Women’s Hormone Health, Menopause, and HRT: A Comprehensive Summary

May 13

Introduction

This blog is based on an extensive conversation between Dr. Peter Attia and urologist Dr. Rachel Rubin. The episode focuses on women’s sexual health, menopause, hormone replacement therapy (HRT), and the misinformation that has shaped generations of medical practice. Dr. Rubin sheds light on the neglected reality of women's hormonal health, calling for a systemic overhaul in how medicine approaches menopause and sexual function.

Read the whole detailed transcript in full.

I apologize for some repetition in this summary. AI helped me build it but the transcript was so long I had to do it in chunks and some of it got repeated.

Key Highlights

Menopause Is Not Niche Medicine

Half the population experiences menopause, making this a mainstream health issue.
Yet, menopause care is poorly integrated into standard medical education and practice.
A stark comparison: if men’s genitals were similarly affected at age 52, pharmaceutical responses would be immediate and widely funded.

Three Key Hormones in Women’s Health

Estrogen, progesterone, and testosterone are critical, yet testosterone is often ignored in women.
All humans have and need all three hormones; it's incorrect to associate testosterone solely with men.

Understanding Perimenopause and Menopause

Menopause is described as a “castration event” — a sudden, dramatic drop in hormone production.
Perimenopause involves wild hormonal fluctuations that can cause severe symptoms.
Hormone levels can shift from 50 to 900 and back rapidly, leading to inflammation and discomfort.

Symptoms and Clinical Observations

Mental health deterioration, libido loss, pelvic pain, UTIs, osteoporosis, cardiovascular risks, and cognitive decline.
“Empty gas tank” analogy: menopause leaves women with depleted hormonal reserves, explaining the symptoms.

The Hormone Replacement Therapy (HRT) Controversy

The Women’s Health Initiative (WHI) Fallout

WHI was a billion-dollar NIH study that tested synthetic hormones.
Results were misinterpreted and publicized through a press conference before peer-reviewed publication.
The media highlighted a 24% relative risk increase in breast cancer, failing to emphasize the absolute risk increase was only 0.1%.
The fallout: generational fear of HRT, collapse of hormone therapy prescriptions, and a generation of doctors who were never trained.

What the WHI Really Showed

Decreased risks: colon cancer, fractures, diabetes, overall mortality.
Breast cancer incidence slightly increased only in synthetic combo therapies — not mortality.
Estrogen-only therapy showed reduced breast cancer risk.
Cardiovascular risk was not significantly increased.

The Cost of Inaction

Economic and Social Impact

Vaginal estrogen could save Medicare $6–22 billion/year due to reduced UTIs and hospitalizations.
Women suffer preventable disability and death (e.g., hip fractures, dementia, cardiovascular disease).
50% of women who survive a hip fracture never regain full function.

The Lost Generation

Millions of women denied HRT and a better quality of life.
Medical field failed to educate a new generation of doctors.
Less than 6% of OB/GYNs, internists, or family docs receive even 1 hour of menopause training.

Testosterone: The Overlooked Hormone

The Role of Testosterone in Women

Declines with age beginning in the 30s.
Influences libido, genitourinary health, mood, and muscle tone.
Often depleted further by birth control pills, which suppress ovarian function.

Barriers to Testosterone Therapy

No FDA-approved testosterone products for women in the U.S.
Physicians are untrained or discouraged from prescribing it.
Cultural stigma and misconceptions remain strong.

Clinical Use and Outcomes

Most common side effects: acne, oily skin, increased hair growth (mild).
When dosed correctly (e.g., using men's gel in 1/10th doses), benefits are profound:

Restored libido
Improved urinary health
Greater energy and sense of self

Topical gels preferred over pellets due to controllable dosing.

Testosterone is a critical hormone for women, influencing libido, mood, pelvic health, and even urinary function.
Levels begin to decline in women in their 30s, independent of menopause.
Despite widespread testosterone use in men (often off-label), women face stigma, lack of FDA-approved products, and underdiagnosis.
The most common side effect in women is mild acne or increased hair growth, which can be managed by dose adjustments.
Celebrities like Halle Berry and Kate Winslet have helped normalize its use by publicly endorsing testosterone therapy.

