Angie Davis

When cholesterol goes up after menopause, the first question should not always be, “How do we lower the LDL?” It should also be, “Why did it go up?”

Estrogen has an important effect on cholesterol, insulin sensitivity, blood vessels, and metabolism. As estrogen levels fall during menopause, LDL cholesterol often rises. That does not automatically mean every woman needs a cholesterol-lowering medication.

Statins can be very important for women who already have cardiovascular disease or who are at high risk. But for otherwise healthy women using them only for primary prevention, the overall benefit can depend heavily on the woman’s individual risk factors. Statins can also have side effects, including muscle symptoms, and they can modestly increase the risk of developing type 2 diabetes in some people.

This is where menopause deserves more attention. If the rise in cholesterol happened alongside the loss of estrogen, it makes sense to look at the entire picture instead of treating one lab value in isolation. Menopausal hormone therapy can improve some aspects of cholesterol and insulin sensitivity, although hormone therapy should not be prescribed solely to prevent heart disease.

The bigger point is that LDL is important, but it is only one part of cardiovascular risk. A woman’s blood pressure, blood sugar, triglycerides, HDL, smoking history, family history, inflammation, body composition, insulin resistance, and evidence of actual plaque or cardiovascular disease all matter too.

Instead of automatically assuming that every menopause-related increase in LDL needs medication, women deserve individualized cardiovascular risk assessment that also recognizes the major metabolic changes happening during menopause.

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What if your hormone levels look “normal,” but you still don’t feel right?
SHBG can change how much estrogen and testosterone are actually available for your body to use, which can directly affect symptoms and treatment results. If hormone therapy isn’t working the way you expected, SHBG may be part of the reason.

SHBG and Hormone Therapy: How It Affects Estrogen, Testosterone, and Treatment Results Learn how SHBG affects free estrogen and testosterone, common causes of high or low SHBG, and why it may influence women’s hormone therapy results.

“Nonhormonal” does not mean “risk-free.”

Veozah is often presented to women who want relief from hot flashes but are afraid of estrogen, particularly because they have been told hormone therapy may increase their risk of cancer. But women deserve the full picture when comparing their options.

Veozah, also known as fezolinetant, is a relatively new medication. It was FDA approved in 2023 for moderate to severe menopausal hot flashes. It works by blocking neurokinin 3 receptors involved in the brain’s temperature-regulation system. It can reduce hot flashes, but it does not replace estradiol or provide the other physiological effects that estrogen has throughout the body.

And being nonhormonal does not make it free of significant risks. Veozah now carries an FDA BOXED WARNING for hepatotoxicity because rare but serious liver injury has occurred after the medication reached the market. Women taking it require liver testing before treatment, monthly testing during the first three months, and additional testing at months 6 and 9.

There is another issue women should at least be aware of. During the clinical development of fezolinetant, FDA reviewers identified a numerical imbalance in malignancies between women receiving the medication and those receiving placebo, with the highest rate occurring in the 45 mg group, which is the dose ultimately approved.

This does NOT mean researchers have proven that Veozah causes cancer. The FDA concluded that the available evidence was not sufficient to establish a causal relationship and did not include a cancer warning in the prescribing information.

However, the discussion did not end there. More recent researchers have continued examining the neoplasm signal and the possible biological effects of blocking the NK3 receptor pathway. There are hypotheses involving kisspeptin signaling and other pathways associated with tumor growth, angiogenesis and metastasis. These are still areas of investigation, not proof that the medication causes cancer, but they are legitimate questions that require longer-term research.

And this is where perspective matters. We have decades of research on estrogen therapy and an enormous body of scientific literature examining its benefits, risks, dosing, routes of administration and long-term health effects. Estradiol has been studied in women for far longer than fezolinetant, a drug that has only been FDA approved since 2023.

That does not mean estradiol is appropriate for every woman, and it does not mean Veozah is a bad medication. Veozah may be an important option for women who cannot or do not want to use hormone therapy.

But women should not be told that one option is “dangerous because it is hormonal” while another is automatically “safer because it is nonhormonal.”

Every medication has benefits, risks and unanswered questions. Women deserve to know the known risks of estradiol. They also deserve to know the known risks and remaining uncertainties surrounding newer nonhormonal medications.

That is what informed consent should look like.

One of the strangest arguments I hear about hormone testing in perimenopause is, “There’s no point checking levels because hormones fluctuate.”

Of course they fluctuate. That is part of what perimenopause is.

Blood pressure fluctuates. Heart rate fluctuates. Blood sugar fluctuates. Body temperature fluctuates. We do not respond by saying those measurements are meaningless. We interpret them in context.

The same should be true with hormones.

A single estradiol level should not be treated like a permanent snapshot of a woman’s hormonal status. Estradiol can rise and fall significantly during perimenopause, sometimes within a very short period of time. Progesterone can vary depending on whether ovulation occurred. FSH can be elevated one day and look very different later.

That does not mean the information has no value.

It means we need to know when the test was drawn, where a woman may be in her cycle, what symptoms she is experiencing, whether she is taking hormone therapy, what dose and delivery method she uses, when she last took that dose, and how her results compare with previous testing.

The mistake is not measuring a hormone that fluctuates.

The mistake is looking at one number without context and assuming it tells the entire story.

Symptoms matter. History matters. Timing matters. Trends matter. Treatment response matters. Lab values can be another piece of that clinical picture.

And when a woman is already using hormone therapy, measuring levels may also provide information about absorption, exposure, dosing, and whether what she is taking is producing the expected physiologic response.

