Is It Ever Too Late for HRT? Timing, Tests and What to Ask your Doctor

Hi Phoenix friend,

Have you heard the joke about the birthday card women get at 65?

You get a cake. Underneath it says "Happy birthday. No more hormones for you." And that card is from your doctor.

It's not a very funny joke, but it's not really a joke either. This is what women actually hear on their 60th birthday, sometimes their 65th. You hit a number, and the thing that's been protecting your bones and your heart gets taken away. But your arteries don't know what birthday it is. Your bones don't either.

So let's talk about what actually decides whether you start or stop hormones. It isn't the number on the cake.

Prefer to watch? The full hour is here:

WHO I ASKED

This is part two of a Q&A I ran with Steve Goldring, RPh. He's been a licensed pharmacist for over 30 years, and he spent that time compounding hormones for women in menopause. Now he trains the doctors and nurse practitioners who prescribe them.

Part one covered menopause overall, the 2002 Women's Health Initiative study and what's changed since, and the full menu of hormone options. This part is the practical half: is it too late, how do you stop being dismissed, what do you test, and a lightning round of everything else you asked.

IS IT TOO LATE?

I put five of your questions to Steve at once, from Melanie (ten-plus years past menopause) to Theresa (twenty-plus years, never took anything) to Trisha (when's the right time to stop). His answer to all of them was the same, and it wasn't about years:

"It's never really too late for a woman to take hormones, but you do need to look carefully at each individual woman's risks, especially cardiovascular risks."

Here's the number that surprised me. Women have substantially less cardiovascular disease than men at age 50. By 60, they're about even. Steve's read: that's the roughly nine or ten years most women spend without estradiol after menopause, catching up.

The tools he uses to look at an individual woman's actual risk, instead of guessing from her age: a coronary artery calcium scan, which finds hard, calcified plaque, and a CIMT (carotid intima-media thickness) scan, an ultrasound of the artery in your neck that gives a good proxy for what's happening in your heart.

His bottom line, and I think about this one a lot: "You have to pick your risks. You're gonna face risks either way, whether you take hormones or you don't take hormones."

THE 65 CUTOFF

Steve actually made a video of a birthday cake that says "Happy birthday, no more hormones for you," because that's exactly what so many women are told the moment they turn 60 or 65. His words: "That is a blanket policy that is really harmful to women."

Here's why. If a woman has been on hormones since she went into menopause at 51, and she's now 65, she has been protected by estradiol for 14 years. Cutting her off because of a birthday number ignores everything that estradiol has already done for her arteries. The test was never supposed to be her age. It's her risk.

HOW TO STOP BEING DISMISSED

If you've been told "we don't test for that" or "come back when you have symptoms," you already know this feeling. Steve built a framework for exactly this, and it's designed to open a conversation instead of putting a doctor on the defensive. He calls it the HRT questions:

H, how do you feel about treating women in perimenopause or menopause?
R, what are your go-to remedies for menopause symptoms that work the best in your practice? And what remedies do you stay away from?
T, explain your training and experience in treating women in perimenopause and menopause.

Then a fourth question, a straight multiple choice: does your philosophy look like A, "I never touch the stuff," B, lowest effective dose for the shortest time, or C, "I want to return all your hormones to optimal levels ... in order to eliminate your symptoms and reduce your long-term health risks."

Why this matters: Steve says most OB-GYN and family practice doctors get "just a few hours of training in menopause and hormones." He even asked his own primary care provider about APOE4, and "he had no idea what it was." That's not a knock on your doctor. It's the system. Which means the informed one in the room, more often than you'd think, is you.

WHAT TO TEST, WHAT TO AIM FOR

Steve's own clinical target for estradiol is 100 picograms per milliliter, with 60 to 100 as the range he treats as protective for bone density and cardiovascular risk. I want to be precise here: that's Steve's clinical target from his own practice, not a published guideline.

His approach to dosing, in his own words: "I don't really care what number you put in your mouth or on your skin. What I care about is where does it end up in your blood." He treats the blood level, not the dose on the label.

On testing methods: serum (blood) has by far the most research behind it, and it's what nearly every clinical trial uses. Urine testing, including the 24-hour test and the DUTCH test, comes second, with a real but smaller body of evidence. Saliva testing he doesn't trust for repeatability: "you could take the exact same sample, test it three different times, and get three different results."

One thing worth flagging for this community specifically. Steve's reading is that APOE4 carriers are more sensitive to low T3 and free T3, the two thyroid markers, and that this matters more for us than for the general population. I went and checked it, because he does not cite a study on camera. The association is real and published: in one analysis, higher T3 tracked with better verbal memory in APOE4 carriers and with worse memory in non-carriers. What has not been shown is the next step, that raising T3 helps carriers. That is Steve's own hypothesis, and it is also his explanation for why the thyroid trials in Alzheimer's disappointed, because they used T4 rather than T3. Worth a conversation with your doctor. Not worth acting on alone.

LIGHTNING ROUND

A few fast ones from the last part of the hour:

Local vaginal estrogen for recurrent UTIs and vaginal atrophy has very little absorption into the rest of your body, and Trudy told us it completely resolved UTIs she'd been getting since menopause. Vaginal symptoms, unlike hot flashes, tend to get worse over time rather than better.

SHBG (sex hormone binding globulin) came up from two members, Christy and Trudy. Steve's blunt take: "it is a conundrum that's not easy to fix." His advice is to walk around it rather than fight it directly, by watching your total testosterone and your free testosterone (the part not bound to SHBG) side by side, rather than chasing the SHBG number itself.

And on what's actually inside the capsule: Steve's own compounded progesterone was just progesterone and hydroxypropyl methylcellulose in a gelatin capsule. Most commercial progesterone capsules use peanut oil and contain titanium dioxide. His advice is to look for PCAB accreditation, where a compounding pharmacy has to keep every batch within plus or minus 10% of its labeled potency. One Phoenix member's compounded estradiol came back at 423, which is a real illustration of why that accreditation matters.

Every one of those questions came from a Phoenix member. That's the entire structure of this community. You ask, I take it to someone who actually studies it, and you get the answer back.

If you are not in yet, join Phoenix here

NEXT WEEK

I'm sitting down with a second expert on thyroid and testosterone, so you get two independent reads inside the same monthly theme.

None of this is medical advice, and Steve's numbers are his own clinical experience, not a universal standard. Take this to your own clinician and have a sharper conversation than you would have had without it.

Cheers,
Kevin

P.S. If there's a hormone question we didn't get to, or one Steve's answer raised for you, hit reply. That's how the next expert conversation gets built.