We Keep Asking the Wrong Question

A patient conversation about hormone therapy — and the half of the story we never tell

This afternoon I was chatting with a patient, a lovely woman, post-menopausal, sharp as a tack, and what she said has been sitting with me ever since.

"I had a hysterectomy years ago. I was fortunate to be put on estrogen therapy back then. But over the last few years, everyone's been trying to take it out of my hands."

She kept going.

"I want access to what I feel I need to be my best. Don't I have a right to that? What about my sexual health? Shouldn't that matter too?"

My vibe at this point was something like preach, girl, and although she couldn't see it over the phone, I am pretty sure my hands were in a "praise" type motion.

She didn't need more fuel, but I gave her a little anyway.

I added: now imagine a man walked into his doctor's office and said, "I'm having trouble with sexual performance." How many prescriptions would land on the counter before he finished the sentence? Meanwhile, women say the same thing about their own bodies and get a shrug, a suggestion to try a glass of wine, or nothing at all.

That contrast is the whole conversation in miniature. And despite the recent noise on social media, the very public pushback from Dr. Rachel Rubin, Dr. Kelly Casperson, and others in front of the FDA, this exact scene is still playing out in exam rooms every day. Just like this one.

What the guidelines actually say

Here's what's frustrating: the clinical guidance already supports her.

In 2022, The Menopause Society (formerly NAMS) issued a position statement affirming hormone therapy as effective treatment for vasomotor symptoms, genitourinary syndrome of menopause, and bone loss prevention, and noted that women who start within 10 years of menopause, or before age 60, tend to see the most favorable benefit-to-risk ratio. That's often called the "timing hypothesis," and it's been reinforced by longer-term data since, including survival analyses showing meaningfully lower cardiovascular event rates in women who started hormone therapy early and stayed on it for a decade or more.

But, and this is the part that gets skipped, the guidance doesn't say hormone therapy becomes off-limits after that window. A large analysis of Medicare records covering roughly 10 million women from 2007 to 2020 found that the effects of hormone therapy after 65 vary by type, route, and dose, not a blanket "stop at 65" rule.

The Menopause Society's own 2022 statement says the same: there is no across-the-board age cutoff. For a healthy woman with persistent symptoms, continuing hormone therapy past 65 can be a reasonable choice, with ongoing counseling and regular reassessment.

In every case, the guidance points to shared decision-making, not a form letter telling a patient her prescription has expired because of a birthday.

The half of the story we skip

The conversation around hormone therapy almost always frames it as: what's the risk of taking it? Fair question. But it's half the question.

The other half, the one that rarely gets airtime, is: what's the risk of not treating at all?

We know hormone therapy helps prevent osteoporosis and the fractures that follow it, which for older women carry real mortality risk. We know low-dose vaginal estrogen is considered first-line therapy by urology guidelines for recurrent UTIs in post-menopausal women, because it restores vaginal tissue health and lowers infection risk, and recurrent UTIs are a leading driver of falls, hospitalizations, and yes, urosepsis in older women. We know that estrogen depravation has serious impact on both neurodegenerative diseases and emerging insulin resistance.

And in women who start hormone therapy in that early window and stay the course, longer-term data has linked it to lower all-cause mortality, not higher.

None of this means hormone therapy is risk-free, or right for every woman, or something to hand out without a real conversation. It isn't. But "there are risks" has become the entire sentence, when it should be the first half of one.

The second half, the risks of leaving symptoms, bone loss, and genitourinary changes untreated for years, deserves equal weight at the table.

The right to be part of the decision

My patient wasn't asking me to hand her a prescription pad and walk away. She was asking for something much simpler: to be included in the conversation about her own body, the same way a man would be about his.

That's the whole model at Ember. Not "here's a hormone, good luck," and not "come back when it's more serious." A real conversation, grounded in where the data actually stands, about what your options are and what's reasonable for you specifically.

On Ember's main website, we have an entire page of discussion and data dedicated to post-menopausal hormone therapy. Our goal is to include you in the conversation that you have been continually left out of.

If you've been told your hormone therapy has an expiration date, or you've stopped asking because you're tired of being brushed off, that's exactly the conversation we're set up to have.

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