HRT?

Any post-menopausal lady climbers out there? What are your thoughts on HRT?

I’ve commented on this extensively over the years to my friends. I have some long writups at home but I’m on the road now. Will get back to this when I can.

jmswrote:

Any post-menopausal lady climbers out there? What are your thoughts on HRT?

I'll give a very brief, very anecdotal account, and then back out of this conversation. After many years of hormone struggle, my wife finally found a willing doctor to check her hormones. They found some minor thyroid issues, and in the end, a low-dose thyroid medication & progesterone cream 'fixed' most of the issues. I think she's pre-menopause now, so we'll keep close with lab levels and minor tweaks. Her energy levels and physical fitness noticed a huge improvement.

If you haven't found a naturopathy doctor, I would highly suggest it. You'll receive a much higher level of personal care, and accurate diagnosis & treatment. At least in our experience, the treatment was pretty mild & easy, but accurate hormone testing was required first, which most primary-care doctors don't care shit about, unfortunately.

Best of luck. (I'll duck out now.)

Short answer: I’m a big believer in HRT if:

You have the right med background and genetics ( no BRCA 1/2)

You start at the right time - the risk/ benefit profile changes with age. Start early. You can’t start most HRT later (65-70). Localized estrogen vaginally is the exception.

You use the right drugs in the right formulation. I’m not a fan of oral HRT (with possibly micronized progesterone as an exception). Bioidentical topical is my preference. Some MDs like the pellets.

FACOG MDs are most qualified to prescribe and monitor. Ones who are Pro-HRT are out there, you just have to search to find them.

Will say more in a week…

I just reached out to my athlete friend (post menopausal) who recently started HRT (and is having a transformative positive experience with it). She’s recommending FB’s Hit Play Not Pause group. 

I am strongly in favor of MHT / HRT.  There is so much info now that wading through it all is a challenge.  I second the recommendation to check out Hit Play not Pause Podcast.  There are many others, but this podcast specifically focuses on athletes. Over a hundred episodes on many different perimenopause and menopause topics. 

 
Neeley at Training beta podcast recently did a podcast episode 295 on perimenopause.

https://podcasts.apple.com/us/podcast/the-trainingbeta-podcast-a-climbing-training-podcast/id827233918?i=1000723721957

Several books have been published recently. I recommend Estrogen Matters by Avrum Bluming.

Also, this organization has a find a provider site.
https://menopause.org/........

https://www.cnn.com/2025/10/02/health/menopause-hrt-warning-change-makary

Sorry I haven't had time to get back to this, but this is good news...

The misinterpretation of the original WHI study and the flawed study design has caused tremendous suffering for millions of women.

i've been on HRT for about 20 years.  First topical progesterone for premenopausal craziness and symptoms, then after menopause and ever since, topical estradiol gel (Divigel is brand name but there are generics), with topical formulated progesterone gel.

Here is the opinion I promised to share. Sorry it took so long for me to get back to this:

I think MDs have a really hard job, and they are really caught in the middle when patients ask them to do something that is against the current AMA guidelines.  That’s why I think the best course of action is to to find an MD that already subscribes to a long term use of HRT (typically this will be a FACOG gynecologist). There are a number of genetic issues and health concerns (e.g family history, prior cancers of certain types), that if they pertain to an individual, would make long term use of HRT more risky.

My background is that I have a Ph.D in Biochemistry and worked in the pharmaceutical industry. I worked for a major pharma co. for 5 years on a project with a goal to produce "designer estrogens" that would have a clinical endpoint of increasing bone density, without negative side effects on other markers.  I read many hundreds of papers on these topics during that time.  Since then, I follow the literature periodically, but not constantly.  I have a physician friend in the Bay Area who is a proponent of long term HRT use.  She still follows the literature closely. I checked with her last year and she is still a proponent of the benefits of using HRT long-term, when started around perimenopause or menopause.  

