The Truth About Hormone Therapy: Why Modern Medicine Failed Women

A urologist reveals how medical fear-mongering deprived millions of women of life-changing treatment and what needs to change now.

Key Takeaways

• The Women's Health Initiative study was catastrophically misinterpreted, creating unfounded fear around hormone replacement therapy for over two decades
• Less than 4% of women currently receive hormone therapy, down from 40% before 2002, despite evidence showing significant health benefits
• Medicare could save $6-22 billion annually if eligible women used vaginal estrogen to prevent urinary tract infections
• Medical schools provide virtually no menopause education, leaving doctors unprepared to prescribe hormone therapy safely and effectively
• Women have three critical hormones—estrogen, progesterone, and testosterone—all of which decline during menopause and can be safely replaced
• Vaginal estrogen reduces UTI risk by over 50% and should be considered for virtually all postmenopausal women
• The medical establishment's paternalistic approach to women's health has created a generation unable to prescribe basic hormone therapy
• Quality hormone therapy requires individualized treatment plans using FDA-approved products, not expensive compounded alternatives
• Starting hormone therapy later in life (after 60) can still provide significant benefits when properly managed

Timeline Overview

• 00:00:00–00:18:03 — Opening bombshell: How medical misinterpretation of the Women's Health Initiative created "an entire generation that has forgotten how to prescribe hormone therapy." Dr. Rubin reveals the shocking truth that estrogen alone actually decreased breast cancer risk and death rates, while also reducing colon cancer and fractures significantly. The analogy emerges: "If a penis shriveled up at age 52, we'd probably have a vaccine sponsored by Pfizer."
• 00:18:03–00:21:25 — The devastating consequences of hormone deprivation: Women in their 60s without hormones face dramatically increased risks of UTIs, sepsis, osteoporosis, hip fractures, dementia, and cardiovascular disease. The comparison is stark—more people die from hip fractures than breast cancer, yet we've abandoned the therapy that prevents them.
• 00:21:25–00:47:21 — The Women's Health Initiative exposed: A deep dive into how a billion-dollar study was catastrophically misinterpreted at a press conference before publication. The study showed a 24% relative increase in breast cancer risk but only 0.1% absolute increase—one additional case per 1,000 women. Meanwhile, estrogen-only users had decreased breast cancer risk, a finding buried by fear-mongering.
• 00:47:21–00:50:47 — Testosterone: The forgotten hormone for women: Despite having 10x more testosterone than estradiol when normalized to the same units, women's testosterone needs are completely ignored. Global consensus supports its use for libido, yet no FDA-approved formulation exists due to arbitrary regulatory hurdles.
• 00:50:47–02:18:00 — The practical playbook: Comprehensive coverage of the three critical hormones (estrogen, progesterone, testosterone), delivery methods (patches, gels, rings, oral), dosing strategies, and the art of individualized treatment. Key revelation: systemic estrogen often isn't enough—most women also need local vaginal estrogen for optimal urinary and sexual health.
• 02:18:00–02:24:39 — Finding qualified practitioners and avoiding predators: Red flags include doctors offering only one treatment option, expensive proprietary compounds, pellet clinics charging thousands, and practices that profit from selling hormones directly. Resources include ISSWSH.org and menopause.org for finding properly trained providers.

The Greatest Medical Injustice of Our Time

Dr. Rachel Rubin pulls no punches when describing what happened after the Women's Health Initiative study results were announced in 2002. "100% of people are heavily impacted by what we just discussed. They misinterpreted the data so drastically and scared everybody with so much fear that you actually have an entire generation that has forgotten how to prescribe hormone therapy."

The numbers tell a devastating story. Before 2002, approximately 40% of menopausal women were using hormone replacement therapy. Today, that figure has plummeted to less than 4%. This dramatic shift didn't happen because the therapy became less effective or more dangerous—it happened because of what many experts now consider the most catastrophic misinterpretation of medical data in recent history.

• The Women's Health Initiative study, which cost over a billion dollars and took five years to complete, was designed to answer important questions about hormone therapy safety and efficacy through rigorous randomized controlled trials
• Researchers held an unprecedented press conference before the study was even published, announcing they had to stop the trial early due to increased risks of breast cancer, blood clots, and cardiovascular disease
• The announcement sent shockwaves through the medical community and caused hormone therapy prescriptions to virtually disappear overnight, creating what Dr. Rubin describes as a "lost generation" of doctors who never learned to prescribe these medications
• What the press conference didn't emphasize was that women taking estrogen alone actually had a decreased risk of developing and dying from breast cancer—a finding that completely contradicted the fearful narrative
• The increase in breast cancer risk for women taking both estrogen and synthetic progesterone was a relative increase of 24%, but the absolute risk increase was only 0.1%—meaning one additional case of breast cancer per 1,000 women treated
• Women on hormone therapy showed significant benefits including decreased colon cancer risk, dramatically reduced fracture rates, lower diabetes incidence, and decreased overall mortality

The study's fundamental flaw wasn't just in interpretation—it was in design and applicability. The WHI used one specific medication (Premarin and Prempro), at one dose, in a specific population. Yet the results were broadly applied to all hormone therapies, regardless of type, dose, or delivery method.

