Is HRT Safe? 10 Questions Women Ask Most — Answered by a Functional MD

Hormone replacement therapy is one of the most talked about—and misunderstood—topics in women’s health. For years, women were told HRT was dangerous. Now, the conversation is shifting, but many are still left confused about what’s actually safe, when to start, and whether hormones are even right for them. In today’s episode, I’m joined by Dr. Cindy Geyer from my clinic, The UltraWellness Center, to answer the most common questions we received from our audience about hormone replacement therapy, including: What the latest research actually says about the safety of HRT—including breast cancer and cardiovascular risk Why timing matters and the critical “window of opportunity” around perimenopause and menopause The difference between bioidentical hormones, synthetic hormones, compounded options, and patches vs. oral therapy How hormones impact sleep, brain fog, weight distribution, insulin resistance, libido, bone health, and healthy aging Natural strategies that can support hormone balance alongside—or without—HRT, including nutrition, exercise, stress reduction, and targeted supplements How functional medicine personalizes hormone therapy through testing, estrogen metabolism, gut health, genetics, and lifestyle factors Menopause is not just a hormone issue—it’s a full-body metabolic transition. And hormone therapy isn’t one-size-fits-all. The key is understanding your biology, your symptoms, and your long-term health goals so you can make informed decisions that support vitality, resilience, and healthy aging. Visit ⁠functionhealth.com for 160+ lab tests at just $365 a year. Want more on brain health? Sign up for the Brain Shaping Academy HERE. Have a question you’d love answered on Office Hours? Submit it here As a special thank you for our listeners, we’re offering $300 off a Functional Medicine Consultation Package, the most comprehensive service offering at Dr. Hyman's Functional Medicine Clinic, The UltraWellness Center. To learn more and book your consultation, please schedule a New Patient Discovery Call at the link HERE and reference the Dr. Hyman Show. Disclaimer: Offer expires July 31, 2026. Functional Medicine Consultation Appointments must be booked by July 31,2026 but may take place at a later date. The initial call with a New Patient Engagement Coordinator is required to book the appointment. Offer not valid on other appointment types or existing appointments. Offer valid for bookings with Dr. Boham, Dr. Geyer, Dr. LePine and Dr. Papanicolaou. (0:00) Welcome, introduction, and overview of hormone replacement therapy (1:26) Introduction of Dr. Cindy Geyer and safety of HRT (4:13) Timing, risks, and cancer concerns with HRT (7:06) Functional medicine perspective and factors in starting HRT (12:10) Benefits, timing, and natural alternatives to HRT (16:33) Prescription, bioidentical, and compounded hormones (19:20) Symptoms improved by HRT and libido considerations (22:24) Vaginal estrogen, progesterone, and recognizing need for therapy (24:25) Health markers and types of hormone testing (27:08) Duration, contraindications, and tailored hormone therapy (33:34) Preview: Dr. Sharon Malone on breast cancer risk (42:24) Introduction and details of Brain Shaping Academy

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:12Dr. Mark Hyman?

  Welcome to Office Hours. This is our dedicated 101 space to go deeper, get clear, and explore what truly moves the needle for your health. I'm Dr. Mark Hyman, and each week, we're going to pull back the curtain and share the insights, the research, the lessons that don't always make it into our conversations with guests. Because at the end of the day, you are the CEO of your own health. And for many of you, your family's health too. And you might not feel it all the time, but you have far more power and agency than you realize. I'm glad you're here.

• 0:41Dr. Mark Hyman?

  This episode is brought to you by Function Health, empowering you to live 100 healthy years with over 160 lab tests for just $365 a year. And use the code MARK2026 to get $50 off your membership. Hormone replacement therapy is one of the most talked about and most misunderstood topics in women's health right now. For some, it's seen as a game changer. For others, it still feels confusing or even risky. Questions about safety, cancer risk, when should I start, whether you even need it, a lot of noise out there and a lot of conflicting information. So today, we're cutting through all that. We asked what your biggest questions were on social media, and we got over 800 responses. And today, we're answering your most common questions about hormone replacement therapy,

• 1:22Dr. Mark Hyman?

  what it is, who it's for, what the risks actually are, how to think about it in the context of your overall health. And today, I'm joined by someone who works really closely with patients every day on this topic. It's Dr. Cynthia or Cindy Guyer from the Ultra Wellness Center. We've worked together for the better part of a quarter century now. She brings a lot of functional medicine perspectives to hormone health. She helps patients understand not just if HRT or hormone replacement therapy is right for them, but how it fits into the bigger picture of aging, metabolism, long-term health. And because this isn't just about managing symptoms, it's about understanding what's happening in your body, but how it fits into the bigger picture of aging, metabolism, and long-term health. Because this isn't just about managing symptoms. It's about understanding what's happening in your body, and it's about making informed decisions that support your health over time. So let's get to your questions.

• 2:07Dr. Mark Hyman?

  What are the top 10 questions on hormone replacement? Replacement therapy. The first, the biggest one is Cindy is, is HRT safe? Is it actually safe long term?

• 2:15Speaker 01

  I love the way you teed it up, Mark, that hormones are a small part of the bigger picture of what's happening, happening for women in this time of life. So we have to look at it in context of everything else. So there's a lot going on, not just in terms of hot flashes, night sweats and changes in sex hormones. When we're talking hormone therapy, estrogen and progesterone, there's shifts in insulin signaling and cholesterol regulation and an uptick in bone loss, weight distribution shifts. We start to move it from our buttocks and thighs to our midsection and hormones play a role, but it's not the only thing.

• 2:47Dr. Mark Hyman?

  That's not fun.

• 2:48Speaker 01

  Mitochondrial function can change. We might be more stiff and achy and collagen turnover can change. There's also a lot going on for women in their relationships. You know, they might be having teenagers that are in their own hormonal environment or kids that are leaving home or reassessing a long-term relationship or even having more caregiving responsibilities for aging parents. So to just think about, do we take estrogen and progesterone or not? Is it safe? Without looking at the big picture, I think it's a missed opportunity to really work with women to optimize their health. So one of the big shifts in official guidelines is related to hormone safety. It used to be only take hormones in the lowest dose for the shortest period of time for symptom management.