Prior to 2002, it was common for women to be given HRT at menopause.  The most widely prescribed formulation was called Premarin.  However, around 2002, the use of Premarin for HRT was incorporated into an arm of the Women’s Health Initiative study, with the expected outcome of proving how great it was for women’s health.  It was thus a surprise to the study personnel that the initial data showed that Premarin increased, not decreased, the risk of a certain  negative health events.  Use of HRT immediately dropped dramatically and eventually resulted in the current restrictive guidelines.  The current AMA guideline is only to use HRT for the “shortest time possible and at the lowest dose necessary to relieve symptoms”.  However, this recommendation to stop using HRT after a short time rather than continue some form of HRT for long term use is not universally agreed with.  Many scientists think the risk of stroke, breast cancer and Alzheimer’s diseases is overstated because many of the conclusions are drawn from the “wrong” drugs and delivery methods, and because the WHI study included women who were many years past menopause without ever being on any HRT drugs. In fact, when the data was reanalyzed by age band, it was concluded that the risks were minimal when HRT is started around menopause.  Many scientist have concluded that the benefit to bone density, sexual function, mental function, and general physical health and well-being outweighs the risks.  They argue that the risk vs. benefit needs to be assessed for each patient.

The biggest problem in this field is that there is zero incentive for a pharmaceutical company to conduct a clinical trial unless they have a proprietary drug or formulation.  That's why the original WHI was done with Premarin (a proprietary drug).  Estradiol (17-beta estradiol) and progesterone are not proprietary, but their formulations can be (whence estrogen patches and micronized progesterone pills – see below). There were a flurry of small studies right after the WHI results, but not much since.  I think most “pro” HRT gyns just made up their minds from the data that the dangers were blown out of proportion, and just prescribe based on their own observations in their clinical practices. So even after all this time there is not a large study on women who are on drug regimens like I take (see below).

My, and others, issues with using Premarin as the drug for which to base global guidelines for women’s health are threefold: 1.  The delivery is oral, which leads to metabolic differences due to “first pass”by the liver. 2.  The predominant estrogen in Premarin is Estrone, not 17-beta estradiol.  2.  The progestin in Premarin is medroxyprogesterone acetate and not progesterone.

Oral vs. transdermal delivery: When you take a drug orally, it is “seen” first by your gut and liver before it enters the bloodstream.  This “first pass” effects a number of things that change the pharmacodynamics and pharmacokinetics of the drug.  There is some data that the oral route is less safe because the first pass may induce prothrombotic and proinflammatory factors.

As an example of the literature, see –

https://www.ncbi.nlm.nih.gov/pubmed/22011208

Estrogen differences: I’m less of a fan of conjugated estrogen mixtures such as found in Premarin than I am of using 17-beta estradiol.  The predominant estrogen in conjugated estrones is estrone, which is 17-beta metabolite with different potency etc.  The only reason conjugated estrogens were ever used was because there was an abundant, cheap starting material (mare’s urine) and it was cheap to purify.  A number of companies now make bioidentical (17-beta estradiol) patches, gels and creams and pills.

See for example:

https://www.ncbi.nlm.nih.gov/pubmed/23313336

Progesterone vs. a progestin:  there are marked physiologic and pharmacologic differences between progesterone and the most commonly prescribed progestin, medroxyprogesterone acetate.  I think progesterone is far preferable to medroxyprogesterone, and that a topical delivery may possibly be preferable to a micronized progesterone pill.  The downside with a compounded progesterone is that you have to really trust the compounding pharmacy, that they are putting the right drug and the right amount in your drug. Topical progesterone is formulated by a compounding pharmacy. Some physicians refuse to prescribe compounded drugs because they have concerns about possible quality control.  

As an example see:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4960754/

I hate posting personal info online, but I think it's really important for woman to share their stories, so here is myy own experience with HRT:

About 5 years pre-menopause I started having bad PMS symptoms.  Blood tests showed progesterone had dropped but estrogen was still normal.  This is typical for women at perimenopause. This is when I started on formulated topical progesterone, which helped tremendously.