The Medical Education Crisis

Perhaps even more troubling than the initial misinterpretation is the lasting impact on medical education. Dr. Rubin recently taught at the largest internal medicine conference in the country, addressing over 20,000 physicians. Her course on female sexual dysfunction was the only menopause-related content at the entire conference.

• Less than 6% of internal medicine, OB/GYN, or family practice doctors receive even one hour of menopause education during their training
• Many physicians who previously prescribed hormone therapy either retired or died, leaving no one to train the next generation
• Current medical school curricula teach that hormones are dangerous, associating them with bodybuilders and "snake oil salesmen" rather than evidence-based medicine
• Endocrinologists, who are literally hormone doctors, often claim they're not comfortable prescribing hormone therapy for menopause
• Psychiatrists report that their malpractice insurance won't cover them if they prescribe hormone therapy, despite hormones being among the most effective antidepressants available for menopausal women
• The knowledge gap has created a situation where urologists like Dr. Rubin are teaching hormone specialists how to prescribe estrogen and progesterone

This educational void has created a perfect storm. Women suffering from menopausal symptoms are told by their doctors that hormone therapy is too dangerous, while those same doctors admit they don't know how to prescribe it safely. Meanwhile, the void has been filled by less qualified practitioners offering expensive, unregulated alternatives.

Understanding the Three Critical Hormones

Contrary to popular belief, women don't just need estrogen—they require three key hormones that all decline during menopause. Dr. Rubin emphasizes this point: "I don't know who decided that men get testosterone and women have estrogen. We have both of the hormones."

The testosterone revelation is particularly striking. When normalized to the same units of measurement, women actually have ten times more testosterone in their bodies than estradiol at peak levels. This makes testosterone deficiency a critical component of menopausal health that's almost universally ignored.

• Estrogen (estradiol) is the primary hormone responsible for hot flashes, bone protection, cardiovascular health, and brain function—levels drop to essentially zero after menopause
• Progesterone protects the uterine lining when estrogen is present, provides significant sleep and anxiety benefits, and has a calming effect on the nervous system through GABA receptors
• Testosterone begins declining in a woman's 30s (not at menopause), affects libido, energy, muscle mass, bone density, and has receptors throughout the genitals and urinary tract
• Birth control pills, widely accepted as safe hormone therapy, actually suppress natural testosterone production and replace it with synthetic alternatives that don't include testosterone replacement
• Global medical consensus supports testosterone therapy for postmenopausal women with low libido, yet no FDA-approved formulation exists for women in the United States
• The lack of testosterone replacement contributes to increased UTI risk, sexual dysfunction, depression, and potentially cognitive decline

Dr. Rubin's patients consistently report transformative results when all three hormones are properly replaced: "When we get estrogen and progesterone right for our patients, it is by adding that third piece, that testosterone... All the patients come back and they say to me, 'Wow, I feel like me again.'"

Delivery Methods and Practical Implementation

Modern hormone replacement therapy offers multiple delivery options, each with distinct advantages and limitations. The key is matching the right method to each woman's lifestyle, preferences, and medical history.

• Transdermal patches come in twice-weekly and once-weekly formulations, with twice-weekly versions generally better tolerated—they provide steady hormone levels but may not adhere well for very active women or those with sensitive skin
• Topical gels and sprays allow for daily dosing flexibility and easy dose adjustments, though they require time to dry and consistent application timing for optimal absorption
• Vaginal rings offer the ultimate convenience with three-month duration, delivering systemic hormone levels while also providing local vaginal benefits—though some women find them uncomfortable and they can be expensive
• Oral estradiol remains underutilized despite being safe for most healthy women and often more familiar to patients accustomed to taking pills
• Sublingual administration of oral tablets may bypass liver metabolism and reduce clotting risk while maintaining effectiveness, though more research is needed in this area
• Compounded bioidentical hormones are generally unnecessary given the wide range of FDA-approved options available, and may introduce quality control and dosing consistency concerns

The choice of delivery method often determines success or failure. Dr. Rubin emphasizes the importance of having a full toolkit: "If you're going to a doctor and they give you one type of hormone therapy and that's the only type, please run. They need to know the menu because you are not a one-size-fits-all."