• 3:31Speaker 01

  But in November of 2025, the FDA removed the black box warning for hormones. So guidelines now from the American College of OB-GYNs and from the Menopause Society say for most women, the benefits probably outweigh the risks for hormone therapy, especially if it started within the five to 10 year window around your last menstrual period. So that's a sea change, Mark. That's a sea change.

• 3:53Dr. Mark Hyman?

  That's big, yeah.

• 3:54Speaker 01

  And I think it's, I'm really glad that we're focusing more on the potential benefit of hormone therapy for managing symptoms and potentially organ system benefits. But at the same time, I don't want women coming away from this thinking if I can't take hormones, or I don't want to take them, I'm somehow missing out and can't age well.

• 4:13Dr. Mark Hyman?

  One of the things Cindy that I kind of see as a big shift is this conversation, and you mentioned it briefly, you started like right at menopause or within five to 10 years. What is the danger of starting later if women later on wants to get support from hormone health? Like, is there, is there a reason it's five to 10 years or within five to 10 years?

• 4:30Speaker 01

  So one of the reasons why the benefits may outweigh the risks in that five to 10 year window is in, a woman probably hasn't had a lot of chance to build up plaque in her arteries. And older studies that use primarily hormones by mouth, if women already had plaque, there was a higher risk for clotting and higher risk for heart attack and stroke. Newer evidence suggests if you're using hormones through the skin, it's probably not going to impact negatively cardiovascular risk and may have some benefits. There's also this concept that when we're newly in that menopause transition, our tissues and our organs are better able to respond to estrogen because there hasn't been a change in receptors. So even the response may be less as the further out we get from that last menstrual period.

• 5:14Dr. Mark Hyman?

  People are concerned about other things like risk, right? So, so I think the biggest concern really is, is what about breast cancer and uterine cancer also, but particularly women worry about breast cancer. Can you talk about the different forms of therapy, the different, you know, estrogen only with progestins or with progesterone, or the different natural or bioidentical and synthetic versions, and how that all plays a role in trying to figure out what to do?

• 5:36Speaker 01

  That is probably the biggest concern is what is the long-term risk with hormone therapy and breast cancer? And if we go back, if we look at women's natural history without hormone therapy, starting your periods earlier, ending them late, there's a statistical slight increased prevalence of breast cancer in women with that longer tissue exposure to estrogen. The data about hormone replacement therapy, slight increased risk the longer you stay on it and the higher the dose. But the formulation really, really matters. Even in the, even in the Women's Health Initiative, for women who'd had a hysterectomy and only took estrogen, there was actually a reduction in breast cancer risk. So something about-

• 6:18Dr. Mark Hyman?

  That's fascinating.

• 6:19Speaker 01

  Yeah, and something about adding in the progestin, which was not a bio-identical progesterone, was what, was the combination that was associated with increased breast cancer risk.

• 6:28Dr. Mark Hyman?

  Yeah, so basically they were using this like Provera, which is a synthetic progesterone, instead of a micronized progesterone, which is a prescription you can get as well, but it mimics your body's natural progesterone.

• 6:38Speaker 01

  It seems to be better. The, the more recent research shows that the bio-identical progesterone, the micronized progesterone, at least up to five years, does not seem to increase breast cancer risk. So that's very, very reassuring.

• 6:48Dr. Mark Hyman?

  And the uterine cancer you need, you need, you have to worry about uterine cancer with estrogen only if you're not taking the progesterone.

• 6:53Speaker 01

  Correct. If you still have your uterus and you're thinking of estrogen or progesterone replacement therapy, you have to take the progesterone to prevent the overthickening of the lining and potential risk for uterine cancer. Using the two together, there's no increased risk.

• 7:06Dr. Mark Hyman?

  And there's one bit to this question I want to ask. It's really a functional medicine perspective because typically when you get on hormones, your doctor just prescribes the hormones and that's it. Maybe they'll check your levels, maybe not, go by symptoms. But what we look at in functional medicine is not just the blood levels of estrogen or progesterone or testosterone. We look at the urine metabolites, of what happens when you process these hormones and how you're processing them. And that depends on our genetics, our environment, our microbiome and so many things. So can you talk a little bit about that? How it's used, why it's important? And what we should make sense of, how we should make sense of it?

• 7:39Speaker 01

  I think that's, that's great, Mark, because all of this data is coming from population data. Individuals are highly different in terms of the genes they come into the world with, their type of diet, how healthy their gut microbiome is, what's happening with other hormones like insulin. And we know that, that whatever estrogen you make or take can get shifted down different pathways that is influenced both by your genetics, also by your exposures to potential endocrine disrupting chemicals, your diet, if you're meeting your needs for B vitamins and magnesium, how much cruciferous vegetables you're eating. So we want to personalize the information because all of that can influence for a given woman, is that estrogen going to be more likely

• 8:22Speaker 01

  or less likely to contribute to breast cancer risk? So it's not just about putting people on hormones. It's looking at their genetics. It's looking at those urine estrogen metabolites that tell us, are they shifting it down those pathways that are less risky? And if not, how can we support them by optimizing gut health, supporting them nutritionally, avoiding exposures to those endocrine disrupting chemicals?

• 8:47Dr. Mark Hyman?

  Yeah, and I think that's really the cancer risk framework is important because we really need to be able to look at how do we decide who's at risk, who's not at risk, which, how do you manage it? How do you even look at, you know, ongoing risk based on their estrogen metabolism? I think that's a really important piece that gets overlooked that needs to be done. And we do that at the Osgood Wellness Center. We look pretty routinely as a part of our care for people who are getting hormone replacement therapy. Okay, so when should you start it? We talked a little bit about it, but what's the right age, the timing? Is it should be perimenopausal? It should be only when you stop your period for a year? You know, it should be based on symptoms, should be based on prevention, should be based on like their risk of bone health? What are the things you take into consideration about deciding when to start?

