By Dr. Jesica Mills, PharmD, MBA, ND | October 2025 | Morris & Dickson Clinical Corner

Overview

Menopause marks a major endocrine transition in women’s lives, often accompanied by fluctuating hormones, evolving health risks, and shifting medication needs. Pharmacists are uniquely positioned to guide women through these stages with individualized counseling, supplement and screening recommendations, and medication therapy management (MTM) reviews.

The use of estrogen and progesterone hormones to manage menopausal symptoms has also shifted over time. While the term “hormone replacement therapy” or “HRT” has long been a mainstay in menopausal treatment, this term has fallen out of favor in the past twenty years. It’s more commonly known today as “menopausal hormone therapy” or just “hormone therapy” (HT). This reflects a shift toward individualized treatment using the lowest effective dose to manage symptoms and not attempting to replace hormone levels to those of younger women following the Women’s Health Initiative of 2002. This large long-term health study looked at HT use in post-menopausal women and changed HT prescribing habits. Subsequent research has continued to refine the evidence that was initially presented with overly broad safety concerns. Today, pharmacists can perpetuate the message that benefits can outweigh the risks in younger women seeking symptom relief.

Hormonal Transitions: From Perimenopause to Post-Menopause

• Perimenopause (ages 40–50): Erratic ovarian function causes variable estrogen/progesterone secretion, elevated Follicle-Stimulating Hormone (FSH), hot flashes, mood shifts, and sleep
• Menopause: Defined after 12 months of Estrogen deficiency drives urogenital atrophy, bone loss, and increased metabolic and cardiovascular risk.
• Post-Menopause: Persistently low levels of estradiol (E₂) and progesterone (P₄) with relative androgen excess leads to central adiposity, dyslipidemia, insulin resistance, and cognitive or libido changes.

Screening Recommendations for Women 45 and Older

Pharmacologic and Lifestyle Interventions

HormoneTherapy

• Estrogen-only Therapy (ET): Gold standard for vasomotor and genitourinary symptoms, only prescribed to women who have had a hysterectomy.
• Combined Estrogen-Progestin Therapy (EPT): Progestin is needed for women with an intact uterus to prevent endometrial hyperplasia due to estrogen exposure.
• Preferred Formulations for lower thrombotic and metabolic risk:
  • Transdermal 17-β-estradiol – the predominant, most biologically active form of estrogen
  • Micronized progesterone – identical to the body’s natural progesterone in lieu of synthetic progestins

Non-Hormonal Options (mostly off-label uses)

• SSRIs/SNRIs: Paroxetine or venlafaxine for hot
• Gabapentin: Effective for night sweats and sleep
• Clonidine: Alternative option for vasomotor control.

Lifestyle Optimization

• Diet: Mediterranean pattern, plant phytoestrogens (soy, flaxseed).
• Weight-Bearing Exercise: Walking, stair climbing, and light resistance training to preserve bone density.
• Quit Smoking: Women who smoke are more likely to have more frequent and severe hot flashes.
• Stress Reduction: Mindfulness, consider adding adaptogens (herbs/roots/mushrooms in Eastern medicine, such as ashwagandha or rhodiola).
  • During perimenopause, fluctuating estrogen and progesterone levels disrupt hypothalamic-pituitary-adrenal (HPA) axis regulation, leading to erratic cortisol patterns that heighten stress, fatigue, and sleep issues; adaptogens such as ashwagandha and rhodiola help restore HPA balance by modulating cortisol secretion and improving the body’s resilience to stress.
• Sleep: Magnesium glycinate 200–400 mg at bedtime; avoid caffeine after

Counseling Tip: Women on Levothyroxine (Synthroid®)

Breast Cancer and Cardiovascular Risk with HT

• Breast Cancer: Risk increases after > 5 years of EPT; estrogen therapy alone may not increase risk in women without a uterus (WHI follow-up).
• CVD: Starting HT < 10 years from menopause may lower CHD risk; initiating after 60 raises stroke/VTE risk.
• Formulation Choice: Transdermal estradiol + oral micronized progesterone is cardiometabolically neutral and preferred in hypertensive or overweight

Pharmacist Counseling Tips for Common Hormone Therapies

Pharmacist Counseling Pearls (Summary)

1. Review Medication Interactions — HT, thyroid replacement, and OTCs often interact through absorption and binding changes.
2. Promote Preventive Care — Encourage DEXA, mammogram, and lipid screenings at checkouts and during MTM reviews.
3. Optimize OTC Support:
   • Vitamin D3/K2 2000–5000 IU/day + Calcium Citrate 1000–1200 mg (for bone health)
   • B-complex & Magnesium (for energy and sleep)
   • Omega-3 ≥ 1 g EPA/DHA (for lipid and mood support)
   • Adaptogens and collagen products (for stress and skin integrity)

Revenue Tie-Ins for Community Pharmacies