Menopause BHRT


An approach that recognizes menopause as a complex
and individual process can lead to optimum health.

From the perspective of health, changes that occur at this time require an individualized approach. Although many women experience comparable symptoms during this stage, in actuality the health profile of each woman is somewhat unique.

When a women transitions into menopause, the ovaries slow their production of estrogen, progesterone, and testosterone. These hormonal shifts can cause profound changes in sleep patterns, energy, mental function, mood, sexuality, quality of life and other aspects of a woman’s health. Preventative health strategies become very crucial at midlife.

Many of the changes women experience during menopause can be managed successfully through an individualized program of optimized nutrition, vitamin supplements, herbs, stress reduction, and exercise, in addition to bioidentical hormones. Each woman’s program will be based on a careful medical evaluation and key lab results.

Three important aspects of my approach include:


  1. Each woman is unique and needs individualized assessment.
  2. Hormone levels need to be measured before and during treatments.
  3. Use only BIO-IDENTICAL HORMONES. These hormones are the same as human females (or males) make and are plant derived. Many studies suggest that synthetic progesterone and horse-derived estrogen are not safe.


Estrogens:  Estrogens can help with hot flashes, sleep, energy, depression, anxiety, irritability, brain fog, memory, joint or muscle pain, bone strength, sex drive, vaginal dryness, dry skin, and much more. Many women “feel themselves” again, or just feel that
their quality of life is better because they feel better physically and emotionally.

Many studies show estrogens can help prevent dementia, heart disease,  and osteoporosis, especially if administered by skin absorption and not by mouth.

Research shows that estrogen increases the levels of the brain neurotransmitters serotonin and dopamine and improves mood and mental energy. Medical studies also show that estrogen improves blood flow to the brain and can lower the risk of dementia.

NO ESTROGEN BY MOUTH.  Estrogen should always be applied to the skin by cream, gel, or patch. Estrogens in pill form can lead to increased risk of blood clots, stroke, or heart attack.

Naturally occurring estrogens in women have several forms with differing properties:
estradiol, estriol, and estrone. Estradiol and estriol are favorable estrogens and estrone is less favorable. In our compounded estrogen prescriptions we give estradiol and estriol but not estrone.

EXCESS ESTROGEN can be deleterious and lead to uterine and breast problems. This is why it is so important to have your hormones measured so we can individualize each woman’s treatment.

Women on estrogens need regular physical breast exams and other studies, including mammograms and breast thermograms (heat studies), to make sure their breasts are healthy.

Progesterone: Progesterone can be very calming and help with sleep, anxiety, and mood. In some women, it will improve libido; in a smaller number it will decrease libido. In some cases, it will decrease swelling and pain. A small percentage of women do not tolerate progesterone well.

Progesterone is usually, but not always, needed when a woman is taking estrogen.
Bioidentical progesterone can be safely taken by mouth or as a skin cream. Some women will  prefer the capsules for convenience. Another advantage of the oral route is the increased sleep inducing effect when taken at bedtime. For some women progesterone capsules are a sleep miracle because they strongly stimulate the GABA receptors in the brain. Progesterone applied to the skin

Transdermal (on the skin)  progesterone does not have as strong an impact on sleep as oral progesterone does but does improve sleep in many women because it lowers anxiety and creates calmness.

Some women’s BREAST health will improve on progesterone and some may not.
See section on improving breast health and decreasing the risk of breast cancer. Many studies have shown that synthetic progesterone, Provera, significantly increases breast cancer risk.

One of the reasons we give progesterone when a woman is on estrogen is to protect the health of the uterus.If a woman is on estrogen without progesterone, the UTERINE lining,(medical term: “endometrium,”) may overgrow (cellular changes and thickening of the lining or “hyperplasia”) and over time this can lead to cancer of the uterine lining (endometrial cancer). Adding progesterone to the estrogen can reverse this overgrowth in most cases.


  1. Testosterone is also an important hormone for women’s sexuality, both libido and orgasmic function. It increases muscle mass and exercise endurance.
  2. Testosterone can improve mood, motivation, brain focus, and sense of pleasure or reward, because it increases the neurotransmitter dopamine in the brain.
  3. Testosterone cream applied to the clitoral area can increase sexual responsiveness and pleasure.
  4. This hormone should always be used topically or on the skin as a cream, gel, or patch.
  5. BEWARE METHYLTESTOSTERONE, a synthetic form of testosterone. This has been shown to have significant liver toxicity.

Acknowledging the unique nature of each woman’s experience.  The constellation of symptoms experienced by one woman may be quite different from those of another. Consequently, the health of each woman needs to be supported in a different way. I provide every patient with an in-depth evaluation. This gives us an opportunity to develop an individualized treatment plan focused on the patient’s specific needs and gives the patient the information and resources they need to make informed choices.