I went through menopause with very few symptoms.  After menopause was complete, I started on HRT. 

 I use a generic version of bioidentical estrogen gel called Divigel, (which comes in 0.1, 0.5 and 1 mg dose packs).  I have always used the highest dose but if you look at the clinical trial data, the average circulating blood estradiol concentration at the 1 mg dose is 30.5 pg/ml.  For premenopausal women the average blood ranges from 30-400 pg/ml depending on point in the cycle.  So it’s not like it a mega amount.

I also use a cream formulation for progesterone 100 mg/gm, 1 gm per day, and for testosterone 2 mg/gm, ½ gram per day.   Both of the later hormones are prescribed by my gynecologist and formulated by a compounding pharmacy.  They are sent to me by mail. A lot of docs prefer the oral micronized progesterone Rx to the compounded version and that is also a good choice.

Some gyns and patients like the bioidentical hormones formulated as pellets.  These are inserted into the buttocks every 3-6 months.  My gyn offered me this as an option.

About 3 years ago I was starting to have issues with UTIs again, and my urologist wanted me to go on Vagifem in addition to my HRT for genitourinary syndrome of menopause (GSM). This has worked great. I use one vaginal tab about every 5 days. Just recently a big conference on the topic of GSM was convened by urologists, gynecologists, etc. They issued  findings concluding that GSM is very underdiagnosed and that woman are suffering needlessly when there are many options for treatment.

 I am currently 73 and have been on an HRT regimen for about 17 years.  My bone density when last checked a couple of years ago is normal and has not changed since my initial baseline bone density scan.  Since starting HRT at menopause, I have had 3 uterine ultrasounds to monitor my uterine lining, and it is normal thickness. My skin is healthy, I sleep very well, my brain is sharp,  I have a lot of energy and I am quite strong. I don’t suffer from any of the cartilage  degeneration seen regularly in post-menopausal woman. My current gyn, who follows all the latest studies, has told me (paraphrasing) that as far as she is concerned I can stay on my current HRT regimen until I croak.

Phylp phylp- 

I am so very grateful to you for both the scientific and personal information that you have shared as well as the time it must have taken you to write it all out.   It is incredibly helpful as a woman who 6 years ago was told they HAD to go off HRT (smallest dose for shortest time philosophy based on that WHI study as you mentioned),  and I feel like I have unnecessarily lost a lot due to that medical decision.  

I’m meeting with a new doctor soon to discuss options and whether or not going back on HRT can still help with my bone loss, muscle loss, joint pain, hair loss, energy levels, brain fog, etc etc etc.  The information you provided (as well as a very eye-opening read Estrogen Matters) have given me the information I need to be a better advocate for myself.  

Again- I really appreciate you.   I’ll post back what I find out and end up doing, as you stated, to share the story to hopefully help other women.

Jen (jms) 

Jen I'm so sorry you have had to go through this - best of luck going forward. We do need to advocate for ourselves.

Here's another article in the popular media I came across today on this topic:

https://variety.com/2025/biz/news/selma-blair-constance-zimmer-menopause-flow-space-women-1236546807/

phylp phylpwrote:

I also use a cream formulation for progesterone 100 mg/gm, 1 gm per day, and for testosterone 2 mg/gm, ½ gram per day.   Both of the later hormones are prescribed by my gynecologist and formulated by a compounding pharmacy.  They are sent to me by mail. A lot of docs prefer the oral micronized progesterone Rx to the compounded version and that is also a good choice.

do you have any thoughts on being perimenopausal (Not to menopause yet) and optimizing testosterone?  mine was low normal on a test, but I've been having issues with motivation etc, and was wondering if there was any harm in trying a low dose testosterone if a practitioner felt comfortable prescribing and monitoring it? 