Systemic Bias and the WHI Fallout

The Women's Health Initiative (WHI) study in 2002 led to fear and misinformation about HRT.
Estrogen was wrongfully linked to breast cancer and cardiovascular risks, resulting in black box warnings that still persist despite contradictory evidence.
Testosterone therapy for men saw faster regulatory correction (e.g., the Traverse Trial), revealing a double standard.
A billion-dollar trial on testosterone for women was halted because the FDA demanded five more years of data, stalling industry support.

Progesterone: Risks, Benefits, and Delivery Methods

Micronized progesterone is safe and often helps with sleep and mood.
Some women react negatively to it (e.g., irritability, depression), and alternatives like IUDs or vaginal delivery can help.
Progesterone must be used if a woman has a uterus and is on estrogen to protect the endometrial lining.
Cyclical and daily dosing approaches are both valid, depending on the patient.

Estradiol: Safe, Flexible, and Underused

Estradiol (E2) is the most potent and studied estrogen for HRT.
Preferred delivery methods are transdermal patches and gels, which avoid liver metabolism and reduce clotting risks.
Oral estradiol is underused but effective for women without cardiovascular risk factors.
Compounded creams like “biestrogen” are not recommended unless necessary, due to inconsistent dosing and lack of data.

Vaginal Estrogen: Safe for All Women

Local vaginal estrogen is extremely safe—even for elderly women—and effective at treating genitourinary symptoms like dryness, UTIs, and pain during intercourse.
It remains underprescribed due to misplaced fears, outdated FDA warnings, and lack of awareness.
Products include tablets, creams, rings, and DHEA suppositories, all low-dose and non-systemic.

Cultural and Medical Failures

The conversation highlights a paternalistic, outdated view of women’s health in medicine.
Women are often dismissed or denied treatment based on outdated data or provider ignorance.
This vacuum has led to a rise in fringe hormone clinics, some of which exploit women by selling expensive, unregulated compounds.

Menopause Is Not Niche Medicine

Half the population experiences menopause, making this a mainstream health issue.
Yet, menopause care is poorly integrated into standard medical education and practice.
A stark comparison: if men’s genitals were similarly affected at age 52, pharmaceutical responses would be immediate and widely funded.

Three Key Hormones in Women’s Health

Estrogen, progesterone, and testosterone are critical, yet testosterone is often ignored in women.
All humans have and need all three hormones; it's incorrect to associate testosterone solely with men.

Understanding Perimenopause and Menopause

Menopause is described as a “castration event” — a sudden, dramatic drop in hormone production.
Perimenopause involves wild hormonal fluctuations that can cause severe symptoms.
Hormone levels can shift from 50 to 900 and back rapidly, leading to inflammation and discomfort.

Symptoms and Clinical Observations

Mental health deterioration, libido loss, pelvic pain, UTIs, osteoporosis, cardiovascular risks, and cognitive decline.
“Empty gas tank” analogy: menopause leaves women with depleted hormonal reserves, explaining the symptoms.

The Hormone Replacement Therapy (HRT) Controversy

The Women’s Health Initiative (WHI) Fallout

WHI was a billion-dollar NIH study that tested synthetic hormones.
Results were misinterpreted and publicized through a press conference before peer-reviewed publication.
The media highlighted a 24% relative risk increase in breast cancer, failing to emphasize the absolute risk increase was only 0.1%.
The fallout: generational fear of HRT, collapse of hormone therapy prescriptions, and a generation of doctors who were never trained.

What the WHI Really Showed

Decreased risks: colon cancer, fractures, diabetes, overall mortality.
Breast cancer incidence slightly increased only in synthetic combo therapies — not mortality.
Estrogen-only therapy showed reduced breast cancer risk.
Cardiovascular risk was not significantly increased.

The Cost of Inaction

Economic and Social Impact

Vaginal estrogen could save Medicare $6–22 billion/year due to reduced UTIs and hospitalizations.
Women suffer preventable disability and death (e.g., hip fractures, dementia, cardiovascular disease).
50% of women who survive a hip fracture never regain full function.

The Lost Generation

Millions of women denied HRT and a better quality of life.
Medical field failed to educate a new generation of doctors.
Less than 6% of OB/GYNs, internists, or family docs receive even 1 hour of menopause training.

Testosterone: The Overlooked Hormone

The Role of Testosterone in Women

Declines with age beginning in the 30s.
Influences libido, genitourinary health, mood, and muscle tone.
Often depleted further by birth control pills, which suppress ovarian function.

