You finally get the appointment. You tell your doctor you’re not sleeping, the weight is climbing, and your moods feel like someone else’s. You leave with a prescription for an antidepressant, or with nothing at all.
Dr. Deborah Kwolek, assistant professor of medicine at Harvard Medical School and director of Harvard’s Women’s Health and Menopause course, joins me to talk about why so many doctors were never taught menopause care and what she’s doing to change it. We cover the questions to bring to your next appointment, the labs to know, who may need to think harder about hormone therapy, and what to do when you hear “I don’t believe in hormones.”
In This Episode
- Timestamps
- Meet Dr. Deborah Kwolek
- Harvard had hundreds of courses and none on menopause
- Why your doctor may never have been taught this
- A fear that’s out of proportion to the data
Timestamps
- 00:00 - Meet Dr. Deborah Kwolek
02:48 - Why Harvard had no menopause course
07:00 - Why most doctors were never trained in menopause
08:10 - Is the fear of hormone therapy out of proportion?
11:23 - 3 questions to ask your doctor
17:35 - Your estrogen levels, by the numbers
25:15 - Can you stay on hormones after 65?
33:46 - Who should think twice about hormone therapy?
50:08 - What to do when your doctor says no
Meet Dr. Deborah Kwolek
Gorgeous, have you ever left a doctor’s appointment feeling like you weren’t heard?
You walked in with the night sweats, the 3am wake-ups, the ten pounds that showed up uninvited. You walked out with “that’s just normal for your age.”
That moment is exactly why I wanted you to meet Dr. Deborah Kwolek.
She first reached out to me on LinkedIn when she was putting together Harvard’s first-ever Women’s Health and Menopause course. I was honored to speak there, and I was the only integrative health speaker on the program.
Dr. Deborah is an assistant professor of medicine at Harvard Medical School and the founding lead of the Mass General Women’s Health and Sex and Gender Medicine program. She’s a certified menopause specialist and a practicing primary care physician with more than thirty years in women’s health. She co-wrote the first textbook in this field for primary care clinicians and trainees, and she still sees patients herself.
She’s also one of the kindest, most brilliant women I know. Here’s what I want you to take from our conversation.
Harvard Had Hundreds of Courses. None on Menopause.
Part of Dr. Deborah’s job at Harvard is running continuing education courses that keep doctors current.
A few years ago, she noticed something. Harvard offered hundreds of courses across every specialty, and not one of them taught clinicians how to care for a woman in midlife. There were a couple of one-day conferences, and that was it.
So she went to the head of her department and made the case. They gave her the green light.
Her course has run two years now, with a third coming up, and she shared that it’s been one of the biggest courses at Harvard. What moves her most is how many doctors and nurse practitioners leave ready to take better care of the women in front of them.
Why Your Doctor May Never Have Been Taught This
This one surprised me, and I’m an OB/GYN.
In medical school, women’s health is traditionally taught in OB/GYN. So the other specialties feel off the hook.
Dr. Deborah trained in internal medicine, and she said there was zero training on the changes that come with menopause. Maybe one lecture on prescribing a birth control pill. Maybe how to do a Pap smear.
Here’s why that matters for you. If your main doctor is a primary care physician or an internist, hormones may not be the first thing she considers. Even when you tell her you’re not sleeping, you’re moody, and you’re gaining weight.
A Fear That’s Out of Proportion to the Data
The second gap is fear.
After the Women’s Health Initiative study, hormone therapy got painted as dangerous, and that fear spread to doctors and patients alike. Dr. Deborah called it out of proportion to the data.
She gave a comparison I loved. Your primary care doctor has probably started prescribing GLP-1 medications. No special certification. She attended a lecture or two, started prescribing, and kept learning as she went.
Dr. Deborah sees no reason a lot of menopause care couldn’t work the same way.
I shared my side too. Through all of it, in my rural practice with the National Health Service Corps and beyond, I read the research and kept prescribing bioidentical hormones. I didn’t realize until recently how many patients were simply told no.
Menopause care has nuance. For a lot of doctors, it’s just unfamiliar territory.
Your Estrogen, By the Numbers
This is the part I want every woman to hear.