• 9:31Speaker 01

  Yeah, so that is also an evolving story. It used to be that doctors would wait until women have been a full year without their period and they're missing the window when the symptoms are the most intense. So hot flashes, night sweats, changes in cycles, disrupted sleep, that may start a decade before that last menstrual period. So if it's pre-menopause, I often use symptoms and then test to kind of look and see where somebody is. So if somebody comes to me and they're 45 years old and they're starting to have more trouble with their sleep, especially before their period, they're starting to have some hot flashes and night sweats, but they haven't started to change their periods yet, we might do estrogen and progesterone levels, but that might be a time where depending on where

• 10:16Speaker 01

  they are, we start with progesterone only or cycling progesterone. So even how we treat somebody may differ, whether they're in the early perimenopause or they're starting to skip periods. The emerging research is suggesting that the increased turnover of bone may start well before women start skipping periods. So if there's osteoporosis in your family, if you're at risk for osteoporosis, there is increasing evidence that starting full hormone therapy, estrogen and progesterone earlier in the perimenopause might sort of set you off on a good path to maintain that bone density.

• 10:54Dr. Mark Hyman?

  Did you know that heart disease is the leading cause of death in women? Not breast cancer or ovarian cancer. And this is a statistic that makes me sit up straight. And yet, the average woman is still being evaluated with the same cholesterol panel we've used for 50 years or more. Here's what most women are never told. LDL cholesterol is not the only predictor of your cardiovascular risk. ApoB is way more precise, way more predictive. It counts the actual particles that wedge into your arteries. And LP little a is a genetic marker, but it's almost never checked. Or take HSCR P, it measures the inflammatory environment that makes those particles dangerous. A woman can have normal cholesterol, quote

• 11:36Dr. Mark Hyman?

  "normal," but still be at risk. And I've seen it far too many times. The least we can do is measure the data that matters. It's time to stop guessing. Check your health with Function. Function gives you access to over 160 lab tests every year, including advanced lipoprotein testing. It's time to stop guessing. Check your health with Function. Go to functionhealth.com/mark. And if you're one of the first 1,000 people this week, use the code MARK2026 for a $50 credit toward your $365 a year membership. That's functionhealth.com/mark and use the code MARK2026 today. Well, basically, you for symptoms and don't wait until you're already a year

• 12:20Dr. Mark Hyman?

  out from when you had your last period. It's great for helping prevent bone turnover and prevention of osteoporosis. It may help prevent plaque even in the heart if you start early. It helps blood sugar, insulin signaling, mitochondria. So there's so many benefits that, you know, I think it's coming kind of more into. The swing that because I remember when we were practicing Canyon Ranch, that's when the women's health initiative came out and it was like everybody was on hormones. Then the next day they were off hormones and it was kind of a nightmare. And we've kind of been trying to for the last almost kind of 25 years trying to re correct that story. And meanwhile, a lot of women have suffered unnecessarily. So I think, you know, it's really important if people take, take this seriously and both for their symptoms and there's no reason not to to manage your symptoms.

• 13:02Dr. Mark Hyman?

  Even, you know, sexual health is a big one for women and that we didn't talk about that, but that's a big one. What about natural alternatives? Like if you don't want to take hormones or if you're concerned about them, like, are there ways to regulate hormonal balance without having to take hormones?

• 13:17Speaker 01

  So the first thing I would say is by far and away estrogen and progesterone therapy is the most effective for troublesome hot flashes and night sweats. There are other things that can help and I think this window of opportunity to really think about the bigger picture brings us back to lifestyle. So think for a lot of women, when we think about what drives hot flashes and night sweats. Interestingly enough, there's recent research that it may be a marker for somebody who's at higher risk for heart disease. So we want to be thinking about what's going on with blood sugar regulation and cholesterol. A fluctuating blood sugar is a potent trigger for hot flashes. Other potent triggers for hot flashes caffeine, alcohol, some people spicy foods.

• 14:02Speaker 01

  So just taking a nutrition forward approach and eating a whole foods diet with lots of fiber, not a lot of starchy carbs and refined carbohydrates, eating in a way to regulate your blood sugar may actually help hot flashes and night sweats.

• 14:16Dr. Mark Hyman?

  So sugar, alcohol and caffeine, right? All the fun stuff, right? But it makes a difference. It does make a difference. I mean, excess caffeine. I mean, even cigarettes, we can talk about that alcohol, blood sugar issues. These are all things that you have a lot of control over and and actually work. And then you mentioned foods, but there's some really cool foods we should talk about. What are the other lifestyle factors that you can do? And then what are the kind of supplements, foods, things that we should be thinking about specifically that are therapeutic?

• 14:43Speaker 01

  So the foods that show the best benefit in terms of helping hot flashes and night sweats are soy foods. Whole soy foods, ideally organic, non GMO soy. So thinking edamame, tofu, tempeh. Those have been shown to be effective in reducing hot flashes and night sweats. Stress is a huge contributor contributor as well. So there's evidence that breath-based practices, yoga, acupuncture, those strategies can also help many women manage their symptoms. Exercise above and beyond just the breath-based practices, exercise, and that probably becomes one of the single most important things we can do when we're thinking of not just helping

• 15:25Speaker 01

  symptoms, but setting us up for healthy aging for the second half, because it is probably, you know this, Mark, you talk about this all the time, one of the most powerful tools we have for keeping our bones healthy, our, our muscles resilient and strong, our protecting our heart, protecting our brain. If we could bottle it up, we'd be incredibly rich.

• 15:46Dr. Mark Hyman?