Barriers to Testosterone Therapy

No FDA-approved testosterone products for women in the U.S.
Physicians are untrained or discouraged from prescribing it.
Cultural stigma and misconceptions remain strong.

Clinical Use and Outcomes

Most common side effects: acne, oily skin, increased hair growth (mild).
When dosed correctly (e.g., using men's gel in 1/10th doses), benefits are profound:

Restored libido
Improved urinary health
Greater energy and sense of self

Topical gels preferred over pellets due to controllable dosing.

Systemic Change Is Needed

Training and Policy Reform

Urologists and advocates like Dr. Rubin are training psychiatrists, internists, and gynecologists.
Resistance persists: malpractice insurance limitations, institutional inertia, misinformation.

Call to Action

Every medical specialty needs to be engaged — menopause impacts the heart, brain, bones, and more.
HRT and menopause education must be standardized across medical training.
Awareness must extend to the public and policymakers to reverse decades of harm.

This conversation is a wide-ranging, passionate, and evidence-based discussion about hormone therapy (HRT) for women, the neglect of testosterone in women’s health, and the systemic biases that have distorted the medical understanding of menopause care.

The Testosterone Gap in Women’s Health

Testosterone is a critical hormone for women, influencing libido, mood, pelvic health, and even urinary function.
Levels begin to decline in women in their 30s, independent of menopause.
Despite widespread testosterone use in men (often off-label), women face stigma, lack of FDA-approved products, and underdiagnosis.
The most common side effect in women is mild acne or increased hair growth, which can be managed by dose adjustments.
Celebrities like Halle Berry and Kate Winslet have helped normalize its use by publicly endorsing testosterone therapy.

Systemic Bias and the WHI Fallout

The Women's Health Initiative (WHI) study in 2002 led to fear and misinformation about HRT.
Estrogen was wrongfully linked to breast cancer and cardiovascular risks, resulting in black box warnings that still persist despite contradictory evidence.
Testosterone therapy for men saw faster regulatory correction (e.g., the Traverse Trial), revealing a double standard.
A billion-dollar trial on testosterone for women was halted because the FDA demanded five more years of data, stalling industry support.

Progesterone: Risks, Benefits, and Delivery Methods

Micronized progesterone is safe and often helps with sleep and mood.
Some women react negatively to it (e.g., irritability, depression), and alternatives like IUDs or vaginal delivery can help.
Progesterone must be used if a woman has a uterus and is on estrogen to protect the endometrial lining.
Cyclical and daily dosing approaches are both valid, depending on the patient.

Estradiol: Safe, Flexible, and Underused

Estradiol (E2) is the most potent and studied estrogen for HRT.
Preferred delivery methods are transdermal patches and gels, which avoid liver metabolism and reduce clotting risks.
Oral estradiol is underused but effective for women without cardiovascular risk factors.
Compounded creams like “biestrogen” are not recommended unless necessary, due to inconsistent dosing and lack of data.

Vaginal Estrogen: Safe for All Women

Local vaginal estrogen is extremely safe—even for elderly women—and effective at treating genitourinary symptoms like dryness, UTIs, and pain during intercourse.
It remains underprescribed due to misplaced fears, outdated FDA warnings, and lack of awareness.
Products include tablets, creams, rings, and DHEA suppositories, all low-dose and non-systemic.

Cultural and Medical Failures

The conversation highlights a paternalistic, outdated view of women’s health in medicine.
Women are often dismissed or denied treatment based on outdated data or provider ignorance.
This vacuum has led to a rise in fringe hormone clinics, some of which exploit women by selling expensive, unregulated compounds.

A Call to Action

Every physician who sees midlife women should be educated and empowered to prescribe hormone therapy safely.
Doctors must engage in open, curious conversations with patients, asking: “What are you afraid of?” and “What are your goals?”
Education, humility, and patient partnership are key to shifting menopause care into the 21st century.

Conclusion

This episode represents an urgent plea for modern medicine to recognize and rectify its mishandling of women’s hormonal health. By bringing clarity, data, and deep compassion to the discussion, Dr. Rubin and Dr. Attia advocate for empowering both patients and practitioners. The time has come to put menopause medicine where it belongs: at the heart of human healthcare.

Bett Bollhoefer