Sexual Health Pt II: The Change & HRT
- Daniel Fosselman
- Sep 9
- 4 min read
Updated: Sep 24
Midlife Hormonal Shifts: A Common Crossroad
Around midlife, hormone levels begin to decline—gradually in men, more abruptly in women. This shift often leads people to seek hormone replacement therapy (HRT) in search of symptom relief, vitality, and long-term health. Over the past two decades, there's been a marked increase in interest, spurred in part by pharmaceutical marketing and the emergence of specialized hormone clinics.
Men have historically been more targeted for testosterone replacement, while women are now experiencing a renewed wave of attention toward estrogen and progesterone therapy. This increase in awareness is largely due to a reevaluation of data from the Women's Health Initiative (WHI), originally published in 2004, which had placed a black box warning on estrogen due to cancer risk. New analyses suggest that the risk may have been overstated, and that warning may soon be lifted.
Similarly, testosterone therapy for men was once thought to increase cardiovascular risk. Recent clinical trials have largely debunked this concern, showing no significant increase in long-term cardiovascular events in appropriately selected patients.
Social Media and the “Feel Good” Revolution
Social media influencers and wellness platforms have helped amplify the perceived benefits of HRT—improved mood, energy, libido, and quality of life—creating a cultural momentum that’s hard to ignore. Patients, especially those struggling with vague or life-altering symptoms, are now more proactive in exploring hormonal options.
However, the narrative is often oversimplified. Hormone therapy isn’t a silver bullet, and the decision to begin treatment should be grounded in individual assessment, not hype.
Male and Female Hormonal Decline: Different Patterns, Similar Frustrations
Men and Andropause
Testosterone production in men starts to decline around age 35–40, at an average rate of 2–3% per year. This phenomenon, sometimes called “andropause,” can lead to:
Low libido and erectile dysfunction
Increased body fat and reduced muscle mass
Fatigue, irritability, and depressive symptoms
These symptoms often overlap with other medical or psychosocial conditions, which makes careful evaluation critical before prescribing testosterone.
Women and Menopause
Women experience a more abrupt hormonal transition. Menopause—the cessation of menstruation for 12 months—typically occurs around age 51 in the U.S., though many women now experience symptoms much earlier.
The perimenopausal period can include:
Hot flashes and night sweats
Sleep disturbances
Mood changes and anxiety
Vaginal dryness and discomfort
An emerging trend is the earlier onset of menopause, sometimes in women as young as their early 40s. Whether this is due to earlier menarche, environmental factors, or other causes remains unclear.
Why Hormones Matter
Sex hormones such as estrogen, progesterone, and testosterone—derived from cholesterol—have wide-ranging effects on nearly every system in the body:
Metabolism and weight regulation
Bone density and fracture risk
Cardiovascular health
Cognitive function and mood
Sexual health and reproductive function
Because of this broad influence, many midlife symptoms are attributed—sometimes correctly, sometimes not—to hormonal changes. This is why marketing often presents HRT as a panacea for everything from fatigue to brain fog to joint pain.
To Treat or Not to Treat?
The question patients often ask is: “Should I start hormone replacement therapy?” And the answer, as with most medical decisions, is: “It depends.”
Benefits
Risks
A small but real increased clotting risk (especially with oral hormone formulations)
Cost, as most insurance plans won’t cover therapy unless there’s a clear clinical diagnosis
Unmet expectations, particularly when HRT is seen as a cure-all for complex life issues like relationship problems or burnout
Evidence Gaps
While there are signs HRT may reduce the risk of certain chronic diseases, such as osteoporosis and possibly dementia, there’s limited data confirming major improvements in lifespan or cardiovascular outcomes—especially when started late in life.
Key Questions Before Starting HRT
What symptoms or conditions am I trying to address? Start with clear, measurable goals.
Can I afford this therapy long-term? Out-of-pocket costs can be substantial, especially with compounded bioidentical hormones.
Am I prepared to monitor and adjust? Ongoing labs and clinical evaluations are essential to maximize benefits and minimize harm.
Am I addressing the root cause of my symptoms? Hormones won’t fix stress, poor sleep, marital issues, or sedentary lifestyles.
My Perspective as a Clinician
I’ve seen both sides: some patients feel revitalized by hormone replacement; others see little to no benefit. Unfortunately, this variability is rarely acknowledged online.
Also concerning is the growing overlap between medical care and business incentives—when hormone prescribing is tied to physician profit, objectivity can suffer.
Despite that, I believe HRT is underutilized in many appropriate candidates—especially among women, where estimates suggest only 4% of eligible patients are offered treatment.
Final Thoughts: It’s a Personal Decision
Hormone replacement therapy is neither a miracle cure nor a marketing scam—it’s a therapeutic tool that can be life-changing for the right person when used thoughtfully and monitored closely.
Key principles:
Personalize treatment based on goals, labs, symptoms, and values
Avoid pressure from clinics with a financial incentive to sell you therapy
Work with a trusted provider who can offer objective guidance
Start with clarity: what are you trying to fix, and why?
If you do decide to pursue HRT, make sure it’s part of a broader plan for long-term health—including sleep, movement, nutrition, and emotional well-being. Hormones may help—but they can’t replace the fundamentals.
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