From puberty to menopause, your estrogen cycles every month. Dr. Deborah described it moving through a range of about 30 to 300 or 400 on a lab report. In pregnancy, it can climb into the thousands. In perimenopause, it can swing all over the place.
Hormone therapy, she explained, is a low dose compared to what your body lived with for about forty years.
She also noted that a large study last year found transdermal estrogen, meaning through the skin rather than a pill, did not appear to raise the risk of blood clots.
And estrogen works far beyond reproduction. Almost every cell in your body has estrogen receptors.
What to Say at Your Next Appointment
Dr. Deborah sees this as a two-way relationship. Your doctor needs more education, and you can bring the question into the room.
Start here.
“Could this be my hormones?”
“Could this be perimenopause?”
If you’re having night sweats or feel hot at night, say it in those words. Some doctors are listening specifically for hot flashes.
Still having periods? Say that too. According to Dr. Deborah, current guidance says hormone therapy can begin during perimenopause, before your last period.
If you’re past menopause or over fifty and you’re not feeling well, she suggests saying it plainly. “I’m interested in hormone therapy. I think it could help me feel better. Can I try it?”
And if that first visit doesn’t go your way? She reminded me that asking the question challenges your doctor to learn more. The next visit may go differently.
One more note. If you’re under fifty and your periods have stopped, Dr. Deborah wants that evaluated. In her view, hormone therapy is often recommended until about age fifty unless there’s a reason not to.
The Labs Worth Knowing
At minimum, Dr. Deborah expects a primary care visit to include your cholesterol, your hemoglobin A1C (your average blood sugar over about three months), your weight, and a real conversation about your symptoms.
She sees a pattern in her late-forties patients. Weight goes up. LDL goes up. A1C creeps to 5.7 or 5.8, right into the prediabetes range.
If you want more detail, ask about fasting insulin and CRP, a marker of inflammation. I also like to watch FSH (follicle-stimulating hormone), estradiol, testosterone, adrenal hormones, and inflammatory markers. High FSH in menopause is associated with bone loss and brain changes, so if it isn’t coming down, I want to know why.
I shared something else I’ve been studying. More frequent hot flashes are associated with insulin resistance, so supporting your insulin sensitivity matters.
As Dr. Deborah put it, menopause is a whole-body transition. It touches your metabolism, your heart, and everything in between.
Timing, and Why There’s No Set Stopping Point
Here’s what may surprise you.
According to Dr. Deborah, there’s currently no recommended stopping point for hormone therapy. If you’re doing well and want to continue into your sixties and beyond, that’s a conversation to have with your doctor.
She used bone as an example. A lot of menopausal bone loss happens within a year or two of your last period. Starting hormone therapy before then may help preserve bone. Stop later, and that benefit can fade.
I brought up last year’s study of about 10 million women on Medicare, where hormone therapy use past age 65 was associated with lower rates of disease and death.
And I asked the question I ask in my lectures. Doctors don’t stop someone’s insulin at 65. They don’t stop thyroid hormone at 65. So where did “stop your hormones at 65” come from?
Dr. Deborah was clear that not every woman needs or wants hormone therapy. Her hope is that every woman who could benefit is at least offered it, then decides for herself.
Who May Need to Think Harder About Hormone Therapy
Dr. Deborah said the list of contraindications for transdermal estrogen is short. Here’s what she named.
Active estrogen receptor-positive breast cancer. This is her clearest no.
A history of breast cancer, or high risk. Not automatically a no, she said, but a nuanced conversation with an experienced provider and your oncologist.
Severe liver disease, such as advanced cirrhosis.
A high risk of blood clots, stroke, or heart attack.
She also made a point I want you to hold onto. Your full medical history matters. She’s had patients tell her they’ve never had a blood clot, and then she finds a pulmonary embolism in their chart. Nobody remembers everything, and medical terms are confusing. That’s one reason she prefers care from someone who knows your whole record.
I feel the same way. I like to do a full head-to-toe exam before I prescribe anything. I once saw a beautiful woman in her seventies who was on hormone therapy, and her exam showed significant swelling in her legs. That told me there was more going on, and I would have missed it on a video call.
