When the Food and Drug Administration announced that the agency would be removing the black-box warning from hormone replacement therapy, or HRT, women everywhere threw their hands up in celebration.
And rightly so. America’s health agencies are finally acknowledging that women are not simply “little men,” and that research and clinical care must account for a woman’s unique biology and hormonal fluctuations across every stage of life.
But amid the cheering, some important nuance is being overlooked. The FDA’s decision to remove the black-box warning from HRT is just one example of how recommendations offered without adequate context or distinction may do more harm than good.
The idea that estrogen supplementation is a cure-all for the symptoms women commonly experience during perimenopause and menopause — hot flashes, disrupted sleep, fatigue, muscle aches, inflammation, weight gain, bloating, and mood swings — is a myth.
Often, women are not suffering from a lack of estrogen, but from what Kitty Martone, a holistic health educator who works with women to navigate perimenopause and menopause, refers to as estrogen dominance — a state in which estrogen outweighs progesterone, producing symptoms that look identical to low estrogen.
Estrogen does not act in isolation, but the details are rarely explained to women. To be tolerated well, estrogen must be balanced by adequate progesterone and supported by a healthy metabolic rate. For many women, progesterone is the first hormone to decline — often years before estrogen meaningfully drops — due to chronic stress, under-eating, thyroid suppression, and blood sugar instability.
This creates a common paradox: estrogen may appear “normal,” or even low, on a lab test, yet functionally feel excessive in the body because there is not enough progesterone to counterbalance its effects. Women are then told they are estrogen-deficient and prescribed more estrogen, while symptoms such as anxiety, insomnia, migraines, heavy or irregular bleeding, bloating, and inflammation intensify rather than improve.
In these cases, simply prescribing more estrogen does not resolve symptoms. In fact, it can make them worse.
These mechanisms were not understood properly during the Women’s Health Initiative study, which was abruptly halted in the early 2000s upon a suggested correlation between HRT and breast cancer as well as heart disease. In an effort to recover from the fallout of the highly flawed study, which caused millions of women to abandon hormone therapy altogether, the pendulum has swung in the opposite direction.
Cue the pharmaceutical ads: dancing women in sunflower meadows, singing about how wonderful life is with the latest HRT option. The fine print instructs women to “ask your doctor if it’s right for you,” but many doctors may not be properly equipped to offer nuanced guidance.
Over the past few decades, medical visits have been reduced to 15–20 minute symptom reviews that are translated into billing codes entered into a computer. While this system serves insurance and data collection, it fails to treat women as whole individuals. It leaves little room to explore how diet, stress, thyroid function, gut health, or metabolic status influence hormonal symptoms — particularly in perimenopausal women.
Martone argues that this system has created an environment where estrogen is prescribed casually, without sufficient context. “Doctors now essentially have carte blanche to prescribe estrogen for any hormone complaint — without evaluating detox pathways, metabolism, liver function, or estrogen clearance.”
Some clinicians have been cautioning against this oversimplification for decades. Dr. Ray Peat, who studied hormones, metabolism, and stress physiology extensively, wrote about how estrogen tends to accumulate under conditions of chronic stress and low thyroid function, while progesterone plays a stabilizing, protective role for both the nervous system and bodily tissues.
In plain terms, how a woman feels on hormones can have less to do with hormone levels and more to do with improper functioning of the liver, metabolism, and stress load at the time therapy is introduced. Two women can take the same prescription and have completely different outcomes — not because one is “doing it wrong,” but because their internal terrain is different.
This helps explain why so many women feel dismissed when HRT is presented as a simple solution. When symptoms worsen, they are often told to increase the dose or switch brands, rather than step back and ask whether the body is prepared to handle additional estrogen.
Martone emphasizes that women often need to experiment with hormones to discover individualized therapies that are right for them. Even low doses may require careful adjustment, alternative delivery methods, and significant trial and error — an experience that can be costly, frustrating, and far from straightforward.
Meanwhile, big pharmaceutical companies are circling middle-aged women like sharks around blood. With the FDA’s decision, they’ve gained an expanded customer base — one encouraged to start hormone therapy earlier and remain on it for decades.
The truth is no one — not even a doctor — can predict exactly how a woman will respond to HRT. Hormones are powerful biological signals, not cosmetic fixes. Their effects depend heavily on the body’s metabolic health, stress physiology, and ability to process and clear them.
The renewed interest in hormone therapy reflects a real and valid desire for relief for women. But before removing warning labels and declaring HRT a universal solution, it’s worth asking why those cautions existed in the first place.
Hormone replacement therapy is not a magic bullet. Women deserve care that honors complexity, not just convenience.
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Jennifer Galardi is a Senior Policy Analyst for Restoring American Wellness in Heritage’s DeVos Center.
The views expressed in this piece are those of the author and do not necessarily represent those of The Daily Wire.
