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Hormone Health · Menopause

Hormone Replacement Therapy Is Personal: Why the Right Dose, the Right Hormones, and Your Health History Matter

Understanding estrogen, progesterone, and testosterone through a functional health lens.

There is something I wish more women understood about hormone replacement therapy.

What works beautifully for one woman may not work for another.

One woman may feel incredible with estradiol and progesterone. Another may benefit from progesterone alone for a particular symptom. Some women may be candidates for testosterone, while others may not need it or may experience side effects that make it inappropriate.

And then there are women whose medical histories make certain hormones unsuitable altogether.

This is why I believe hormone replacement therapy should never be approached as a standard prescription that everyone follows. Our bodies are far too individual for that.

Menopause is not simply about replacing hormones that have declined. It’s about understanding how those hormonal changes interact with the rest of the body. And that is where a functional health perspective becomes so valuable.

Your hormones don’t work in isolation

Estrogen, progesterone, and testosterone are often discussed as three separate hormones. But they don’t operate independently. They interact with numerous systems throughout the body, including:

• The brain and nervous system
• Metabolism and insulin sensitivity
• Bone and muscle health
• Sleep and temperature regulation
• Sexual health and vaginal tissues
• Cardiovascular and vascular function

Estrogen plays an important role in thermoregulation, bone remodeling, and vaginal tissue health. Progesterone supports the uterine lining in a different way and can influence sleep and sedation. Testosterone contributes to female sexual physiology, although replacing it is not necessary or appropriate for every woman.

During perimenopause, hormones can fluctuate significantly before settling into the lower levels associated with postmenopause. This helps explain why symptoms can feel unpredictable.

One month, sleep is the biggest struggle. The next, it’s hot flashes, joint discomfort, mood changes, or difficulty recovering from exercise.

The key is understanding which symptoms are likely hormone-related and which may have additional contributors.

Why I believe in starting low and making thoughtful adjustments

One of my strongest beliefs about hormone therapy is that more is not necessarily better.

The goal shouldn’t be to prescribe the highest dose a woman can tolerate. The goal should be to find the lowest effective dose that meaningfully improves her symptoms while minimizing unnecessary risks. This is consistent with clinical guidance supporting individualized dosing.^[1]

In my approach to functional health, I also value making changes thoughtfully rather than introducing several new interventions at the same time. When clinically appropriate, introducing treatments in stages can make it easier to understand how a woman responds.

• Is her sleep improving?
• Are hot flashes becoming less frequent?
• Is she experiencing breast tenderness, headaches, changes in mood, or unexpected bleeding?

These details matter.

However, starting hormones separately should never mean delaying medically necessary uterine protection. When systemic estrogen is prescribed to a woman with a uterus, an appropriate progestogen regimen generally needs to be part of the treatment plan from the beginning.^[1]

“Hormone therapy is not something to set and forget. It’s a process of evaluating, adjusting, and periodically reassessing.”

— Nicola Lewis, Founder of Riovie

Estradiol: understanding its role

Estradiol is the primary estrogen during the reproductive years.

As estradiol levels fluctuate and eventually decline, women may experience hot flashes, night sweats, vaginal dryness, sleep disruption, and changes in their overall quality of life.

Systemic estrogen therapy is among the most effective treatments for menopausal hot flashes and night sweats. It also helps prevent bone loss while treatment continues.^[1]

But how estrogen is delivered matters.

Oral estrogen versus transdermal estrogen

Estradiol may be prescribed through oral tablets, skin patches, gels, or sprays.

Oral estrogen passes through the liver before entering the systemic circulation, while transdermal estrogen enters through the skin. This distinction may be particularly important for women with cardiovascular risk factors or concerns about blood clotting.

Transdermal estrogen is generally associated with a lower risk of venous blood clots than oral estrogen, although individual risk still requires careful evaluation.^[3]

Not every woman is a candidate for systemic estrogen, regardless of the route.

Progesterone: more than just another hormone

Progesterone deserves more attention in the menopause conversation.

Its most established role in combined systemic hormone therapy is protecting the uterine lining from excessive estrogen stimulation. Without adequate progestogen protection, systemic estrogen can increase the risk of endometrial hyperplasia and endometrial cancer in women with a uterus.^[1]

But progesterone may also influence sleep.

Oral micronized progesterone has sedating properties, and some women report improved sleep while taking it. However, the evidence varies by population and indication, and it isn’t a universal sleep treatment.

Some women tolerate progesterone very well. Others experience dizziness, bloating, breast tenderness, or mood-related side effects. Even the dose, schedule, and formulation can change the experience.

Can a woman take progesterone without estrogen?

In selected circumstances, yes.

Progesterone may be prescribed independently for specific indications or symptoms, depending on menstrual status and clinical circumstances.

But progesterone alone is not equivalent to estrogen therapy and does not provide all the benefits of estrogen for menopausal symptoms, vaginal tissue health, or prevention of bone loss.

The right question isn’t whether progesterone is better than estrogen. It’s whether a particular treatment addresses that woman’s needs safely.

Testosterone: helpful for some women, but not a requirement

Testosterone is naturally present in women, and it has a role in sexual physiology.

However, I believe we need to be especially careful about the growing narrative that every menopausal woman needs testosterone.

She doesn’t.

