Felice Gersh, MD

Hormone Therapy Dosing in Menopause: Why the “Lowest Dose” Approach Is Wrong | Felice Gersh, MD

Dr. Felice Gersh argues that the prevailing "lowest dose" mantra for menopausal hormone therapy is outdated and potentially harmful, especially when the goal extends beyond merely quelling hot flashes. She traces the origin of this approach to the fallout from the Women’s Health Initiative, which prompted a blanket retreat from estrogen use and cemented the idea that minimal dosing minimizes risk. Gersh emphasizes that dose matters for systemic outcomes: bone density, cardiovascular health, brain function, and muscle maintenance all respond to estradiol levels comparable to those of a young, fertile woman. She highlights the variability of transdermal patch absorption—studies showed a scatter of blood concentrations from the same patch dose—making serum monitoring essential. The highest‑dose 0.1 mg patch was the only formulation consistently achieving ~100 pg/mL, the threshold linked to optimal bone growth. She critiques the symptom‑only model, noting that a “whiff” of estrogen may eventually suppress night sweats but fails to address the broader metabolic shift of menopause. By referencing her early work on estrogen patches and the need for cyclic progesterone to mirror natural luteal phases, she illustrates how a more physiologic regimen can better support stem‑cell health and tissue regeneration. The takeaway for clinicians is clear: prescribe hormone therapy based on target serum levels, not arbitrary low doses, and consider cyclic regimens that reflect natural hormone rhythms. This individualized strategy promises healthier longevity for women navigating midlife transitions, shifting the conversation from symptom palliation to systemic optimization.