  Billionaires, we'd be the richest people on earth. But I, I think, I think, I just want to look back to something you said about soy foods, because people think, oh, soy foods, you know, and I've heard so many oncologists tell their patients not to eat tofu if they have breast cancer, which is just insane, because it's a, it's an estrogen modulator. It doesn't actually cause breast cancer and may protect against it, except, and I'll, there's a big except here, and this is data from the NIH, that when they fed animals highly processed soy extract, like basically the soy protein powders that are hydrolyzed soy protein, it seems to actually cause cancer. So whole soy foods, tofu, tempeh, miso, natto, all those things, fine, edamame, whatever you want, that's fine, but it shouldn't be

• 16:29Dr. Mark Hyman?

  an industrial soy food. And, and what about herbs and stuff? Are there herbs that work also for menopause?

• 16:33Speaker 01

  Yes, mixed data about herbs, but some of the best exists for black cohosh, pyknogenol, which is a pine bark extract. There's some evidence that that might help with, with vasomotor symptoms. It's also a great antioxidant. There are a few others as well. The, the research is somewhat mixed, but I think if they're safe, it's worth a try, because some women find them very helpful.

• 16:52Dr. Mark Hyman?

  Next question we got is, is what about this whole issue of like prescription hormones, bioidentical, compounded versus, you know, pharmaceutical grade, bioidentical, there's all these different kind of conversations. And, you know, the problem is I saw when, when the hormones were starting to be used, they were only the prescription versions which were So either horse urine or for estrogen, primorin, or a synthetic progesterone, which is kind of highly problematic with the side effects it has. So I think there's other better versions and we've been using those for a long time. And maybe you can kind of walk through how to think about it, how to do them. What is sort of an approach that makes sense for proper dosing delivery in form of the nutrients?

• 17:33Speaker 01

  Sure, I think that's a great question. And a lot of the confusion about the risks of estrogen was exactly related to those synthetic forms, and that doesn't seem to be borne out with what we call bio-identical. From my perspective, bio-identical doesn't mean it's necessarily compounded versus pharmaceutical grade. It means that your body doesn't tell the difference. It is the exact same form of the hormones that you would have made before menopause. So there are pharmaceutical-grade bio-identical options. A good example is an estradiol patch. That's probably one of the most common ways that we'll use estrogen replacement. I like it because it's convenient. There are multiple doses that allow you to personalize it to the person's symptoms and to their blood levels and everything else that's going on.

• 18:17Speaker 01

  You change it twice a week, pretty simple. There are also gels that are prescription pharmaceutical and you can also get insurance coverage, which for some women makes a big difference. There are a lot of women prefer using the compounded estrogens. In my experience, sometimes it's more difficult to get a good blood level if that's what we're trying to do, although it's possible. Sometimes depending on the quality of your compounding pharmacy, it may vary batch to batch. So I tend to use the pharmaceutical-grade but bio-identical estrogens and progesterone. The other big piece is the route of administration matters. So when we use estrogen by mouth, even bio-identical estrogen by mouth, there's a first-pass effect in the liver.

• 19:01Speaker 01

  And in the liver, we make clotting factors and we make triglycerides. So even bio-identical estrogen by mouth can raise clotting factors in triglycerides. So I tend to use the transdermal because I think it's better tolerated. It's easier to titrate the dose and you're not going to have those same risks for clotting and triglycerides.

• 19:20Dr. Mark Hyman?

  Yeah, one of the things I noticed, you know, some of these oral hormone versions of estrogen tend to increase inflammation, so they increase CRP.

• 19:27Speaker 01

  Yes, thank you.

• 19:28Dr. Mark Hyman?

  And the pill does that too. So that's an important consideration because, you know, inflammation is the driver of all chronic illness and disease. So you don't want to be spike in inflammation with hormones if you don't have to. And the best way to do that is avoid the liver, like you said. So Cindy, what about the next question we got, which is what are the symptoms, the main symptoms that taking hormone replacement therapy will really help with? Is it, is it like brain fog, weight gain, sleep, sex drive?

• 19:52Speaker 01

  So estrogen and progesterone, as I mentioned before, the most effective for the hot flashes and the night sweats. So that's really where they shine. However, there's also benefits with sleep quality and there's some suggestion that estrogen and progesterone may prevent or slow down the emergence of sleep disordered breathing that starts to emerge in the menopause transition because our connective tissue gets more lax. So when we improve sleep quality, that improves mood, it improves brain fog, it may even improve insulin signaling. So I think there's, there's, whether the benefit on brain fog is directly related to the hormones, I think it could be, but it also could be secondary to better quality sleep.

• 20:34Speaker 01

  I think what's really interesting is that estrogen and progesterone, not from a symptom standpoint, but it, it helps with insulin signaling. So insulin resistance becomes more prevalent in the menopause transition and estrogen and progesterone seems to mitigate that to a great degree. That's fantastic.

• 20:52Dr. Mark Hyman?

  So does that, does that, does that mean, does that mean like it helps you not put the weight on your

• 20:57Speaker 01

  Yes.

• 20:57Dr. Mark Hyman?

  stomach, but more on your butt?

• 20:58Speaker 01

  Yes, that was going to be the next thing that I was going to say. What we see about it is it, I wouldn't use, think about it as helping weight loss. But it helps the weight distribution. So it helps prevent that shift that we talked about earlier that goes from the buttocks and thighs to the belly. And that increase in belly fat, as you have talked about many times, is a lot of what's driving the worsening insulin signaling, the higher rates of inflammation and the higher rates of cardiovascular disease that start to emerge. So there does seem to be a protective benefit there. In terms of libido, some women find that, we'll talk about testosterone in a minute, but just estrogen and progesterone alone improve sex drive libido. Libido is very complicated because it's not purely hormonal.

• 21:43Speaker 01

  It's also related to being sleep deprived, feeling overstretched if there's a lot going on, how you feel about your partner. I mean, those are important factors that also negatively impact libido. Even using a patch of estrogen, it may not be enough for some women to help with the vaginal dryness, thinning and pain. So there can be an additional role for vaginal estrogen, which has also been shown to improve libido, or vaginal DHEA, which has been shown to improve libido above and beyond just improving the health of the tissues. Lastly, there can be a role for some women to use testosterone, low dose testosterone, which can move the needle if those other things have not helped.

