Hormones and Midlife

Why it's often missed

A standard visit often checks only TSH and perhaps a single estradiol level drawn on a random day. Both can look normal even when you feel terrible. Hormones fluctuate from day to day in perimenopause, so one result rarely tells the full story. Reference ranges are also designed to flag disease, not to show whether your levels support you feeling well.

Midlife symptoms also overlap with other problems. Low iron stores, blood sugar changes, thyroid issues, stress and poor sleep can all cause fatigue and brain fog, and they often occur at the same time as hormonal shifts. If only one is addressed, you may not feel much better.

How I sequence treatment

My approach follows The Longevity Hierarchy™, a framework I developed for organizing care around what your body can tolerate right now. It has two aims: reduce the load your body is carrying, and expand its capacity to handle treatment. Hormones work in both directions. They respond to stress, poor sleep and other burdens, and when they're significantly out of balance, correcting them can expand capacity. Hormone therapy that restores sleep, for example, often makes everything else easier.

In practice, that usually means:

1. Build the foundation. Sleep, iron stores, blood sugar, protein and strength training have an outsized effect in midlife. Resistance training is the strongest tool for preserving muscle, bone and insulin sensitivity.
2. Consider hormone therapy when it fits. Progesterone is usually the first hormone to decline in perimenopause, and it plays a direct role in deep sleep. Estradiol, often through the skin, may help hot flashes, sleep, mood and bone health. Every prescription has a clear reason, goals, and a plan to reassess.
3. Look underneath. If symptoms persist, I look at what else may be driving them, such as thyroid function, stress, gut health, or environmental load like mold.
4. Reassess and adjust. Your hormones keep changing through this transition, so the plan changes with them.

Hormone therapy decisions are individual. The risks and benefits depend on the type of hormone, how it's taken, your age and timing, and your history. If you have a history of breast cancer or other conditions, I can coordinate with your oncologist or other doctors.

Frequently asked questions

Do you treat perimenopause and menopause for patients outside the Bay Area?

Yes. I see patients for perimenopause, menopause and hormone therapy anywhere in California by video. I'm licensed in California, so patients need to be located in the state. If you live outside California, your own doctor can still get my guidance: clinicians can book a one-on-one case consult with me about your care, while they remain your treating physician.

My labs are normal, but I feel awful. Could it be perimenopause?

It could. Hormones fluctuate widely in perimenopause, and a single blood test on a random day often misses what's happening. Low ferritin, insulin resistance and thyroid changes are also commonly overlooked. I look at your symptoms, test at the right time in your cycle, and read results against ranges associated with feeling well.

Is hormone therapy safe?

It isn't safe or unsafe for everyone. The risks depend on the hormone, the dose, how it's taken (a skin patch versus a pill, for example), when it's started, and your personal history. I go through the evidence with you so you can make an informed decision, and I coordinate with your other doctors when needed.

Do you prescribe bioidentical or compounded hormones?

I use bioidentical hormones, which have the same structure as the hormones your body makes, such as estradiol and micronized progesterone. Many are FDA-approved and available at regular pharmacies as patches, gels or capsules. I use compounded hormones for specific needs, such as a slow-release progesterone or a formula without fillers you're sensitive to. I also use estriol in a face cream to support collagen, and vaginal estrogen, often as estriol, for genitourinary support. For estrogen therapy that works throughout the body, I generally prefer estradiol over combination creams such as Bi-Est. Estriol can dilute estradiol's effect, which matters for bone health, and compounded products can vary in strength from batch to batch.

Do you prescribe testosterone for women?

Sometimes. The strongest evidence for testosterone in women is for low sexual desire after menopause, using a low dose applied to the skin. It isn't FDA-approved for women, so any use is off-label. A low lab value alone isn't a reason to start it. For muscle and strength, resistance training and adequate protein are better supported.

Do you treat low testosterone in men?

Yes. I evaluate symptoms along with morning blood tests, usually repeated, because testosterone varies from day to day. I also look for what may be lowering it, such as poor sleep or sleep apnea, weight and insulin resistance, medications, and stress. When treatment makes sense, we go over the options together, including the fact that testosterone therapy can reduce sperm production, which matters if you want children.