Midlife Hormones, Medical Training, and an Open Mind — A Direct Primary Care Doctor's Journey

When I went through medical school and residency, midlife women's health felt like an afterthought. We learned that women on estrogen needed progesterone, that hormone replacement was only for menopause, and that it shouldn't exceed three years due to risks of breast cancer and blood clots. Testosterone was for men without working testicles. Women could have it too — but only for low libido, and with no FDA-approved formulation to actually give them. The message was clear: leave this to the specialists.

When you're learning to be a doctor, there's precious little time to question what you're taught. You drink from the firehose pointed at your face and keep moving.

Then, 8 years ago, my wife asked me what I knew about menopause. I said "not much." She said "hell no" — no doctor husband of hers was going to stay ignorant about this. But good information was hard to find. One OB-GYN told a room full of family doctors that bioidentical and synthetic hormones were interchangeable — effectively dismissing a legitimate therapeutic option. Men seeking testosterone were stigmatized as drug seekers. Endocrinologists trained us to deny requests unless strict lab criteria were met over three months, and only if the patient had a "normal" BMI.

Speaking of BMI — I started distrusting it. The body mass index is a ratio developed by a Belgian statistician in the 1830s to understand the average white Belgian man. It was never designed as a health metric, doesn't differentiate fat from muscle, and doesn't apply equally across genders or ethnicities. And yet it was gatekeeping care.

My thinking shifted further through my work with transgender patients. Providing gender-affirming hormone therapy — technically "off-label," since the FDA doesn't recognize this use — required informed consent around real risks like blood clots and infertility. But it also showed me something: when patients are informed and willing, physicians in primary care, gynecology, urology, and endocrinology regularly prescribe hormones outside narrow guidelines. So why were cisgender men and women losing muscle mass, sex drive, and cognitive sharpness without the same options?

The answer, I came to believe, was stigma — not science.

The biggest shift came when I embraced compounding pharmacies. These are legitimate, regulated operations that mix FDA-approved ingredients in non-approved formulations for off-label use. My entry point was GLP-1 medications — semaglutide (Ozempic, Wegovy) and tirzepatide (Zepbound, Mounjaro) — which are first-line treatments for type 2 diabetes and obesity but are almost never covered by insurance for weight loss. Compounding pharmacies made them accessible. They do the same for hormone therapies, and I had patients already using them under outside providers' supervision.

Eventually I attended a lecture on prescribing, dosing, and monitoring testosterone for peri- and post-menopausal women. The principles were no different from anything else I'd been doing for years — listen, test, diagnose, prescribe, monitor. Where had this been in my training?

Here's what the evolving evidence actually shows:

Estradiol is not associated with increased breast cancer risk — that's synthetic progestins. Bioidentical hormone replacement therapy may actually lower breast cancer risk. Transdermal bioidentical estrogen carries no meaningful increased clotting risk, even in patients with prior clots. Women and men both benefit from testosterone — for libido, mood, energy, cognition, muscle mass, and bone density. And a man's prostate is fully saturated at a serum testosterone level of 250 — the common "normal" cutoff — meaning higher levels don't increase prostate cancer risk.

None of this is medical advice. It's an honest account of how the things I was taught had to be unlearned and replaced — years after training ended — because I stayed curious.

I'm grateful for those gaps. They showed me exactly where to go with my practice: not just for my midlife patients, but for everyone navigating this phase of life in a system that still stigmatizes some of our most effective therapeutic options. If your doctor dismisses your questions about bioidentical hormone replacement, perimenopause, or testosterone therapy — find one who won't.

That's what I'm building at Metronome Family Medicine in Longmont, Colorado. Founding member spots are open to patients across Colorado. Call or text 720-856-4058, email DoctorJuan@metronomeMD.com, or book a free 10-minute call at www.metronomemd.com/schedule-consultation.