• 22:24Dr. Mark Hyman?

  The good thing with the, but even if you had breast cancer, you can use vaginal estrogen safely.

• 22:28Speaker 01

  I think that's really important to point out because it doesn't tend to get systemically absorbed. And that's also been a shift in the last several years, even women with estrogen positive breast cancer, if they're having an informed conversation with their oncologist, it seems to be pretty safe and it's, it can really make a difference in symptoms.

• 22:44Dr. Mark Hyman?

  And the last thing is you touched on a little bit, but sleep is definitely helped by just reducing the hot flashes with estrogen. But progesterone has a particularly unique effect around sedation, sleep. So maybe you can chat about that. And even you can use that even before you use any estrogens in the perimenopausal period effectively. So that's in a way of helping manage a lot of the symptoms of heavy bleeding, clotting, sleep issues, PMS, it all starts to accelerate in the late perimenopause.

• 23:09Speaker 01

  Progesterone has a, has a calming, sedating effect. And in the early perimenopause transition where there's bigger oscillation. Patients in estrogen for women who are prone to migraines, they can really flare. For women who have more histamine related symptoms, those can also flare. And interestingly enough, giving progesterone by itself can kind of re-regulate those wider swings and help with those symptoms. So that might be an instance where we're focusing on high dose progesterone initially in the in the menopause transition.

• 23:37Dr. Mark Hyman?

  All right. So people are sitting there wondering, okay, how do I know if I need it? How do I know if I start? What are the signs I should consider it? Is it testing? Is it my symptoms? Like, what what's the way to approach this?

• 23:47Speaker 01

  Again, this is a great opportunity to kind of check in with what's going on in your life. How do you feel? Are you starting to notice hot flashes, night sweats? Is your sleep changing? Are you having worsening premenstrual symptoms with mood swings? That would be a good time to start talking to your doctor about what's going on and whether hormones make sense then. Testing is tricky in perimenopause because it's going to change day to day and week to week and month to month. So you can do a snapshot in the moment and it's not going to tell you the whole picture, but it can provide some clues. We treat the person, not the level in the perimenopause. I think it's also a great time to get a baseline. What's happening with your insulin? What is your A1C?

• 24:29Speaker 01

  What is your cholesterol? If you can get a baseline bone density, that would be fantastic. If you can't, you can start looking at these markers of bone turnover. Are you just looking like your bones are starting to turn over more rapidly, which is a predictor of future decline, current and future decline?

• 24:47Dr. Mark Hyman?

  I mean, don't you think women should be like, ask for a kind of a mandatory BEXA scan for bone density and body comp and they're like at least by their mid 40s? I think it's just a non-starter almost.

• 24:56Speaker 01

  I know, but right now, insurance, unless you're high risk, typically doesn't cover it until you're 60.

• 25:00Dr. Mark Hyman?

  They're not that expensive. Like, I went to this place in Austin. I think it was 80 bucks for both. It was like super affordable.

• 25:06Speaker 01

  It's much easier to get it. And I'm glad you brought up the bone density. Because your weight doesn't tell you the whole story. Women might, especially if they haven't been physically active, might actually have low muscle mass. And identifying it early, we can take steps to add in more resistance training. Make sure you're getting enough good quality proteins, supporting digestion absorption at a gut level to help you with your body composition.

• 25:32Dr. Mark Hyman?

  And the good news about the DEXA scan, it can do both, the bone density and the body composition. Okay, well, Cindy, let's talk about testing because I think people are confused to check blood test. What about urine test? What about saliva test? Like, there's so many options. So how do you think about diagnostics when it comes to hormone therapy? Obviously, you're going to be looking at all the standard stuff like cortisol, thyroid, vitamin D, and so forth. But what about hormones themselves?

• 25:54Speaker 01

  You know, Mark, I just have to say, it's interesting that you said the obvious stuff like thyroid and cortisol and vitamin D and insulin, but it's actually not obvious to everybody. Think about how many people come in and they're just looking at estrogen and progesterone. So I'm really glad you called that out. We look at the big hormone picture.

• 26:11Speaker 01

  I tend to use blood levels for quantity. I think they're probably the best if I'm looking to see where somebody is. Also, looking at the pituitary hormones, the FSH and LH. And then if we're monitoring somebody after we're starting treatment, I rely on the blood levels for quantity of the hormones. Saliva.

• 26:30Dr. Mark Hyman?

  To help manage prescriptions?

• 26:32Speaker 01

  Yes. To help manage prescriptions, to track somebody, especially if they're not responding. Do we need to change the dose? The saliva test, I don't use as much for estrogen and progesterone, but they're really great for looking at cortisol levels throughout the day. They correlate pretty well, and that gives us a snapshot of adrenal reserve, how stressed somebody might be, what things could be spiking their cortisol or not. And then for those estrogen metabolites and testosterone metabolites, the urine levels are what we look for.

• 27:07Speaker 01

  So it's a combination of things.

• 27:08Dr. Mark Hyman?

  So yeah, so you can use saliva for cortisol, you use blood for hormones, you also use urine for estrogen metabolism. So you kind of need a cocktail of things to really understand what's going on. And then helps you understand where they're at, what to do. But the thing is, as you're going through perimenopause, your hormones are all over the place. So any one mark, any one level, any one time doesn't really give you the whole picture. So it's a combination of like your clinical expertise, plus symptoms, plus the lab testing, all gives you sort of a framework. It's sort of like multiple ways of navigating. And so it's important to sort of track that stuff. And particularly if you're on hormones, you want to make sure you're not overshooting with estrogen, progesterone, testosterone. All right. So let's say somebody starts on it and they're like 50 and they get on it, or do they stand until they die? Or like, you take it forever? Or you take it for a

• 27:53Dr. Mark Hyman?

  few years till your symptoms are over? Like, are there 80 year olds having hot flashes who haven't gone, who haven't been on hormones? Probably not. So the question is like, what is the right amount of time?

