just how much of a hormone is present and a test like the DUTCH (dried urine testing for comprehensive hormones) looks beyond “just levels.”

Because most hormones are quickly cleared from circulation and exert their effects in tissues, not serum, a single blood draw captures only a fleeting glimpse (“snapshot inaccuracy”) of what’s in transit at that time. But urine testing measures the integrated pool of hormone metabolites excreted over hours, which shows total production, clearance, and downstream metabolic pathways and how the body is processing, detoxifying, and eliminating hormones. For example, with estrogen, it shows whether those metabolites tend to be more or less supportive or damaging to DNA. In my non-medical opinion, this is critical. And blood testing doesn’t do that.

It also offers insights into cortisol metabolism (how you use cortisol), androgen conversion, and overall hormone balance over a full day, again, rather than a snapshot in time.

Additionally, blood is considered unreliable during perimenopause/pre-menopause because of hormone level fluctuation and when women are using topical therapy (cream, gel, patch), blood testing often shows falsely high values. So the provider could say, “See, your values look good. I don’t know why you’re still having hot flashes and night sweats.”

Alternately, blood can reveal “low” values when the body is actually seeing plenty of hormone—just not lingering in the bloodstream long enough to be captured. But urine testing integrates production and clearance over time.

Overall, urine testing is a more accurate representation of the landscape, even though blood testing is and has been considered the “gold standard” in conventional medicine.

Many women (and men) love that they can do the DUTCH test at home. Remember, it doesn’t test thyroid values.

Finally, testing is a tool, not a crystal ball. It doesn’t replace clinical judgment, symptoms, or the larger context of age and health history. And it’s necessarily not the final word on what someone should or shouldn’t do. But it’s a way of getting a clearer map of the terrain before choosing how to move forward.

If interested in a DUTCH panel, you can email us here.

A game of chutes and ladders?

Just as I was getting ready to hit publish on this post, a powerful visualization came to me. Here’s what I saw and my best attempt at explaining it:

All hormone replacement is basically a game of Chutes and Ladders. Anyone remember that game?

The same hormone that gives you a “ladder” can send you down a “chute” in another. One move forward on the board doesn’t mean you’re safe and that hormonal harmony is the new normal. It means you landed on a different square. This is what so many women aren’t told, which is that there’s no single, universal “benefit” or “risk.”

Every hormone, dose, and delivery method is interacting with multiple systems at once and each one can respond in its own way. In my opinion, it’s a series of trade-offs.

For many women, peace begins when they stop overidentifying with “numbers” and start reconnecting with the basics that the body actually anchors to: restorative sleep, strength training, consistent movement that keeps energy circulating, nourishment that stabilizes metabolism and blood sugar, hydration that supports lymph and glymphatic flow, and even just the space to breathe deeply without monitoring every “symptom.”

Remember that your body isn’t broken, you’re not a machine in need of spare parts, your intuition is a powerful tool, and you have the right to walk the path that makes sense for you, not what your doctor (or any article on the internet, including this one), claims you “should” be doing.

As for me, I look forward to continuing the journey into my “forest dweller” years sans pharma.

Finally, I don’t have the final word on any of this—and neither does any single article, book, or podcast. Every woman’s health journey is unique and again, you should always consult with your trusted medical provider before making decisions about hormones, medications, or any other intervention.