A patient of mine — a physician herself — had a hysterectomy and started transdermal estradiol a few weeks later. Then her breasts began to ache. Not a little. Enough that a seatbelt hurt. Enough that she lay awake at 2 a.m. reading about estrogen and breast cancer and arrived in my office certain she had done something dangerous to her own body. She is a trained clinician. She has read papers. And she was still terrified. That tells you something about how thoroughly one 2002 press conference reshaped what an entire generation of women — including the ones with medical degrees — believe about estrogen. So let's go back to what the Women's Health Initiative actually found. Not the headline. The data.

I have a three-page handout I give to women who want to try testosterone. It exists because there is no other way to do this. It tells them that the medication I am prescribing has no FDA-approved version for their sex, anywhere in this country. It tells them insurance will almost certainly not cover it, and to budget roughly $130 out of pocket. It tells them to ignore the instructions printed on the pharmacy label, because those instructions were written for a 200-pound man and following them would deliver roughly ten times the dose I intend. It tells them to squeeze out a pea-sized amount of gel — about half a gram — from a packet designed to be emptied in one application, and to make that packet last ten days.

I've been practicing medicine for over two decades. I've sat with women in clinic, on hospital floors, and now through telehealth — and I can tell you that one of the most common moments I witness is this: a woman describes months of fragmented sleep, hot flashes at 2 a.m., anxiety that arrived out of nowhere, a fog that won't lift — and then adds, almost apologetically, "But I'm afraid of hormones." That fear is real, and it didn't come from nowhere. It came from a 2002 study that made headlines around the world and led millions of women to stop — or never start — hormone therapy. What those headlines missed, and what took two more decades of research to fully untangle, is that not all hormones behave the same way in your body. The type matters enormously.

Many women entering perimenopause are told by their clinicians that a single follicle-stimulating hormone (FSH) blood test will determine whether they are in the menopausal transition and whether they are candidates for menopause hormone therapy (MHT). This practice is widespread, but it is not supported by current evidence or by leading menopause guidelines. Understanding why requires a clear look at what FSH is, how it behaves during perimenopause, and what measures actually correlate with both menopausal status and the likelihood of benefit from treatment.

In our last blog, we discussed how the erratic estrogen fluctuations of perimenopause disrupt the production of serotonin and dopamine — two neurotransmitters essential for mood, motivation, sleep, and emotional well-being. The good news is that in addition to hormone therapy, there are evidence-based nutritional supplements that can support your body’s ability to produce these critical brain chemicals.