As an integrative and functional medicine physician, I prescribe hormone therapy. I also see its misuse daily.
Hormone replacement therapy (HRT), including bioidentical hormone therapy (BHRT), has re-entered menopause care with force, correcting decades of dismissal and undertreatment. That correction was necessary, but the pendulum has swung too far.
What I am seeing clinically is not thoughtful, physiology-based care. It is hormone-first medicine that bypasses stress physiology, nervous system dysregulation, trauma, metabolic dysfunction, and burnout often in the name of “energy,” “vitality,” or optimization.
Hormones cannot do it all
Hormones are being asked to do work they cannot do.
Menopause is not simply a state of hormone deficiency. It is a complex neuroendocrine transition involving the nervous system, metabolism, inflammatory burden, sleep architecture, and psychosocial context. When we reduce it to estrogen levels alone, we practice incomplete medicine.
I see women placed on estrogen for fatigue that is clearly driven by chronic sympathetic activation. Testosterone prescribed for “drive” in women who are profoundly burned out. Progesterone used to sedate a dysregulated nervous system rather than restore safety. When symptoms worsen anxiety, insomnia, irritability, the response is often dose escalation rather than reassessment.
This is not precision medicine. It is symptom suppression.
The safety myth
Bioidentical hormones are often framed as inherently safe. They are not. Molecular identity does not equal physiologic appropriateness. Estrogen, progesterone, and testosterone affect coagulation, breast and endometrial tissue, lipid metabolism, insulin sensitivity, and neurotransmission. They deserve restraint and respect.
Ethical hormone therapy requires asking a harder first question: Is this a hormone deficiency or is this a system under chronic stress expressing itself hormonally?
Many midlife women arrive at menopause exhausted from decades of caregiving, overwork, sleep deprivation, and unresolved trauma. Hormones layered onto this terrain often worsen symptoms because the body cannot receive them well. A dysregulated nervous system does not respond predictably to endocrine input.
Hormone therapy is most effective for clearly defined indications: vasomotor symptoms, genitourinary syndrome of menopause, and select sleep or mood disturbances after root causes are addressed. It is not indicated for chronic fatigue, burnout, or emotional depletion masquerading as “low hormones.”
Commercialization of care
What concerns me most is not inappropriate prescribing alone but the commercialization of menopause care. Hormone therapy is increasingly marketed directly to women as a lifestyle upgrade rather than a medical intervention. Fear is monetized. Nuance is lost. Complexity is inconvenient.
We must do better.
A more ethical approach requires slowing down:
- assessing stress physiology and metabolic health
- addressing sleep, nutrition, and nervous system regulation
- using the minimum effective hormone dose
- monitoring symptoms, not just lab values
- reassessing regularly and being willing to taper or stop
Hormones should support adaptation, not override it.
Menopause is not a pathology to be fixed. It is a physiologic, psychological, and dare I say spiritual threshold that demands integration and comprehension. When we bypass that work with prescriptions alone, we fail our patients.
Hormone therapy remains an important tool but it should never become the entire treatment plan, nor a business model that profits from women’s exhaustion.
Ethical menopause care must honor the whole woman not just her labs.
Kay Corpus is an integrative and functional medicine physician.