• 28:04Speaker 01

  And there is no perfect answer there either, Mark, because I think if we just look back at how much the pendulum has shifted, there is still ongoing research. And every year we get new information that might shift the equation. So it's also about, okay, if you're thinking about hormones now, making the best decision you can with all the information you have, but checking in every year, is it still the right option for me? How do I feel? What are my goals? What are my levels? What am I trying to achieve with hormones? And I would say there isn't a black and white answer to that. You know, some women might try it and they don't like how they feel. Progesterone, some women don't do well with progesterone. I mean, there's just can be, most women do, but some women don't. So we

• 28:46Speaker 01

  might need to shift gears there. Or maybe they go in for a mammogram and they get a new diagnosis of breast cancer, and then we really need to shift gears there.

• 28:57Speaker 01

  There could be other health changes or priority changes. So I think it's a, it's an evolving conversation. It's about establishing benchmarks and then having a partner you trust that can continue the conversation every year.

• 29:10Dr. Mark Hyman?

  And also tracking things, right? You want to check your mammogram, your Pap test, your bone density, your cardiovascular risk factors, your insulin, all the things that you want to be tracking. And that's what, you know, we do at the Ultra Wellness Center in Lenox. We have, we do this for a long, we do this for a long time. And we have the ability to really kind of dive in and help people navigate this. And it's, it's, it's like one of the most satisfying parts of practice for me because it just, you really can help people not suffer. And I don't think women should have to suffer.

• 29:34Speaker 01

  I think one of the other misinterpretations of this, if you start within five to 10 years, physicians for a long time would say, okay, you've been on it 10 years, you have to stop your hormones. That's not true either. There are women who continue to stay on their hormones beyond the 10 years. If they're doing well, they're feeling well, it's working for them. I don't routinely take people off just because it's meta magic earmark based on some population data.

• 29:59Dr. Mark Hyman?

  Right, exactly. Just like how you make up those numbers, they just sort of make them up out of the air. Last question is really about who should not take hormones at hormone replacement therapy.

• 30:09Speaker 01

  Yeah, so we talked a lot about breast cancer. Even breast cancer is not all the same. Women who've had an estrogen positive breast cancer or progesterone receptor positive breast cancer, it's still really considered relatively contraindicated unless you're using the vaginal estrogen. There's some newer evidence calling that into question, but that's really an informed discussion with your oncologist. Triple negative breast cancer, they're starting to look at maybe there might be a subset of women who could tolerate or have estrogen. But again, I think that is an informed conversation with your oncologist. So active breast cancer, I would say no. If you have unexplained vaginal bleeding, you don't know where it's coming from, that could potentially be a sign of uterine cancer,

• 30:54Speaker 01

  you need to figure that out first. Active liver disease, not take hormone therapy. The research is also shifting. If you've had a personal history of blood clots or you have genetics for blood clotting, there's some emerging evidence that if you're using estrogen through the skin and you've got bothersome symptoms, that could be a possibility. But again, I would probably defer you to your hematologist for that. Those are the main contraindications.

• 31:20Dr. Mark Hyman?

  And liver disease probably too, right? Some breast cancer, clotting, liver disease. Yeah.

• 31:24Speaker 01

  I would say you have to know yourself. If you're somebody who doesn't want to take them, who is going to, every day you take it, feel like, oh, my gosh, is this not right? Am I going to cause breast cancer? It may not be the option. I'm not going to force anybody to take hormones who doesn't feel like it's right for them.

• 31:43Dr. Mark Hyman?

  I mean, that's important because, you know, people don't have to take them. They can do well with other ways of managing symptoms or these diseases or conditions that they're risk for. But I, I think that the current thinking, and who knows, this might change as more data comes in, is it's a more nuanced view than we had. And if people are confused or want to learn how to do this or need help and support, you know, our practice, Delta Wellness Center, we have five physicians, lots of physicians, assistants, nutritionists, nurses. It really helps support people on this whole journey. So, Cindy, thanks so much for joining us. You, you have given us a lot to think about and a great explanation of how to just get to the nuts and bolts and the meat of the issue, so to speak. And as you can see, everybody, hormone replacement therapy isn't like just one size fits all for everybody. It's nuanced.

• 32:26Dr. Mark Hyman?

  It depends on your symptoms, your medical history, your, your goals, your, in the bigger picture of your health, you know, whether you have osteoporosis or heart disease or other things. And then, you know, hopefully what this conversation has done is cut through some of the confusion. You know, for a long time, the conversations around hormone therapy has been really about fear and about misinterpreting the data and outdated information. And what we know now is way more nuanced than that, right? For the right person at the right time, hormone replacement therapy can be a powerful tool. And it's just that, it's a tool. It's not the only answer and not something to approach without guidance. So if you're navigating these questions for yourself, the most important step is to work with a practitioner, ideally a functional medicine practitioner, who can help you. Look at your full picture, not just your hormones in isolation because this isn't just about managing symptoms.

• 33:11Dr. Mark Hyman?

  It's about improving your long-term health, your metabolism, your brain health, and how you want to feel as you get older. And that's really the goal. If you found this helpful, I encourage you to share it with someone who's navigating the same questions because the chances are they are. And if you want to dive deeper into this topic, look out for my upcoming episode with Dr. Sharon Malone, who's a board certified OB-GYN and menopause specialist with decades of clinical and leadership experience in women's health. And here's a clip from that conversation. The thing that just maybe we should just unpack is this black box warning that came from the FDA because it's what got people really scared. And I remember because I was practicing really heavily with women that during that time, when that study came out and it stopped the study, they literally stopped the study because they were concerned about the harmful effects.

• 33:54Dr. Mark Hyman?

  So that's a big deal. And overnight, I think 50 million women stopped hormones, which created a catastrophe.

• 34:03Speaker 02

  How well I know.

• 34:04Dr. Mark Hyman?