The strongest evidence supports carefully monitored systemic testosterone therapy for selected postmenopausal women experiencing hypoactive sexual desire disorder, a condition involving persistent low sexual desire that causes personal distress.^[2]

Evidence is insufficient to routinely recommend testosterone for general fatigue, brain fog, weight management, muscle building, or anti-aging.^[2]

Excess testosterone can also cause acne, unwanted facial hair, scalp hair thinning, and other androgen-related effects. Some changes, such as voice deepening, may be irreversible.

Monitoring matters, and treatment should avoid pushing testosterone above normal physiological female levels.^[2]

Testosterone is another example of why hormone therapy must remain individualized. A woman should not feel pressured to take three hormones simply because someone else feels better on all three.

Your medical history changes everything

Before beginning hormone replacement therapy, a woman’s health history deserves serious attention.

Not a quick checklist. A meaningful conversation.

There are circumstances where systemic hormone therapy may carry risks that outweigh its potential benefits. Important considerations include:^[1]

• A personal history of breast cancer or another estrogen-sensitive cancer
• Previous deep vein thrombosis, pulmonary embolism, or known blood-clotting disorders
• A history of stroke, heart attack, or significant cardiovascular disease
• Unexplained vaginal bleeding
• Certain forms of liver disease
• Uncontrolled hypertension or substantial cardiovascular risk factors
• Age, time since menopause, and previous hormone exposure

Some of these are contraindications to systemic hormone therapy, while others require individualized risk assessment or specialist input.

This is also where the route of administration matters. An estrogen patch and an oral estrogen tablet do not necessarily carry identical risks.

And in some cases, a woman who cannot use systemic estrogen may still be eligible for certain local treatments, such as low-dose vaginal estrogen, after an appropriate medical assessment.

The point is not to frighten women away from HRT. It’s to make sure women understand that a prescription should reflect their health history, not just their symptoms.

“A prescription should reflect your health history, not just your symptoms.”

— Nicola Lewis, Founder of Riovie

The functional health perspective: look beyond hormones

One of the reasons I am so passionate about functional nutrition is that hormones are only one part of the larger picture.

Consider a woman who is struggling with fatigue, weight changes, poor sleep, and low motivation.

Could declining estrogen contribute? Absolutely.

But what else might be happening? Could she have poor sleep quality, inadequate protein intake, iron deficiency, thyroid dysfunction, insulin resistance, or significant ongoing stress? Those questions deserve attention too.

Hormone therapy may help with symptoms caused by hormonal changes, but it isn’t designed to correct every metabolic or lifestyle issue.

I believe the strongest approach considers both medical treatment and foundational health. That means looking at muscle preservation through resistance training, adequate protein, blood sugar regulation, dietary quality, sleep consistency, and cardiovascular health.

When appropriate, we can also evaluate concerns such as thyroid function, anemia, or metabolic risk through targeted laboratory testing.

This isn’t about ordering every hormone panel available. For most healthy women over 45 with typical menopausal symptoms, treatment decisions can be made using their symptoms and clinical history rather than repeatedly chasing hormone levels.^[4]

It is about knowing when additional information will genuinely improve care.

What if your first hormone prescription doesn’t feel right?

This is something I really want women to hear.

Your first prescription may not be your final prescription.

Some women respond well to a low-dose patch. Others need an adjustment in dose or delivery method. A woman may tolerate one progesterone formulation better than another.

And sometimes, what initially seems like a hormone side effect turns out to have another contributing cause.

The answer isn’t always to increase the dose. Sometimes it’s to lower it, change the formulation, address another issue, or reconsider whether that particular treatment is appropriate.

Follow-up is important. An initial review around three months is commonly recommended, with earlier evaluation when symptoms or side effects warrant it.^[4]

Persistent or unexpected vaginal bleeding should always be assessed appropriately.

And no woman should feel that she has failed because a particular hormone treatment didn’t agree with her.

Hormone therapy should be about quality of life, not chasing numbers

I don’t believe the goal of menopause care should be making a woman’s hormone levels look like they did at 25.

The goal is helping her feel well and function well during a different stage of life. That may mean:

• Fewer hot flashes
• Better sleep
• Less disruption to everyday life
• Improved vaginal comfort
• Or finding a medical treatment that supports her ability to stay active and engaged in the things she loves

For some women, systemic hormone therapy can make an enormous difference. For others, nonhormonal treatments or targeted local therapies may be more suitable.

And for some, the best approach involves a combination of medical treatment, nutrition, movement, and other supportive strategies.

There is no single formula for a healthy menopause.

My final thoughts: you deserve individualized care

If there is one thing I hope women take away from this article, it’s that hormone replacement therapy should be personal.

You are not simply a set of lab values. You are not another prescription to fill. And you certainly do not need to follow someone else’s hormone protocol to have a successful menopause experience.

I believe in understanding the whole woman: her medical history, symptoms, lifestyle, metabolic health, concerns, and personal goals.

Sometimes that means hormone therapy. Sometimes it means carefully adjusting the approach. And sometimes it means recognizing that hormones may not be the right treatment at all.

At Riovie, our philosophy has always been that education and individualized care belong together. Because when we understand how the body works, we can make more informed decisions about how to support it.

Everything is connected. Your care should be too.

— Nicola LewisFounder, Riovie

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