**Attached at the bottom is the most current re-review of the Women’s Health Initiative (1998) findings and updated guidelines (2024-2025) for women starting hormone therapy.

Hormone Optimization Membership:

Initial New Patient Consultation Fee

I understand that a valid payment method (credit card) must be kept on file prior to my hormone optimization program consultation. A one-time, non-refundable consultation fee of $149 will be charged by Wellbeings Medical PAPC or PLLC using the payment method on file.

If a valid payment method is not on file before the scheduled appointment time, Wellbeings Medical reserves the right to cancel the appointment and offer a rescheduled date and time.

Should I choose to enroll in the hormone optimization program following the consultation, the $149 consultation fee will be credited toward my first month's program fee. If I decide not to enroll in the program after the consultation, the $149 consultation fee remains non-refundable.

New Patient Hormone Evaluation Fee: $149/month then $49/month for maintenance.
This includes initial evaluation, lab review, treatment plan, follow up labs and video visits at a monthly cadence until a hormone plan and balance is achieved, then you will transition to the $49/month with labs every 3-6 months.

Active $299/month Weight Loss Members: hormoneevaluation and management included in membership fee

Bridge $199/month Weight Loss Members: new hormone evaluation is an additional $149/month and $49/month for hormone maintenance management

GLP-1 + Hormone Optimization Maintenance Membership: $129/month

For current GLP-1 maintenance members:
If you are starting a hormone optimization evaluation, you will pay the standard new hormone patient fee of $149/month in addition to your GLP-1 maintenance membership until your hormone treatment reaches maintenance status.

Once both programs are in maintenance, your memberships will be combined into a single $129/month maintenance membership.

This low monthly maintenance fee is designed to make ongoing provider expertise more affordable by distributing costs over time rather than requiring large annual or quarterly payments.

Monthly Fee Covers:

• Medical Provider Oversight

• Medication Management and Ordering

• Lab Review Visits

• Video visits scheduled on as needed basis

• Access to low cost GLP-1 and peptides

Medication Costs are in addition:

• Prescription medications are not included in the monthly fee and vary based on medication and route of administration. They are provided at wholesale pricing (no markup).

• FDA-approved medications (e.g., estradiol patch, oral progesterone, testosterone gel for men) may be covered by insurance at retail pharmacies

• Compounded medications (e.g., specialty creams, injections, oral testosterone) are out-of-pocket expenses, but typically affordable.

Lab Tests are in addition:

• Labs may be completed using insurance or self-pay (insurance coverage is not guaranteed but often covers a portion).

• Other labs, such as DUTCH test or 4 point cortisol saliva testing are out of pocket expenses.

• New patients: initial recheck at 8-12 weeks, then typically every 3 months until steady state is reached 

• Established patients: typically every 6 months

Self-Pay Lab Fees (can vary):

Initial Comprehensive Labs

• Males: $200

• Females: $170

Repeat Labs

• Males: $110

• Females: $85

You can also choose to use insurance to cover labs at Quest Diagnostics, though this does not guarantee coverage and you may be responsible for copay up to $250 or the full amount depending on your insurer. With the self-pay rates listed above, this is what you pay upfront without insurance. I can customize your labs as well.

Program Details

• The initial consultation will review current symptoms, health goals, medical history and lifestyle. After the first visit, lab work will typically be requested to understand hormone levels. This could range from blood, urine, and/or saliva testing.

• The next visit will occur once the labs have returned and this will help guide your treatment options and recommendations. Your provider will be reviewing your labs to understand your entire hormone picture, from sex hormones, adrenals, thyroid, and metabolism.

• Each additional followup visit will be typically every 12 weeks or as needed by treatment plan.

• Typically blood labs are repeated 12 weeks after initiating therapy. Dosing and/or formulations of hormone therapy may be adjusted in the first few months.

• Your provider may recommend advanced hormone testing using the DUTCH (Dried Urine Test for Comprehensive Hormones), which is a highly accurate and safe method for evaluating hormone metabolism. I understand that this test is offered at wholesale pricing (approximately $300–$400) and is not typically covered by insurance.

• A medications through compounding are provided at-cost. Depending on the medication and formulation, you may be able to use insurance to offset some costs. However, all compounded medications (such as testosterone or compounded creams) are not covered by insurance and will require out-of-pocket payment.

• You may discontinue the hormone program at any time by providing written notice to the medical provider or their assistant. Discontinuation will terminate the prescribing and management relationship.

