If you are a woman approaching or going through menopause, you have probably been bombarded with conflicting information. Social media ads promise miracle cures. Start-up clinics offer expensive lab panels and custom-compounded hormones. Friends and family share stories that range from glowing endorsements to dire warnings. So what is the truth about hormone replacement therapy — and how do you know whom to trust?
The answer, like most things in medicine, is nuanced. And that is exactly why it matters to work with a physician who understands the science, the history, and — most importantly — you.
A Brief History: From “Hormones for Everyone” to “Hormones for No One”
For decades, hormone therapy was prescribed to nearly every postmenopausal woman. It was believed to protect the heart, strengthen bones, and keep women feeling young. Then, in 2002, the Women’s Health Initiative (WHI) — one of the largest women’s health studies ever conducted, enrolling over 27,000 women — made headlines when it was abruptly stopped early. The findings suggested that a specific combination of hormones increased the risk of breast cancer, heart disease, stroke, and blood clots.
Practically overnight, millions of women stopped their hormones — many going “cold turkey” — and physicians became afraid to prescribe them. The pendulum swung from “hormones for everyone” to “hormones for no one.”
Both extremes were wrong.
What We Know Now: The Pendulum Finds Its Center
In the more than two decades since, researchers — including the original WHI investigators themselves — have published thousands of studies re-analyzing the data with a more refined lens. What they have found changes the conversation dramatically:
- Age and timing matter enormously. For women under 60, or within 10 years of menopause onset, hormone therapy relieves symptoms effectively and carries very low absolute risk — generally less than one additional adverse event per 1,000 women per year. A 2025 re-analysis of the WHI data confirmed that hormone therapy not only relieved moderate and severe hot flashes in women aged 50 to 59, but did so without raising the risk of heart attack, stroke, or peripheral artery disease.
- The type of hormone matters. The WHI studied one specific oral formulation. Today, physicians have access to FDA-approved bioidentical estradiol (chemically identical to what the body produces) in patches, gels, sprays, and pills, as well as micronized progesterone — options that were not studied in the original trial.
- The route of delivery matters. Transdermal (through-the-skin) estrogen bypasses the liver, resulting in fewer effects on blood clotting and inflammation. Large observational studies suggest that transdermal estrogen carries a lower risk of blood clots and stroke compared with oral estrogen, making it the preferred option for women with obesity, high triglycerides, or moderate cardiovascular risk.
- There is no one-size-fits-all regimen. A woman’s individual health history — her cardiovascular risk, whether she has a uterus, her body weight, her personal and family history — determines which formulation, which dose, and which route of delivery is safest and most effective for her.
The North American Menopause Society, the American College of Obstetricians and Gynecologists, and the American Heart Association all agree: for appropriately selected women, the benefits of hormone therapy outweigh the risks. The key word is “appropriately selected” — and that requires a thorough, individualized evaluation.
More Than Hot Flashes: The Musculoskeletal Syndrome of Menopause
When most people think of menopause, they think of hot flashes and night sweats. But the effects of declining estrogen reach far beyond temperature regulation — and we are only now beginning to appreciate just how far.
Estrogen receptors are found throughout the body: in bone, cartilage, muscle, tendons, the brain, the heart, the bladder, and the skin. When estrogen levels fall, every one of these tissues is affected. That is why menopause can bring not only hot flashes but also joint pain and stiffness, loss of muscle mass, accelerated bone loss, worsening of osteoarthritis, cognitive changes like brain fog and difficulty concentrating, genitourinary symptoms such as vaginal dryness and recurrent urinary tract infections, changes in skin elasticity, and shifts in body composition and metabolic health.
Researchers have recently introduced a term for one of the most underrecognized aspects of this transition: the musculoskeletal syndrome of menopause. More than 70 percent of women experience musculoskeletal symptoms during the menopausal transition, and one in four will be significantly disabled by them. These symptoms — aching joints, morning stiffness, loss of grip strength, new or worsening back pain — are often dismissed as “just getting older” or misattributed to other conditions. In reality, they are frequently driven by the same estrogen decline that causes hot flashes, and they deserve the same attention.
