When Hormone Therapy Isn’t the Right Fit: A More Nuanced Approach to Midlife Health
Hormone therapy has rightfully earned a central place in conversations about perimenopause and menopause. For many women, it can significantly improve quality of life, reduce disruptive symptoms, and support long-term health. At the same time, a growing number of women and clinicians are recognizing an important truth: hormone therapy is not appropriate, effective, or desired in every situation.
In a recent episode of the Women Mastering Midlife podcast, I explored this complexity in depth with functional medicine nutritionist and educator Andrea Nakayama. Our conversation focused on what options exist when hormone therapy is contraindicated, poorly tolerated, inaccessible, or simply not aligned with a woman’s personal health values.
You can listen to the full podcast episode here:
Women Mastering Midlife Podcast
This article expands on that discussion for both midlife women seeking clarity and professionals looking for a more comprehensive framework for menopause care.
Moving Beyond a One-Size-Fits-All Menopause Model
Menopause is often framed as a hormone deficiency state that requires replacement in order to restore normal function. While this model has helped validate many women’s experiences, it can also oversimplify a biologically complex transition.
In clinical practice, we routinely see women who:
Experience persistent symptoms despite guideline-supported hormone therapy
Cannot use hormone therapy due to medical contraindications
Do not tolerate specific formulations or dosing strategies
Choose not to pursue hormone therapy for personal or philosophical reasons
None of these scenarios represent failure or poor compliance. They reflect the reality that menopause care must be individualized and grounded in physiology, not marketing narratives.
The more useful clinical question is not whether hormone therapy is good or bad, but whether the body receiving hormones is able to respond appropriately.
Hormones Do Not Act in Isolation
Hormones are chemical messengers, not standalone solutions. Their effectiveness depends on the internal environment in which they are introduced, often referred to as the physiologic terrain.
For hormones to be effective, the body must be able to:
Synthesize or receive hormones
Transport them via carrier proteins
Utilize them at the cellular level
Metabolize and eliminate them safely
Disruptions in any of these processes can lead to suboptimal outcomes, even when hormone therapy is prescribed correctly.
Key systems that influence hormone response include:
Blood sugar regulation and insulin sensitivity
Liver and gut function, particularly for estrogen metabolism and elimination
Thyroid health
Inflammatory balance
Micronutrient status
Sleep quality and circadian rhythm regulation
When these systems are compromised, hormone therapy alone may not resolve symptoms and can sometimes worsen them. This helps explain why some women feel unwell on evidence-based dosing and why additional escalation does not always lead to improvement.
Menopause Support Without Hormone Therapy Is Not “Doing Nothing”
One of the most important messages from this conversation is that women are not without options if hormone therapy is not part of their care plan.
Clinically meaningful improvements in midlife health are often achieved by addressing foundational physiology, including:
Nutrition and Metabolic Support
Adequate protein, fiber, and healthy fats are essential for hormone signaling, blood sugar stability, and inflammatory regulation. Many midlife symptoms improve when metabolic stress is reduced.
Digestive and Gut Health
Regular elimination is critical for hormone clearance. Impaired gut function can contribute to estrogen recirculation and symptom persistence.
Stress Physiology and Cortisol Regulation
Chronic stress alters hormone signaling and sleep architecture. Addressing cortisol patterns is often essential for symptom relief.
Sleep Quality and Recovery
Sleep is not only restorative but also central to detoxification, immune regulation, and endocrine balance.
Movement, Strength, and Balance
Strength training and functional movement support bone health, insulin sensitivity, and long-term independence regardless of hormone use.
These interventions are not alternatives to medicine. They are foundational components of effective menopause care that support healthspan whether or not hormone therapy is used.
The Risks of Over-Testing and Over-Pathologizing
Another issue increasingly affecting midlife women is the rise of expansive functional testing without adequate clinical context.
Testing can be helpful when it informs targeted decision-making. It becomes problematic when results are used to assign fixed identities such as “estrogen dominant” or “metabolically broken,” often followed by costly protocols that increase anxiety without improving outcomes.
More data does not automatically lead to better health. In many cases, careful history, basic laboratory assessment, and attention to daily physiology provide more actionable insight than extensive panels.
For clinicians and coaches, this highlights the importance of using testing as a tool for context, not as a diagnostic label that limits patient agency.
Midlife Is a Transition, Not a Diagnosis
Menopause is not a disease state. It is a biologically normal transition that intersects with identity, culture, and lived experience.
Physiology is influenced not only by hormones and lab values, but also by connection, purpose, movement, rest, and psychological safety. When menopause care is reduced to a single intervention, women lose access to a broader and more empowering framework for health.
Hormone therapy can be an important tool. It is not a measure of success, worth, or vitality.
Listen to the Episode and Continue the Conversation
This topic resonates deeply because it reflects what so many women are experiencing but rarely see acknowledged.
You can listen to the full podcast episode here:
Women Mastering Midlife Podcast
For readers who want to continue these conversations in a supportive, evidence-informed space, I invite you to join the Women Mastering Midlife Community.
This community is designed for women navigating perimenopause and menopause who want thoughtful guidance, peer connection, and practical application without extremes or fear-based messaging.
Learn more about the community here:
https://www.womenmasteringmidlife.com/community
This is where we move beyond binary thinking and support women in building health on their own terms.