Purpose of Treatment

Hormone Replacement therapy (HRT) is used to treat symptoms related to perimenopause, menopause and estrogen deficiency. These may include neuroendocrine symptoms (anxiety, stress, depression, weight gain, insulin resistance, cortisol imbalance), vasomotor symptoms (hot flashes and night sweats), sleep disruption related to peri/menopause, genitourinary syndrome of menopause (vaginal itching, dryness, pain with intercourse, or frequent or recurring UTIs and vaginal infections), as well as low libido and prevention of bone loss in appropriate candidates. Testosterone therapy may be considered in women for hypoactive sexual desire disorder (aka low libido) after appropriate evaluation and lab testing.

Menopausal hormone therapy is the most effective treatment for vasomotor symptoms. It is not prescribed for the primary prevention of cardiovascular disease, dementia, or other chronic conditions.

Hormone Therapy Options Reviewed

This practices utilizes bioidentical hormones, meaning they are the same chemical structure as the hormones your body naturally produces providing maximal support with minimal side effects.

Estrogen Therapy

Estrogen options include:

• Transdermal estrogen (patches, creams) - first line  

• Oral estrogen - last line

• Local vaginal estrogen cream only does not absorb systemically and does not need opposing progesterone to protect endometrium. 

Progesterone Therapy

In individuals with an intact uterus, progesterone is required when systemic estrogen is used to reduce the risk of endometrial hyperplasia and endometrial cancer. For women without a uterus, progesterone is still recommended.

Options include:

• Oral micronized progesterone - first line 

• Progesterone cream

• Progesterone vaginal suppository.

• Synthetic progestins - will not be used in this practice 

Testosterone Therapy

Testosterone therapy for women is only FDA-approved for the treatment of hypoactive sexual desire disorder in postmenopausal women after appropriate evaluation. Testosterone is not FDA-approved for general use for energy, mood, weight loss, or overall vitality. When considering testosterone replacement therapy in women, a thorough evaluation will be completed including lab testing.

When used, therapy should aim to maintain testosterone levels within the normal physiologic female range.

Medication Options and Estimated Cost

As you could guess, optimizing women’s hormones proves a bit more challenging than optimizing mens (go figure…)

Together we will decide which option or combination of options is best for you based on symptoms, lifestyle/convenience factor, lab results, genetics etc. As a rough estimate, see below for different options and estimated pricing.

• Estrogen Replacement: patch, cream, vaginal cream, newer injectable option and less likely to be prescribed oral.

• Progesterone: oral, cream, and less likely vaginal suppository.

• Testosterone: cream, oral troche, newer liposomal oral option, injectable

• Creams can be custom compounded to include all 3.

• Estrogen patch and oral progesterone can be typically be covered by insurance at your retail pharmacy.

• All creams and custom oral formulations, and testosterone creams are out of pocket expenses, usually < $100/month.

Chosen and Preferred Treatment Regimen

After discussion of available options, benefits, risks, and alternatives, the preferred regimen consists of:

• Transdermal estradiol patch, applied twice weekly

• Oral micronized progesterone, taken nightly, for endometrial protection, sleep, and anxiety improvement

• Topical (transdermal) testosterone or testosterone troche for women with small children who want to avoid transfer risk
  

Rationale for This Regimen

Transdermal Estradiol
Transdermal estradiol avoids first-pass metabolism in the liver and has been associated in multiple studies with a lower risk of venous blood clots and less impact on clotting factors compared with oral estrogen. This route is generally considered safer for individuals with cardiovascular or thrombotic risk factors, though no therapy is risk-free. The dose given through patch is low and will not induce menstrual cycling or interfere with current cycling. It provides a baseline estrogen level to prevent the low dips of estrogen levels which help control the hot flashes and mood swings. 

Oral Micronized Progesterone
Oral micronized progesterone (generic Prometrium) is an effective option for endometrial protection when used with systemic estrogen. Some observational data suggest potential differences in breast cancer risk between micronized progesterone and certain synthetic progestins, though evidence is not uniform and ongoing research continues. **Levonorgestrel-releasing intrauterine device (IUD) releases enough progestin into the body to protect the uterus, however, if you would like symptomatic relief then an oral progesterone can also be added. 

Topical Testosterone
Topical testosterone allows for lower, more physiologic dosing and is preferred over oral or injectable forms to minimize adverse metabolic effects. Use is limited to appropriate indications and requires ongoing monitoring.

Expected Benefits

Potential benefits of hormone therapy include

• Improvement in stress tolerance, anxiety, and depression

• Improvement in metabolic and hormonal functioning across all systems - cortisol, sex, and thyroid, and insulin regulation.