The Vaginal Estrogen Revolution

Perhaps the most underutilized therapy in all of medicine is vaginal estrogen for treating what's now called genitourinary syndrome of menopause (GSM). This condition affects virtually all postmenopausal women to some degree, yet treatment remains rare.

• Local vaginal estrogen reduces urinary tract infection risk by more than 50%, a finding documented since the 1990s in the New England Journal of Medicine
• The therapy is safe for women with histories of blood clots, breast cancer, or any other medical condition—systemic absorption is minimal
• Medicare could save between $6 and 22 billion annually if all eligible women used vaginal estrogen to prevent UTIs, sepsis, and related complications
• The vulvar vestibule, a critical anatomical area surrounding the female urethra, contains both estrogen and testosterone receptors and is often the source of sexual pain and urinary symptoms
• Current FDA labeling warns that vaginal estrogen causes stroke, heart attacks, blood clots, and requires progesterone protection—none of these warnings are supported by evidence for local therapy
• Many women on systemic hormone therapy still benefit from additional vaginal estrogen, as systemic doses often aren't sufficient to restore local tissue health

Dr. Rubin shared a personal story about fighting to get her critically ill mother vaginal estrogen in the ICU: "I had to write up a whole SBAR of here's why it's important. Here's the research. Here's all the literature. Here's the citations... What does everybody else do?"

The economic implications are staggering. A $13 tube of vaginal estrogen could prevent thousands of dollars in UTI treatments, emergency room visits, and hospitalizations. Yet institutional ignorance and regulatory inertia continue to block implementation.

Timing, Duration, and Special Populations

Two of the most contentious issues in hormone therapy involve when to start and when to stop treatment. Current medical dogma suggests starting within ten years of menopause and limiting duration to five to ten years, but these recommendations lack solid scientific foundation.

• The "timing hypothesis" suggesting increased cardiovascular risk with later initiation is based on the flawed WHI study using synthetic hormones and doesn't apply to modern bioidentical hormone therapy
• Australian researcher Susan Davis recently published evidence questioning the timing hypothesis entirely, suggesting the restrictions aren't scientifically justified
• Stopping hormone therapy at an arbitrary time point eliminates all bone benefits immediately and may actually increase health risks by disrupting established hormonal balance
• Women who had hysterectomies for benign conditions and women with DCIS (ductal carcinoma in situ) can generally use hormone therapy safely
• Even women with breast cancer history may be candidates for hormone therapy in certain circumstances, especially when quality of life is severely impacted
• The only clear contraindication is active cancer where hormones are being targeted as part of treatment—hormones don't cause cancer, but may feed existing hormone-sensitive cancers

Dr. Rubin draws parallels to men's health: "If you have prostate cancer, sure, we can give you testosterone. No problem. If you have metastatic disease, we target testosterone. That doesn't mean if you have localized disease that you can't have testosterone therapy."

The key is individualized risk-benefit analysis. As Dr. Rubin explains: "Women are more than breast tissue. They are so much more than their cancer risk. We have to understand and actually have these reasonable conversations with women."

Avoiding Predatory Practices

The medical void created by mainstream medicine's abandonment of hormone therapy has been filled by practitioners ranging from well-meaning but undertrained physicians to outright charlatans. Women need to recognize warning signs of exploitative practices.

• Doctors who offer only one type of therapy or insist on expensive proprietary formulations should raise immediate red flags
• Compounding pharmacies within medical practices create obvious conflicts of interest when doctors profit from selling hormones directly
• Pellet therapy, while potentially effective, involves supraphysiologic doses that can't be easily reversed and isn't FDA-approved for women
• Expensive specialty labs and saliva testing are generally unnecessary—standard blood tests from major laboratories provide adequate monitoring
• Practitioners who claim their compounded products are "safer" or "more natural" than FDA-approved options are making scientifically unsupported claims
• Legitimate hormone therapy should be covered by insurance and use FDA-approved products in most cases

The International Society for the Study of Women's Sexual Health (ISSWSH.org) and the Menopause Society (menopause.org) websites can help women locate properly trained practitioners. However, patients must still advocate for themselves and seek multiple opinions when facing resistance.

Hormone replacement therapy represents one of the most effective interventions available for improving women's health and quality of life during and after menopause. The medical establishment's retreat from this field based on misinterpreted data has created unnecessary suffering for millions of women while contributing to increased healthcare costs and poorer health outcomes. As Dr. Rubin concludes: "If a penis shriveled up at age 52, we'd probably have a vaccine sponsored by Pfizer." The time has come to bring hormone therapy back into mainstream medicine where it belongs.