Perimenopause is complicated precisely because hormones can become unpredictable.

That seems like a reason to gather more useful information, not less.

We are not treating a lab number. We are treating the woman sitting in front of us. But having objective data alongside her symptoms and history can help us understand a much more complete picture of what is happening in her body.

I intentionally changed the argument from “everyone should be tested” to “fluctuation does not automatically make testing useless,” which is a much stronger and more medically defensible point.

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This post is focused specifically on estradiol, but progesterone and testosterone are important hormones too and deserve their own conversations. I know this personally because I spent years on estrogen therapy alone after surgical menopause, many were Premarin only. While estradiol helped some symptoms, I experienced many negative side effects from years of estradiol only and then being on too low doses of estradiol and essentially no progesterone or testosterone. For this post, though, we’re focusing specifically on estradiol and the important role it plays in women’s health.

Fear can make “doing nothing” feel like the safest choice. But when estrogen declines, doing nothing is still a decision, and that decision has biological consequences.

Estradiol is not simply a hormone for hot flashes. Estrogen receptors are found throughout the body, including the brain, blood vessels, bones, immune system, and tissues involved in energy production and metabolism. That is why falling estrogen can affect far more than body temperature.

For many women, the earliest changes are things they are told to accept as part of getting older: poor sleep, forgetfulness, brain fog, difficulty concentrating, mood changes, and irritability.

One Yale study involving women with severe menopausal hot flashes found that 82% reported problems with memory and 80% reported sleep disturbance. After six months of estrogen treatment, those numbers fell to 26% and 10%.

Researchers have also looked at what happened after estrogen use dropped dramatically following publication of the Women’s Health Initiative. Dr. Philip Sarrel and colleagues estimated that tens of thousands of women ages 50 to 59 may have died prematurely during the following decade because estrogen therapy was avoided. That figure was an estimate based on population modeling, not a randomized trial proving that estrogen would have prevented every one of those deaths.

Long-term WHI analyses have also produced an important finding that often gets overlooked: outcomes in younger women beginning estrogen therapy were different from outcomes seen in older women starting treatment many years after menopause. In analyses of women in their 50s who used estrogen alone, researchers reported lower overall mortality during follow-up, along with differences in cardiovascular and other health outcomes.

This is why menopause care should be about much more than asking, “Are your hot flashes bad enough to treat?”

Estradiol affects multiple systems throughout a woman’s body. Choosing hormone therapy or choosing not to use it should be an informed decision based on a woman’s age, health history, timing of menopause, symptoms, risks, and potential benefits.

Doing nothing is still a choice. Women deserve to understand what that choice may mean for their health.

PCOS has a new name, and it tells a much bigger story.

PMOS, or Polyendocrine Metabolic Ovarian Syndrome, reflects what many women have experienced all along: this condition is about far more than ovarian “cysts.” Hormones, insulin resistance, metabolism, weight, acne, hair changes, fatigue, and fertility can all be part of the picture.

Our newest blog breaks down what PMOS is, why the terminology changed, and what women should know.

What Is PMOS? Understanding the Condition Formerly Called PCOS Learn what PMOS is, why it was formerly called PCOS, common symptoms, possible causes, diagnosis, and treatment options for hormone and metabolic health.

A new 2026 study on testosterone therapy in women caught my attention because it looked at so much more than libido.

The study included 332 women receiving individualized testosterone replacement therapy and assessed eight different areas of well-being. Improvement was reported across every area measured.

Energy and fatigue showed one of the strongest responses, with 84.3% of women reporting improvement. More than 65% reported improvement in depression, irritability, anhedonia, and s*xual interest. Overall, 89.7% reported improvement in quality of life.

This is important because testosterone in women is so often discussed only in relation to s*x drive. But women may also notice changes in energy, mood, motivation, mental clarity, concentration, and overall well-being.

For me, testosterone helps me significantly with brain fog, motivation, energy, strength, and libido. I didn't realize what I was missing until it was added to my hormone regimen.

It also reinforces something we see clinically. Hormone therapy is not always an overnight process. Some symptoms may improve sooner than others, while cognitive symptoms such as brain fog and difficulty concentrating may take longer.

This was an observational study rather than a randomized controlled trial, but the findings add to the growing discussion about the role testosterone may play in women’s health beyond s*xual function.

This is why some women notice a difference in brain function after starting BHRT, especially estradiol. As estradiol is restored, women may notice improvements in brain fog, focus, memory, mental clarity, and their ability to think and reason. Many women describe feeling mentally sharper and more like themselves again.

During the menopause transition, estradiol levels begin to fall. At the same time, changes can happen in the brain that are also seen in the early stages of Alzheimer’s disease. The brain may become less able to use glucose for energy, white matter can decrease, and beta amyloid can build up.

Hot flashes are connected to the drop in estradiol. Lower estradiol can affect how the brain’s mitochondria make energy, which can increase heat production. Blood vessels then widen to help the body release that heat.

When the brain has trouble using glucose for energy, it can start breaking down fats in its own white matter to make ketones, which can be used as another source of fuel.

These changes can begin before a woman ever starts having hot flashes. The estrogen related systems in the brain are already changing during this time. This process has also been described as autoimmune in nature and can happen alongside the development or worsening of other autoimmune problems.

"Hormone therapy is associated with a DECREASE in Alzheimer's Disease, Parkinson's Disease, all cause dementia, multiple sclerosis, and ALS". - Dr. Roberta Diaz Brinton