• Improvement in weight balance and body composition

• Improvement in sleep

• Improvement in sexual desire and response

• Reduction in hot flashes and night sweats

• Improvement in genitourinary symptoms when systemic therapy is indicated

• Prevention of bone loss and reduction in fracture risk while therapy is continued
  

Risks and Side Effects

Estrogen-Related Risks

Risks of systemic estrogen therapy may include:

• Venous thromboembolism (blood clots) - risk is very low with estrogen patch 

• Stroke  - risk is very low with estrogen patch 

• Gallbladder disease

• Breast cancer risk, particularly when estrogen is combined with synthetic progestogens and used long-term (Only bioidentical progesterone is used in this practice) 

• Endometrial cancer when estrogen is used without adequate progesterone in individuals with a uterus (Progesterone is always prescribed with Estogen, especially in those with a uterus, except for vaginal only estrogen)

• Very important to test your hormone metabolism with DUTCH panel if you plan to take hormones long-term. This will look at how your body metabolizes estrogen, ensuring it is metabolizing down the protective pathway (2OH) instead of a potentially carcinogenic (4OH) or proliferative pathway (16OH) leading to fibroids etc.
  

Common side effects may include breast tenderness, nausea, headaches, skin irritation at patch sites, irregular bleeding, or emotional swings. If side effects occur dosing or formulation can be adjusted, as well as reviewing hormone metabolism, methylation, and detoxification pathways.

Progesterone-Related Risks

Potential side effects include:

• Sedation or drowsiness (more common with oral micronized progesterone) - dose can be adjusted if this occurs. 

• Mood changes - if you are under high stress, supplementing with progesterone can sometimes make anxiety or stress worse. It is best to work with your medical provider to help reduce stress before or during your HRT. 

• There is a small risk of paradoxical reaction to progesterone supplementation which may worsen anxiety, stimulation, sleep. If this occurs, notify your provider right away.

• Bloating

  • It can occur in 10-15% of people but can be dependent on dosing, timing, and frequency of dose. A continuous low dose is started (100mg nightly). The bloating can be due to slower motility transit, so if you are not already taking magnesium I would add magnesium glycinate (200-300mg) to your nightly routine. In rare cases, it can cause fluid shifts, but the body typically adjusts. 

• Breast tenderness

• Irregular or breakthrough bleeding

Inadequate progesterone exposure increases the risk of endometrial hyperplasia and cancer. (This likely will not happen with oral progesterone, however, it is recommended to complete a DUTCH hormone metabolite panel 3-6 months after starting treatment to look at absorption). 

Testosterone-Related Risks

Potential risks and side effects of testosterone therapy include:

• Acne and oily skin

• Unwanted facial or body hair growth

• Scalp hair thinning

• Voice deepening (may be irreversible)

• Clitoral enlargement (rare with physiologic dosing)

• Mood changes

It is recommended to complete a DUTCH hormone metabolite panel to evaluate your testosterone metabolism pathways. If you favor the DHT pathway genetically, this can cause the above symptoms. We can test this prior to starting testosterone therapy as well as 6 months after. There are DHT pathway blocking medications such as spironolactone (under 50 years) or dutasteride (over 50 years). 

Long-term safety data for testosterone use in women are more limited than for estrogen therapy. Therapy requires careful dosing and monitoring.

Updated Evidence and Regulatory Considerations

Recent regulatory updates have clarified that menopausal hormone therapy should be evaluated based on formulation, dose, route of administration, and patient-specific risk factors rather than generalized class warnings. However, systemic estrogen therapy retains warnings related to endometrial cancer risk when used without progesterone in patients with a uterus.

These updates do not eliminate risk and do not apply uniformly to all individuals.

Individuals Who Should Use Caution

Menopausal hormone therapy should be used cautiously and individualized in patients with:

• Prior blood clots or known clotting disorders

• Migraine with aura

• High cardiovascular risk

• Uncontrolled hypertension or diabetes with vascular disease

• High breast cancer risk

• Liver disease

• Unexplained vaginal bleeding
  

Testosterone therapy requires additional caution in individuals with cardiovascular risk factors, lipid abnormalities, or a history of hormone-sensitive conditions.

