The menopause conversation you should have gotten years ago.
A generation of women was scared off hormone therapy by headlines that the data never fully supported — and another generation is now being sold hormones as a cure-all. Both extremes fail you. This practice offers the middle path: modern evidence, honest risk framing, and treatment matched to your symptoms, timing, and goals.
Perimenopause is a transition, not a lab value.
Perimenopause is diagnosed by pattern, not by a single hormone level — cycles shift, sleep fragments, temperature regulation misfires, mood and memory feel borrowed. Our evaluation maps your symptoms against everything else that can masquerade as "hormones": thyroid disease, iron status, sleep apnea, medication effects, and the metabolic shifts of midlife. The full picture decides the plan.
Then we treat what's actually driving your worst symptoms — which may be hormone therapy, may be targeted non-hormonal treatment, and is almost always paired with the muscle, bone, and cardiometabolic work that determines the next 40 years. Start with the perimenopause timeline and what menopause changes for bone, heart, and brain.
Symptoms we treat
- Hot flashes and night sweats (vasomotor symptoms)
- Sleep fragmentation and 3 a.m. wake-ups
- Brain fog, word-finding, and mood swings
- Genitourinary syndrome: dryness, pain, urinary changes
- Joint aches, palpitations, and cycle chaos
- Libido changes — see Sexual Health & Wellness
Hormone therapy: who it helps, how we use it.
What modern evidence supports
- Most effective treatment for hot flashes and night sweats, by a wide margin.
- Timing matters. Started under 60 or within ~10 years of menopause, the benefit-risk profile for healthy women is generally favorable; starting much later shifts the math.
- Route matters. Transdermal estradiol carries lower clot risk than oral; women with a uterus need progesterone to protect the uterine lining.
- Bone protection is real and guideline-recognized.
- Local vaginal estrogen treats genitourinary symptoms effectively with minimal systemic absorption — underused and often life-changing.
The honest risk conversation
- Breast cancer: combined estrogen-progestogen therapy is associated with a small increase in risk with longer use; estrogen-alone data differ. Your personal and family history shape the decision.
- Blood clots and stroke: risk is route- and age-dependent — lowest with transdermal dosing in the timing window.
- Not a cure-all: hormones are not prescribed here as an anti-aging panacea, and "bioidentical" marketing doesn't exempt a product from the same physiology and the same risks. Compounded hormones are used only where a specific need justifies them — FDA-approved products first.
- Some histories change the answer — hormone-sensitive cancers, prior clots, active liver disease. That's what the evaluation is for, and non-hormonal care is a real plan, not a consolation prize.
Non-hormonal options — graded like everything else here.
What earns its place
CBT and clinical hypnosis for hot-flash burden; fezolinetant (an NK3-receptor antagonist) for vasomotor symptoms; SSRIs/SNRIs and gabapentin in the right patients; vaginal moisturizers and local therapy for genitourinary symptoms.
What the trials actually show
Black cohosh performed no better than placebo in the Cochrane review — we say so. Some botanicals have preliminary signals worth discussing; none replaces effective treatment for severe symptoms. Full breakdown: menopause botanicals, graded.
The midlife foundation
Resistance training and protein to counter the estrogen-loss muscle slide, bone loading, sleep repair, and cardiometabolic tracking — because muscle is a hormone organ, and this decade sets up the next four.
Menopause & HRT — common questions.
I was told hormones cause breast cancer. Is that true?
The 2002 headlines flattened a complicated result. Combined estrogen-progestogen therapy is associated with a small absolute increase in breast cancer risk with longer use; estrogen-alone showed a different pattern. For a healthy woman near menopause with disruptive symptoms, professional societies conclude benefits generally outweigh risks. Your evaluation puts real numbers around your situation — that's the only version of this answer that matters.
Am I too late to start hormone therapy?
Timing changes the math but doesn't always close the door. Beyond ~60 or 10 years post-menopause, systemic MHT is started more cautiously and sometimes not at all — while local vaginal estrogen and non-hormonal treatments remain excellent options at any age.
Do you prescribe "bioidentical" hormones?
Body-identical estradiol and micronized progesterone — FDA-approved versions — are the default here, often transdermal. What we avoid is the marketing framework that sells compounded pellets and untested ratios as risk-free. Compounding is reserved for genuine needs like allergies to standard formulations.
What about testosterone for women?
Evidence supports a trial of low-dose testosterone for some postmenopausal women with bothersome low desire after other causes are addressed — with realistic expectations and monitoring. It's part of the sexual health conversation, not a blanket add-on.
How quickly will I feel better?
Hot flashes and sleep often improve within 2–6 weeks of effective treatment; mood and cognition follow as sleep consolidates. We review at 8–12 weeks, adjust dose or route, and then formally revisit the plan every year.
Can I do this by telemedicine?
Much of perimenopause and menopause care works well by telemedicine across Washington State, with labs drawn locally and in-person visits when an exam matters.
Midlife deserves a strategy.
Hormonal or not — leave with a plan for symptoms now and the decades after.
Book a Menopause Evaluation