And I want to bust a myth I hear all the time. If you’ve had a hysterectomy, you may have been told you don’t need progesterone. Progesterone supports sleep, mood, memory, and bone, with or without a uterus. Testosterone and DHEA belong in this conversation too.
When You Feel Dismissed
Maybe you were offered an antidepressant or metformin first. Dr. Deborah explained that these can help, and some women benefit from both medication and hormones. Her concern is that a single prescription can leave a piece of the puzzle unaddressed.
She also called lifestyle the foundation. Better sleep, real food, and movement can help bring LDL and A1C down.
And if your doctor says, “I don’t believe in hormone therapy”? Dr. Deborah has heard it through her own friends. One friend called her primary care doctor, then her OB/GYN, and heard the same thing from multiple doctors.
Her response stuck with me. Doctors don’t say that about anything else. Nobody says, “I don’t believe in statins.”
You have options. Dr. Deborah’s first choice is a doctor who knows you well. If you’re dismissed, there are other options, including online providers.
So put on your Nancy Drew cap. What is your body telling you? What aren’t you doing that you know would help? There’s always one next right step.
What’s Changing
Dr. Deborah is moving the needle. Harvard’s main primary care course has 88 hours of education. It used to include one hour on menopause. This year, it will have four hours dedicated to midlife and menopause, with women’s health woven through the other topics too.
She shared that some oncologists are becoming more open to hormone therapy for breast cancer survivors, and vaginal estrogen is more widely accepted as having very few contraindications.
Then she told me about her colleague Dr. Steven Isakoff, a Harvard oncologist known as one of the few in the area who will prescribe hormone therapy for survivors. Someone asked if he’d ever been sued for it. His answer?
“I’ve never been sued, but I’ve been thanked a whole lot.”
I love that.
Your Appointment Checklist
Ask out loud, “Could this be my hormones?”
Name every symptom, including night sweats and sleep changes.
Know your numbers. Cholesterol and A1C at minimum, then ask about fasting insulin and CRP.
Bring your medical history, especially any blood clots, cancer, or liver issues.
If you want hormone therapy, say so plainly and ask what’s right for you.
If you feel dismissed, ask again or get a second opinion.
Build your foundation with sleep, real food, and movement.
Resources Mentioned
- Harvard Women’s Health and Menopause course, for clinicians, online and in person in March. Tell your doctor about it.
The transdermal estrogen and blood clot research Dr. Kwolek referenced
Frequently Asked Questions
Why don’t more doctors know about menopause care?
According to Dr. Deborah Kwolek, women’s health is traditionally taught in OB/GYN training, so other specialties like internal medicine may receive almost no menopause education. Fear of hormone therapy after the Women’s Health Initiative also left many clinicians hesitant.
What should I ask my doctor about perimenopause?
Dr. Kwolek suggests asking directly, “Could this be my hormones?” or “Could this be perimenopause?” Mention night sweats or feeling hot at night in those words, and share whether you’re still having periods.
Can hormone therapy start before menopause?
According to Dr. Kwolek, current guidance says hormone therapy can begin during perimenopause, before your last period, for women who have symptoms or could benefit. Talk with your doctor about whether it’s right for you.
Do I have to stop hormone therapy at 65?
Dr. Kwolek says there’s currently no recommended stopping point. Some benefits, such as bone support, may fade after stopping. Decisions about continuing are personal and best made with your doctor.
Who should be cautious about hormone therapy?
Dr. Kwolek named active estrogen receptor-positive breast cancer as the clearest contraindication. A history of breast cancer, severe liver disease, or a high risk of blood clots, stroke, or heart attack call for a careful conversation with an experienced provider.
What can I do if my doctor won’t discuss hormone therapy?
Ask again at your next visit, bring your questions in writing, or seek a second opinion. Dr. Kwolek prefers care from a doctor who knows you well, and she notes there are other options, including online providers.
Your body is always speaking to you. Listen with curiosity, not criticism.
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This content is for educational purposes only and is not medical advice. Talk with your healthcare provider before making changes to your medications, supplements, or hormone therapy. The views shared by podcast guests are their own.