Contraindications

Systemic estrogen therapy is generally contraindicated in individuals with:

• Known or suspected breast cancer

• Estrogen-dependent malignancy

• Undiagnosed abnormal genital bleeding

• Active or prior venous blood clot or arterial thrombotic disease

• Severe liver disease

• Pregnancy

Testosterone therapy is contraindicated in:

• Pregnancy or breastfeeding

• Known androgen-sensitive malignancies without specialist involvement

• Use of supraphysiologic dosing

• Hypersensitivity to formulation components

Monitoring and Follow-Up

Ongoing monitoring is required and may include:

• Regular assessment of symptom response (every 6 months at a minimum) and side effects

• Blood pressure and cardiovascular risk evaluation, this is self-reported during evaluation

• Breast cancer screening per guidelines, patients must continue their annual mammograms with primary care or OBGYN provider

• Prompt evaluation of any abnormal vaginal bleeding

• For testosterone therapy, periodic monitoring of testosterone levels and assessment for androgenic side effects
  

Therapy may be adjusted or discontinued based on benefit, risk, and patient preference.

Acknowledgment

I acknowledge that I have been informed of the benefits, risks, alternatives, and uncertainties associated with menopausal hormone therapy and testosterone therapy. I understand that no therapy is without risk and that treatment decisions are individualized. I consent to treatment as outlined above and agree to appropriate monitoring and follow-up.

Summary of Recent Reviews of the Women’s Health Initiative (WHI) Data (2024–2025)

Recent reviews and reinterpretations of the Women’s Health Initiative (WHI) data—now approximately 30 years from study initiation—have led to a significant shift in how menopausal hormone therapy (HT) is understood and applied in clinical care.

Original Purpose and Core Findings

The WHI was designed to evaluate whether hormone therapy could prevent chronic diseases such as heart disease, stroke, dementia, and cancer in postmenopausal women. The original conclusions remain valid: hormone therapy is not recommended for the primary prevention of chronic disease, particularly in older postmenopausal women.

However, newer analyses emphasize that this was never the appropriate population or goal for evaluating hormone therapy’s role in treating menopausal symptoms.

Importance of Age and Timing

A key insight from recent WHI reviews is the importance of age at initiation and time since menopause:

• The average age of women enrolled in the WHI was in the mid-60s, well beyond the typical age at which hormone therapy is initiated for menopausal symptoms.

• When WHI data are reanalyzed by age and timing, women under age 60 or within 10 years of menopause onset show lower risks and more favorable benefit–risk profiles compared with older participants.

• These findings support the concept that hormone therapy is safer and more effective when started earlier in menopause, particularly for symptom relief.
  

Hormone Therapy for Menopausal Symptoms

The WHI data continue to confirm that hormone therapy is the most effective treatment for vasomotor symptoms, such as hot flashes and night sweats.

• For many symptomatic women under age 60 in early menopause, the benefits of hormone therapy outweigh the risks when appropriately selected and monitored.

• Estrogen-alone therapy (used in women without a uterus) showed particularly favorable outcomes in symptom relief.
  

Cardiovascular Risk Reassessment

Earlier concerns about cardiovascular risk have been refined:

• Newer analyses suggest that women in their 50s who initiate hormone therapy do not experience increased risk of heart disease, stroke, or heart attack.

• Some analyses suggest a potential cardiovascular benefit when therapy is started early, though hormone therapy is still not prescribed for cardiovascular prevention.
  

Breast Cancer Findings

Breast cancer outcomes vary by regimen:

• The combined estrogen–progestin arm of the WHI showed a small increase in breast cancer risk, but the absolute risk increase was low, and breast cancer mortality was not increased.

• In contrast, the estrogen-only arm showed a reduced risk of breast cancer.

• These findings underscore the importance of hormone formulation, duration of use, and individual risk factors.
  

Duration and Discontinuation

Long-term follow-up data suggest that:

• The benefits of hormone therapy diminish after discontinuation.

• This supports the current approach of using the lowest effective dose for the shortest duration needed to manage symptoms, particularly when initiated earlier in menopause.
  

Calcium and Vitamin D

WHI findings also clarified that:

• Calcium and vitamin D supplementation are not effective as universal fracture-prevention strategies in all postmenopausal women.

• Supplements are best used to address dietary deficiencies, rather than as blanket recommendations.
  

Overall Updated Interpretation

The WHI provided essential foundational data, but modern reinterpretation emphasizes that its findings were misapplied too broadly in the past. Current understanding recognizes that:

• Hormone therapy is not a preventive treatment for chronic disease.

• For many women in early menopause, particularly those under age 60 with bothersome symptoms, hormone therapy offers meaningful benefit with acceptable risk.

• Treatment decisions should be individualized, taking into account age, time since menopause, symptom severity, health history, and patient preferences.

• Shared decision-making between patient and clinician is essential.
  

Bottom Line

Recent WHI reviews represent a major shift away from earlier blanket warnings and toward personalized, evidence-based care, acknowledging that for appropriately selected women in early menopause, hormone therapy remains a safe and effective option for symptom relief.