What Every Woman Should Know About HRT – Expert Monitoring Is as Important as the Prescription
By Lynda Sherland, CRNP, FNP-C, IFMCP,
Amy Nutter, MSN, ACNP, BC, IFMCP,
Dr. Jennifer Patterson, DO, MMH, CHt and
Dr. Georgia Tetlow, MD, ABOIM, ABPMR, IFMCP
Not all Hormone Replacement Therapy (HRT) is created equal—and your health depends not only on the prescription, but also on how it is monitored.
For years, HRT had a reputation for being risky, particularly linked to cancer and cardiovascular events (heart attack, stroke, and blood clots). Many women who might have benefitted from treatment avoided it, while providers were discouraged from prescribing it.
Things have changed a lot recently. Expert reviews and new interpretations of long-term data have reversed much of the conventional thinking. Today, HRT is increasingly recognized as a safe and highly beneficial option for many women in perimenopause and menopause. In fact, it not only strengthens bones, it may also reduce cardiovascular risk and improve overall quality of life when prescribed appropriately.
At Philadelphia Integrative Medicine, we’re seeing a sharp rise in questions about HRT, fueled by this growing awareness. Unfortunately, many providers are jumping in without the nuanced knowledge required for proper prescribing, monitoring, and patient support. That’s where expertise matters.
Why the Shift in Perspective on HRT?
The change stems from a deeper re-analysis of earlier studies that once cast HRT in a negative light.
Experts now recognize that the risks were overstated and misunderstood.
In particular:
Cardiovascular protection: HRT may lower risk when started at the right time.
Bone health: Estrogen therapy supports bone density and helps protect against osteoporosis.
Perimenopause support: Used appropriately, HRT can ease symptoms while supporting long-term health.
The FDA recently featured expert testimony underscoring these benefits, reinforcing that HRT, when monitored and individualized, can be a safe and effective therapy.
The Role of Testing in HRT—Why Saliva Matters
One of the most overlooked aspects of HRT is monitoring, especially when it comes to topical hormones like estradiol, progesterone, and testosterone.
Standard blood testing will routinely fail to capture levels—you will not see a change in blood work after starting topical hormones. Most prescribers do not know this.
This means many practitioners are not monitoring HRT correctly. It often leads to overdosing, which, in turn, can cause increased sex hormone binding globulin, making it harder for future HRT to have the desired effects.
For topical hormones, saliva testing from a reputable company is essential. It allows for accurate monitoring of topical hormones. At Philadelphia Integrative Medicine, we have years of experience choosing the best testing, interpreting results, and personalizing your treatment plan—expertise that’s still rare in many conventional, functional, and integrative medicine practices.
Understanding Perimenopause: Progesterone Declines First
Perimenopause isn’t just “early menopause.” It’s a transitional phase where hormones fluctuate dramatically.
The first hormone to decline is progesterone, which can create imbalances long before estrogen levels begin to fluctuate and eventually drop.
Lower or no progesterone often leads to shorter or irregular cycles, mood changes, sleep disturbances, and more. Early monitoring and support can make this transition much smoother, reducing the need for more aggressive interventions later. Blood work is helpful and sufficient to monitor your endogenous hormone levels at this phase and at any time you are not on topicals.
Estrogen Dominance and Symptom Fluctuations
As progesterone falls while estrogen begins to significantly fluctuate, some women experience what’s known as estrogen dominance. This can make perimenopause more symptomatic, with issues like heavy bleeding, breast tenderness, and intense mood swings. If you have had estrogen dominance (higher absolute levels, or higher relative to progesterone) prior to perimenopause, you will also experience fluctuating estrogen more acutely.
At Philadelphia Integrative Medicine, we don’t just look at hormone levels—we also support the body’s ability to process and detoxify estrogen. This integrative approach can often ease symptoms without the immediate need for hormone therapy. At any age, we assess hormone metabolites to understand whether your body is producing more inflammatory forms of estrogen, and if so, how to reduce that tendency.
We also evaluate gut health, since efficient estrogen clearance depends in part on an enzyme at the intestinal brush border called beta-glucuronidase. Using advanced tools such as Precision Analytical’s DUTCH test and the GI-MAP stool analysis, we identify patterns and guide targeted strategies to optimize hormone metabolism and ensure that detoxification pathways are working effectively.
Non-Hormonal Options: Herbal and Nutritional Support
For those who aren’t ready or don’t need HRT, there are effective non-hormonal strategies that can help restore balance:
Vitex (Chasteberry): Supports progesterone production naturally. Not all brands are formulated as powerfully and as consistently as others. Taking Vitex can change the timing of your period. Always consult a healthcare practitioner trained in supplement-drug and supplement-supplement interactions before adding any agent you read about online or heard about on a podcast.
Rhubestryn: A plant-based option that may ease hot flashes and other menopausal symptoms. This herbal supplement formulation is only available by prescription.
These tools, combined with nutrition and lifestyle support, offer meaningful relief and can sometimes delay or reduce the need for HRT.
Our Approach at Philadelphia Integrative Medicine
We recognize that no two women experience perimenopause or menopause in the same way. Our approach is individualized, evidence-based, and rooted in expertise. Key elements include:
Thorough testing, including saliva testing when appropriate.
Careful identification and management of estrogen dominance.
Integrative, non-hormonal approaches to ease transitions.
Expert prescribing and monitoring of HRT, ensuring the right hormone, the right dose, and the right delivery method—always with safety and long-term health in mind.
The Bottom Line
The conversation around HRT has changed—and for good reason. When used correctly, it can be an incredibly powerful tool for protecting long-term health and improving quality of life.
But safe, effective HRT requires more than just writing a prescription.
At Philadelphia Integrative Medicine, we do HRT the right way—combining precise testing, expert interpretation, and integrative care to support you through every stage of perimenopause and menopause.
Whether you’re curious about HRT, looking for non-hormonal options, or needing expert guidance in managing symptoms, we’re here to help you find the right path forward.
Schedule a FREE 20-minute consultation or book an appointment with Philadelphia Integrative Medicine.
With care,
The PIM Team