  Yeah, right. And so we kind of had a backlash. Now we're kind of coming back to a more coherent way of thinking about it. And I'd like you to unpack how you think about prescribing hormones and which hormones and for whom, and what the benefits are, because the Women's Health Initiative did show that increased stroke and increased heart attack. And there were some.

• 34:29Speaker 02

  Did it though? Did it?

• 34:30Dr. Mark Hyman?

  I mean, that's what they said, right?

• 34:32Speaker 02

  Okay, and I'm going to tell you, it didn't really say that.

• 34:34Dr. Mark Hyman?

  Because the effect sizes were small or the.

• 34:37Speaker 02

  The effect sizes were small and they were as prescribed. Remember, the women entering the Women's Health Initiative, the average age was 63.

• 34:48Dr. Mark Hyman?

  Yeah.

• 34:48Speaker 02

  You could be anywhere from 50 to 79 years of age to be in that study.

• 34:55Speaker 02

  They didn't really even say, all right, these are women who've never had hormones before, and now we're going to give some hormones and some not. The criteria for entering and being randomized, you just had to not have taken hormones for three months.

• 35:11Dr. Mark Hyman?

  Yeah.

• 35:11Speaker 02

  Before entering the study. Do you see what I'm saying? So the population was really murky. They were too old.

• 35:16Dr. Mark Hyman?

  Yeah.

• 35:17Speaker 02

  That's not how we're prescribing today. We prescribe. What we do know is that the earlier you start treatment, the more long-term benefit you get.

• 35:26Dr. Mark Hyman?

  And is it riskier to start it when you're older?

• 35:29Speaker 02

  Well, yes, there are some. You get less benefit. And I, and I don't think it takes any leap of faith to understand that if the, the purpose of the Women's Health Initiative was to sort of, sort of figure out whether or not the hormones really were the, the secret sauce in reducing the cardiovascular disease. Cause when the women's, when the nurses study, 50% decrease in the, in heart disease in, in the women who took estrogen.

• 35:56Dr. Mark Hyman?

  Yeah.

• 35:56Speaker 02

  Okay. Is it that or is it something else? And to have women come into the study at 79 years old, I think we can all agree that it doesn't matter what I give you. The, that horse is out of the barn by then. And by having too many women who already had established heart disease, well, how are you going to prevent something that you already have?

• 36:22Dr. Mark Hyman?

  Yes, like, it's like didn't, didn't do angiograms on everybody and see what their hearts look like.

• 36:26Speaker 02

  Exactly. So when you stratify, even the Women's Health Initiative, when you looked at the younger women who were in the minority, but the younger women did not have an increase in the risk of cardiovascular disease. All of the bad things, the only finding from the Women's Health Initiative that was statistically significant was there was an increase in the risk of blood clots.

• 36:50Dr. Mark Hyman?

  Yeah, blood clot. But that does a heart attack is a blood clot, right?

• 36:53Speaker 02

  No, but, but we, yeah, but that's separate. This is listed as separate in part because it's DVTs or deviant thromboses or pulmonary embolism. And that was reported separately.

• 37:03Dr. Mark Hyman?

  But estrogen does mechanistically cause an increase in clotting risk. We know that.

• 37:07Speaker 02

  Yes, yes, it does. However, again, perspective matters. You need to know, to say some, to someone that it's a 50% increase or 100% increase. Well, what's the baseline? You know? And what we do know is that for women who start estrogen, even oral, earlier.

• 37:26Speaker 02

  When you're 40s or 50s, when you start, that increased risk of blood clotting that we don't have it, we don't see it. It happens when you're older. And so a lot of the findings from the Women's Health Initiative that were negative, even the cardiovascular disease was elevated, but only in the first year and not after that. Because again, you're probably giving something to women who already have fairly advanced.

• 37:54Dr. Mark Hyman?

  What about the breast cancer risk?

• 37:55Speaker 02

  Ah, the breast cancer.

• 37:57Dr. Mark Hyman?

  Because that's what freaks them out.

• 37:59Speaker 02

  That is the number one reason why women avoid hormone. They, oh, cardiovascular risk, I don't care about that. It's the breast cancer. That was the, that was really the nail in the coffin.

• 38:10Dr. Mark Hyman?

  Yeah, because it did show some increased risk, right? That's what they reported at least.

• 38:15Speaker 02

  Okay, let me, let me tell you.

• 38:16Dr. Mark Hyman?

  That's what the, that's what the public said, understood for this.

• 38:19Speaker 02

  Oh, trust me, I've been, I've been in the weeds on this for so long.

• 38:22Dr. Mark Hyman?

  I'm just, I'm just framing it so people know, it's like, I'm not just saying.

• 38:25Speaker 02

  No, no, no, no, that was, that was what they held.

• 38:27Dr. Mark Hyman?

  That was the headline.

• 38:28Speaker 02

  That was the press conference. Oh, not only does this, you know, they held a press conference to, when they stopped the Women's Health Initiative to say, oh, not only does it not help your heart, it increases your risk of blood clots and heart disease and strokes. And it went on and on and on. Well, that's very scary. And I would challenge anyone to, to give me another example of when the NIH, the regulators at NIH, held a press conference to announce a study. I mean, that's how big of a deal they thought that was. And I'll also mention that Bernadine Healy was not there at that time. So we're going to give her a pass on that.

• 39:07Dr. Mark Hyman?

  Okay.

• 39:08Speaker 02

  But, but here's the breast cancer story. And I will, I will say this, the data is the data. You don't get to change the data because you don't like it. Okay, you can change your interpretation of the data, but it is what it is. But let's take it at face value. What did the Women's Health Initiative say about women who took estrogen, the Primorin and the Provera? All right, they reported there was a 26% increase in the risk of breast cancer in estrogen and progestin users versus non-users. 26%, that sounds terrible. Who wants that?

• 39:42Dr. Mark Hyman?

  It's relative risk.

• 39:43Speaker 02

  Right, but what did that mean in real terms? That means for women who did not take estrogen and progestin.