Kiki Nwrote:

do you have any thoughts on being perimenopausal (Not to menopause yet) and optimizing testosterone?  mine was low normal on a test, but I've been having issues with motivation etc, and was wondering if there was any harm in trying a low dose testosterone if a practitioner felt comfortable prescribing and monitoring it? 

No I do not have any thoughts on this, nor have I ever researched this topic.

Kiki Nwrote:

do you have any thoughts on being perimenopausal (Not to menopause yet) and optimizing testosterone?  mine was low normal on a test, but I've been having issues with motivation etc, and was wondering if there was any harm in trying a low dose testosterone if a practitioner felt comfortable prescribing and monitoring it? 

I’m 43 and perimenopausal. I’ve been on HRT for almost 2 yrs now. Oral estradiol, oral progesterone, vaginal estradiol since the beginning and topical testosterone that I started about 6 months into my HRT journey. I’m pretty sure the only diagnosis that most Drs will prescribe for and most insurance companies will cover is decreased sex drive (because of course pleasing men is more important than our own wellbeing).

If you’re having issues with motivation, it could possibly be ADHD rearing its ugly head. Before I knew I was perimenopausal, my ADHD symptoms went completely rogue despite being effectively medicated for many years prior. Turns out our hormones play a huge role in that. Once I started HRT, my ADHD meds magically started working again.

I’m also so glad to see this subject come up and this conversation happening without any social stigma overwhelming the discussion. Typically women’s health is taboo to talk about and we’re expected to suffer in silence. And I think it’s so important that we all share our stories to help other women. My mom and grandmother passed away when I was younger and I never knew what their experience was with this. None of my older female relatives or friends shared with me either. When my symptoms initially appeared that weren’t the stereotypical “hot flashes” I didn’t even consider perimenopause as a cause and just thought I was broken or going crazy. I haven’t been shy about my experience with my friends, younger sisters and my teenage daughter, I don’t want any of them to be as unprepared as I was. 

Kiki Nwrote:

do you have any thoughts on being perimenopausal (Not to menopause yet) and optimizing testosterone?  mine was low normal on a test, but I've been having issues with motivation etc, and was wondering if there was any harm in trying a low dose testosterone if a practitioner felt comfortable prescribing and monitoring it? 

I’m 43 and perimenopausal. I’ve been on HRT for almost 2 yrs now. Oral estradiol, oral progesterone, vaginal estradiol since the beginning and topical testosterone that I started about 6 months into my HRT journey. I’m pretty sure the only diagnosis that most Drs will prescribe for and most insurance companies will cover is decreased sex drive (because of course pleasing men is more important than our own wellbeing).

If you’re having issues with motivation, it could possibly be ADHD rearing its ugly head. Before I knew I was perimenopausal, my ADHD symptoms went completely rogue despite being effectively medicated for many years prior. Turns out our hormones play a huge role in that. Once I started HRT, my ADHD meds magically started working again.

I’m also so glad to see this subject come up and this conversation happening without any social stigma overwhelming the discussion. Typically women’s health is taboo to talk about and we’re expected to suffer in silence. And I think it’s so important that we all share our stories to help other women. My mom and grandmother passed away when I was younger and I never knew what their experience was with this. None of my older female relatives or friends shared with me either. When my symptoms initially appeared that weren’t the stereotypical “hot flashes” I didn’t even consider perimenopause as a cause and just thought I was broken or going crazy. I haven’t been shy about my experience with my friends, younger sisters and my teenage daughter, I don’t want any of them to be as unprepared as I was. 

If you haven’t heard it yet, every woman owes herself an undistracted listen to Peter Attia’s interview with Rachel Rubin, MD: Women’s Sexual Health, Menopause, and HRT.
It’s packed with insight, practical information, and Rachel’s signature wit — truly mind-blowing and engaging.

More good news on the HRT front. According to a new large Danish cohort study, women who used menopausal hormone therapy did not have an increased risk of death, and some even had longer survival, 

Among 876,805 women, those who used menopausal hormone therapy had a slightly lower risk of all-cause mortality compared with women without menopausal hormone therapy over a median follow-up of 14.3 years.