Large studies have shown that joint pain and stiffness are significantly more common in postmenopausal women than in premenopausal women of the same age, and that osteoarthritis rates rise sharply after menopause — independent of aging alone. Estrogen loss contributes to thinner cartilage, reduced bone density, and muscle atrophy, creating a cascade of vulnerability across the entire musculoskeletal system.
The good news is that understanding these connections opens the door to better prevention and treatment. Hormone therapy has been shown to reduce bone loss and fracture risk, and emerging research suggests it may also help protect cartilage and alleviate menopausal joint pain. Exercise, strength training, and weight management are also critical. The key is recognizing that these symptoms are real; they are connected; and they are treatable — not just an inevitable part of aging that women have to endure.
This is one more reason why a comprehensive, individualized approach to menopause care matters. It is not just about managing one symptom in isolation — it is about understanding how the loss of estrogen affects the whole body and addressing each woman’s unique constellation of concerns.
Beware of the “Hormone Mill”
Unfortunately, the explosion of interest in women’s health has also brought an explosion of businesses designed to capitalize on women’s suffering. You may have seen clinics — often operating online or through social media — that promise to “optimize” your hormones by ordering thousands of dollars’ worth of blood tests, saliva panels, and urine hormone kits. They may then prescribe expensive custom-compounded hormone creams or pellets based on those results.
Here is what the science actually says: routine measurement of hormone levels like estradiol and follicle-stimulating hormone (FSH) is not recommended for diagnosing menopause or for adjusting hormone therapy doses in most women. The American Board of Internal Medicine’s Choosing Wisely campaign specifically advises against measuring FSH in women in their 40s to identify the menopausal transition, because these levels fluctuate wildly and do not reliably guide treatment. The American College of Obstetricians and Gynecologists states plainly that steroid hormones like estrogen and progesterone “do not meet the criteria” for individualized blood level testing — they do not have a narrow therapeutic window that requires monitoring the way, say, a thyroid medication does.
The diagnosis of menopause is clinical — based on your age, your symptoms, and your menstrual history. And the goal of hormone therapy is symptom relief, not chasing a number on a lab report. Dosing should be titrated to how you feel, not to an arbitrary blood level.
That does not mean lab work is never needed. Basic safety labs — such as screening for thyroid disease, checking lipids, and ensuring you are up to date on routine health screenings — are an important part of responsible care. And in certain specific situations, such as evaluating possible premature menopause in a woman under 40, hormone levels can be genuinely useful. The difference is between targeted, evidence-based testing and a shotgun approach designed to generate revenue.
What to Look for in a Provider
A healthcare provider who practices evidence-based hormone therapy will:
- Take a thorough personal and family medical history before recommending any treatment
- Discuss your individual risk factors, including cardiovascular health, clotting risk, and breast cancer history
- Explain the differences between oral and transdermal hormones and help determine which is safest for you
- Prescribe FDA-approved formulations whenever possible, rather than unregulated compounded products
- Start at the lowest effective dose and adjust based on your symptom response
- Schedule regular follow-up visits to reassess whether therapy is still appropriate
- Be honest about when and what lab tests are — and are not — necessary, saving you money and unnecessary worry
- Educate you so that you can make informed decisions about your own care
Here Is My Workflow:
As a physician who has made hormone therapy a clinical passion, I take the time to sit down with each patient individually. We review your health history, discuss your symptoms, talk through the risks and benefits that apply specifically to you, and build a treatment plan together. I believe in shared decision-making — not a one-size-fits-all protocol, and certainly not an expensive panel of labs that will not change your care.
If you want additional testing, I am happy to discuss it with you. My goal is to educate you on what the evidence shows so that you can make a truly informed choice — and then support whatever decision you make. I will only order what is necessary to keep you safe, and I will always be transparent about why.
Menopause is not a disease — it is a natural transition. But when symptoms are severe enough to disrupt your sleep, your work, your relationships, and your quality of life, you deserve safe, effective, evidence-based treatment from a provider who knows the science and who knows you.
If you are struggling with perimenopause or menopause symptoms and want to learn more, I invite you to schedule a consultation. Together, we can navigate this transition safely — with science as our guide.
– Melissa Kjos, MD is Health West’s Medical Director and sees patients at Health West Pocatello. She completed medical school at Oregon Health and Science University and her medical residency at Health West ISU. Dr. Kjos enjoys traveling, camping, jogging, reading and spending time with her family.