• 39:52Speaker 02

  Thirty, the natural incidence is about thirty per 10,000 women per year will be diagnosed with breast cancer, living long enough to get it. In the estrogen and progestin user group, it went from thirty per 10,000 women per year to thirty-eight per 10,000 per year, with no increase in the risk of dying from your breast cancer, even if you were diagnosed on hormone therapy. So, let's make that sound a little better. All right. Eight per 10,000 additional cases of breast cancer.

• 40:23Dr. Mark Hyman?

  That's 26%.

• 40:24Speaker 02

  That's 26%.

• 40:25Dr. Mark Hyman?

  Right.

• 40:26Speaker 02

  With no increased risk of dying from it. And then make it even better, less than one in a thousand additional cases of breast cancer.

• 40:35Dr. Mark Hyman?

  Yeah.

• 40:36Speaker 02

  In the women who took estrogen and progestin. Now, that doesn't sound nearly as scary as 26%.

• 40:41Dr. Mark Hyman?

  Correct.

• 40:42Speaker 02

  But that was never really put into perspective.

• 40:45Dr. Mark Hyman?

  I think Mark Twain said, "There's lies, or damn lies, and there's statisticians."

• 40:50Speaker 02

  Exactly. And, you know, and there is, and when you put it that way, you say, "Oh, okay, well, eight in a thousand, but I'm no likely, no more likely to die from it, even if I'm taking hormone therapy." And even that statistic itself, and you and I know, in a medical study, if you were going to report a finding, to call it a finding, it has to be statistically significant. It was not statistically significant. But that stuck like glue. It's still with us today.

• 41:21Dr. Mark Hyman?

  Yeah.

• 41:22Speaker 02

  Because doctors and patients still believe that a family history of breast cancer is a reason not to take hormone therapy. So, that's just it. Worst-case scenario, let's, you know, put it on blame the old bad Primorin and Provera. Even that did not statistically increase your risk of breast cancer. And that is what has taken a long time for people to, to really understand those numbers. And because I remember the day that came out, it was 1992, and I had been prescribing for 10 years, well, 2002, and I had been prescribing for 10 years before that.

• 41:58Dr. Mark Hyman?

  Yeah, me too.

• 42:00Speaker 02

  And patients were horrified. "Oh, doctor, I can't believe you're trying to kill me with this stuff." And when I read the study, I said, "Wait a minute, it's not as bad as what they said."

• 42:10Dr. Mark Hyman?

  Yeah.

• 42:11Speaker 02

  And again, remember, applying that data, again, take it as it is, you can't apply that, the same data from 79 year olds and 65 year olds to 45 year olds. They're not the same.

• 42:24Dr. Mark Hyman?

  What if brain fog, anxiety and mood swings aren't simply all in your head? What if the health of your mind actually starts deeper in your body, in your gut, in your hormones, metabolism and your immune system? Well, let me tell you, the connection is real and it affects how you think and you feel every single day. And that's why I created Brain Shaping Academy, a six week program that shows you how healing your body can help you heal your mind. Brain Shaping Academy relies on the same targeted nutrition and lifestyle strategies that I've used for 30 years to help my patients improve their mental, emotional and cognitive health. So if you want to feel calmer, clearer and more in control and stay sharper and protect your brain as you age, check out Brain Shaping Academy at drhyman.com/brainshaping.

• 43:09Dr. Mark Hyman?

  That's drhyman.com/brainshaping. Thanks for joining me for office hours. I love diving into these topics with you. Remember, you are the CEO of your own health and every choice you make can move you closer to healing and vitality. I want to keep these episodes as relevant and useful as possible. So tell me, what do you want to explore next? What questions are you wrestling with? What breakthroughs are you chasing? Share your ideas in the comments on social media or through the link in the show notes. I'm listening. Until next time, keep taking charge, keep asking questions and keep showing up for your health.

• 43:50Dr. Mark Hyman?

  If you love this podcast, please share it with someone else you think would also enjoy it. You can find me on all social media channels at Dr. Mark Hyman. Please reach out. I'd love to hear your comments and questions. Don't forget to rate, review and subscribe to the Dr. Hyman Show wherever you get your podcasts. And don't forget to check out my YouTube channel at Dr. Mark Hyman for video versions of this podcast and more. Thank you so much again for tuning in. We'll see you next time on the Dr. Hyman Show. This podcast is separate from my clinical practice at the Ultra Wellness Center, my work at Cleveland Clinic and Function Health, where I am Chief Medical Officer. This podcast represents my opinions and my guests' opinions. Neither myself nor the podcast endorses the views or statements of my guests. This podcast is for educational purposes only and is not a substitute for professional care by a doctor or other qualified medical professional.

• 44:35Dr. Mark Hyman?

  This podcast is provided with the understanding that it does not constitute medical or other professional advice or services. If you're looking for help in your journey, please seek out a qualified medical practitioner. And if you're looking for a functional medicine practitioner, visit my clinic, the Ultra Wellness Center at UltraWellnessCenter.com and request to become a patient. It's important to have someone in your corner who is a trained, licensed healthcare practitioner and can help you make changes, especially when it comes to your health. This podcast is free as part of my mission to bring practical ways of improving health to the public. So I'd like to express gratitude to sponsors that made today's podcast possible. Thanks so much again for listening. When it comes to supplements, you only want the best for your body, the kind with the highest quality, cleanest and most potent ingredients you can get.

• 45:20Dr. Mark Hyman?

  That's exactly what you'll find at my supplement store, where I've hand-selected each and every product to meet the most rigorous standards for safety, purity and effectiveness. These are the only supplements I recommend to my patients, and they're also what I use myself. Whether you want to optimize longevity or reduce your disease risk, or you're looking to improve your sleep, blood sugar, metabolism, gut health, you name it. DrHyman.com has the world's best selection of top-quality premium supplements, all backed by science and expertly vetted by me, Dr. Mark Hyman. So check out DrHyman.com because when it comes to your health, nothing less than the very best will do. That's DrHyman.com, D R H Y M A N dot com.