 Mortality risk didn't vary by duration of hormone therapy use.

703 women in the study between ages 45 and 54 had had both ovaries removed. Among these, women who used menopausal hormone therapy had 27% to 34% lower mortality risks, depending on duration of therapy use. 

The researchers found that transdermal menopausal hormone therapy is associated with the lowest all-cause mortality with no increased mortality among women who begin treatment at or older than 52 or 57 years. Subgroup analyses showed that users of transdermal menopausal hormone therapy formulations, like patches or gels, had a 15% lower mortality risk compared with women who had never used menopausal hormone therapy. Women who mostly used estrogen monotherapy or estrogen with cyclic progestogen also had marginally lower mortality risks.

 These new findings mirrored the 2017 re-analysis of the 2002 WHI data, that found no difference in all-cause mortality rates for hormone therapy users compared with placebo users. Despite these 2017 conclusions, use of menopausal hormone therapy has never rebounded from the initial flawed interpretation of the WHI study, published in 2002, which spurred a sharp decline in menopausal hormone therapy..

As usual, the conclusions of the study emphasize that some woman may have special concerns with HRT use, based on their particular genetics and family history.

Hey phylp phylp, random question(s) about how patches work that I’ve always been curious about.

I’ve noticed my patches have way more estradiol total than can be delivered for the prescribed duration.

Do you know what % of the total estradiol is deliverable to the patient, and second do you know if the delivery rate stays constant or if it starts to decline as it approaches empty?

Elle Conantwrote:

Hey phylp phylp, random question(s) about how patches work that I’ve always been curious about.

I’ve noticed my patches have way more estradiol total than can be delivered for the prescribed duration.

Do you know what % of the total estradiol is deliverable to the patient, and second do you know if the delivery rate stays constant or if it starts to decline as it approaches empty?

• That’s a good question. I should be able to see that info in the “info for prescribers” section. There is usually a part called pharmacokinetics, or something similar. When I have time I’ll look into it. Might take me a while, things are busy on the home front. 

Hot off the press. My oncologist just highly recommended this book (I’m in the high risk prevention clinic). She adheres to all the author’s data driven recommendations, including that post menopausal women at high risk for, or a survivor of estrogen related cancers, can safely take systemic hormone replacement. Can’t wait to get this book! I haven’t read this entire thread so not sure if this book has already been mentioned, but my provider gave it quite the glowing endorsement so I wanted to share with you all. 

Elle Conantwrote:

Hey phylp phylp, random question(s) about how patches work that I’ve always been curious about.

I’ve noticed my patches have way more estradiol total than can be delivered for the prescribed duration.

Do you know what % of the total estradiol is deliverable to the patient, and second do you know if the delivery rate stays constant or if it starts to decline as it approaches empty?

Elle, I finally had a chance to look this up for one of the more popular patches, Climera, made by Bayer. All the info you are interested in is shown in the prescribing information. If this isn't the one you have, just do a search for the drug prescribing info for your brand and go directly to the manufacturer's website.

Here's just some of the Climera data.  So for example in Fig 1, if you look at the higher dose studied, this is a 12.5 CM2 patch which contains a total of 3.8 mg estradiol.  As you observed, this is much higher than what is delivered, which at this dose is 0.05 mg/day.  Over 7 days that is a total of 0.35 mg used - about 10x less than is actually  in the patch.  This just speaks to the inefficiency of the delivery method - getting drug across the skin. But you can see that even though there is plenty of drug left over in the patch at the end of 180 hours = 7.5 day, the mean serum concentration observed drops very dramatically by that day.  Why this occurs I don't know, I'm sure a formulations person could give some explanation, but operationally it means that that is the working lifespan of the product, and after that you need to apply a fresh patch to a new spot of skin. Hope this answers your question.