In order to get to know you and understand your health history, I typically need to spend an hour and a half on the initial visit. Once a treatment plan has been determined, we schedule one or two follow-up visits to track the response to therapy.

After you are established and doing well we need to meet at least once a year to talk about your overall health and any new problems, check your hormone levels, bone density, breast health with a breast exam, and a mammogram or breast thermogram, blood pressure, weight, cholesterol, vitamin D level, calcium intake, other labs as needed, and several other important health screening factors that are important for women over 50.

  1. Measuring the levels of crucial hormones.   It is valuable to actually measure hormone levels. We can’t just make assumptions about hormone status based on age or symptoms. Lab test are now available that measure hormones in either saliva or blood. The information these tests provide can be extremely helpful for both initial assessment and for follow-up, as women progress through the transition of menopause.
  2. In my experience this testing offers an effective means of individualizing treatment. Initially, levels are measured before and after bio-identical hormones are initiated. Hormone supplements can then be adjusted, based on actual test results, symptoms, and patient response. Later, hormones can simply be measured once a year unless the patient experiences major stress or a life change that affects her hormonally.
  3. The ability to re-measure hormones and compare them against earlier levels also provides us with a unique opportunity to manage a woman’s health after menopause. In addition, this information gives us an exceptional tool for addressing problems such as chronic insomnia, stress response, and burnout.
  4. Replacing the body’s hormones with bio-identical hormone supplements.  When we use hormones, we always use them in a bio-identical form. This means that the hormones supplements are exactly the same hormones as those made by the female body—the same estrogens, progesterone, and testosterone. This approach does not involve synthetic hormones like medroxyprogesterone, provera, or norethindrone; nor does it entail the use of hormone supplements manufactured from the urine of pregnant horses like conjugated equine estrogens or premarin.

Safety. All of the major hormone studies with adverse effects reported in the media and the medical journals have used either synthetic hormones or substances derived from pregnant mares.

Synthetic hormones. These man-made substances are very different than natural bio-identical progesterone, both in terms of chemistry and in their effects on our bodies. Many women experience major depression and fatigue when taking synthetic hormones. The research also shows that when young women are injected with synthetic hormones for birth control, they can experience significant decreases in bone mass. This is an adverse effect to be avoided, especially by post-menopausal women.

Animal-derived hormones. These hormone supplements are manufactured from hormones present in the urine of pregnant mares—hormones that are quite foreign to the human female body. Animal-derived hormones contain a combination of many estrogens, and some are 10 to 20 times stronger than our own estrogens.


Focusing on prevention. Women also need to be aware of the increased risk of health issues as we age. As we move into our 40s and beyond, these risks include heart disease, strokes, breast and other cancers, osteoporosis, arthritis, thyroid disorders, diabetes or difficulties with insulin regulation, dementia, and Alzheimer’s. Since female hormones tend to interact with these risk factors they need to be taken into consideration as we continue to follow your hormonal health.

We urge all of our patients to have regular testing to evaluate their current health status and potential risks. We also make a concerted effort to identify any existing health issues early on since early intervention can significantly increase the potential for a positive outcome.

Applying an integrative approach.  Therapies such as nutritional medicine are powerful tools for preventing disease and managing chronic health conditions. Potential issues can be addressed successfully by taking the time to pay close attention to your specific concerns. For example, we can test your bone density early in menopause and track it if your test results are low. Many of my patients have experienced healthy increases in bone density by using bio-identical hormones, increasing exercise, and supplementing with minerals and vitamin D.

Optimizing genetics and lifestyle.  Health risks are determined by many factors, including genetics, stress, diet, lifestyle, exercise, relationships, outlook, and spirituality. We now know that genetic factors can be modified—genes are “turned off” or “turned on” by our nutrition and other aspects of our day-to-day lifestyle. Disease is not inevitable just because of our genetic make-up.

Reducing your health risks.   If you have a family history of stroke or heart disease, we can recommend specialized testing and put you on a preventative program. If you have an elevated risk of breast cancer, we can design an extensive preventative program for you. These approaches are guided by your family history, your medical history, specialized cutting-edge testing, some genetic testing, and by new research on the risk factors involved. For example, when there is an elevated risk of dementia, it’s useful to know that epidemiological studies have identified strategies that significantly decreased risk. Researchers found that older women were much less likely to develop Alzheimer’s if they were on estrogen replacement for 5 to 10 years in the early period of their menopause.

Women, Estrogen, Cognition, and Alzheimer’s Disease
by Ann Hathaway MD
Published in Townsend Letter, June 2012