Hormone therapy for menopause symptoms
Transdermal estradiol and micronized progesterone for menopause symptoms: hot flashes, night sweats and sleep disruption. You answer an online intake, a licensed clinician reviews it and a pharmacy ships your medication. All FDA-approved generics.
If you have a uterus, you take progesterone with the estradiol. Estrogen alone makes the uterine lining grow and raises endometrial cancer risk. Progesterone protects the lining. That is why we prescribe them together.
In November 2025 the FDA removed estradiol's boxed warnings on cardiovascular disease and dementia. The endometrial cancer warning on estrogen-alone products stayed.
What you get
For systemic therapy we prescribe transdermal estradiol only. Through the skin, estradiol skips first-pass liver metabolism, which lowers the clot and stroke risk that oral estrogen carries. We do not sell oral systemic estrogen, and we do not sell compounded or pelleted hormones. The Menopause Society, ACOG and the Endocrine Society advise against unregulated compounded preparations when an FDA-approved product exists.
- Estradiol transdermal patchtwice weekly
- 0.025, 0.0375, 0.05, 0.075, 0.1 mg/day. Most people settle at 0.05 mg/day. We start low and adjust to your symptoms, not to a blood level.
- Estradiol transdermal gelonce daily
- Divigel and EstroGel, dosed to roughly match the patch steps. Gel is the default if patch adhesive irritates your skin.
- Oral micronized progesteronePrometrium and generics
- 100 mg nightly continuous, or 200 mg nightly for 12 days a month if you are perimenopausal or under a year from your final period. If you have a uterus and take systemic estradiol, you take this. It protects the uterine lining and it is not optional, even when you feel fine. It makes most people sleepy, so you take it at bedtime.
- Low-dose vaginal estradioltablet or cream
- For genitourinary symptoms alone: vaginal dryness, painful sex, urinary urgency. Minimal systemic absorption. You do not need progesterone with vaginal estrogen by itself.
Note on peanut allergy: standard micronized progesterone capsules contain peanut oil. If you are allergic, tell us and we use a peanut-free route.
What the evidence says
- [1]
The WHI and 20 years of rereading it. The Women's Health Initiative (JAMA 2002; 2004) drove the original boxed warnings. The absolute numbers were small: on combined oral estrogen-progestin, about 8 more breast cancers, 8 more strokes and 6 fewer colorectal cancers per 10,000 women per year. The trial used oral conjugated estrogens in women averaging 63 years old, not transdermal estradiol started near menopause. The timing hypothesis, supported by ELITE and KEEPS, shows a favorable benefit-risk profile for symptomatic women under 60 or within ten years of menopause onset.
- [2]
The Menopause Society 2022 Hormone Therapy Position Statement (Menopause 2022;29(7):767-794) and its 2025 update endorse individualized therapy, name transdermal estradiol as the lower-VTE route and set no mandatory stop age.
- [3]
The November 10, 2025 FDA label change. The FDA removed boxed-warning language on cardiovascular disease, breast cancer and probable dementia across products, and removed the boxed warning entirely from low-dose vaginal estrogen. It did not remove the endometrial cancer warning from systemic estrogen-alone products. The change is partial.
- [4]
Transdermal route and clot risk. Observational evidence shows lower VTE and stroke risk with transdermal versus oral estrogen, which is why our systemic formulary is transdermal only.
Who qualifies
- Age 40 to 59 at intake, within ten years of your final period, or perimenopausal at 45 or older with irregular cycles and symptoms.
- Moderate to severe hot flashes or night sweats, or genitourinary symptoms for the vaginal arm.
- Up to date on breast cancer screening for your age, or able to attest to a scheduled mammogram within 90 days.
- None of the conditions listed in the risks section below.
Benefit outweighs risk most clearly when you start before 60 and within ten years of menopause onset. A later or older start can still be the right call, but it needs a video visit first. It is never approved through the online flow alone.
Known risks and who should not use this
Known risks of systemic estrogen: blood clots, stroke and, with estrogen alone in a woman with a uterus, endometrial cancer. The transdermal route carries a lower clot and stroke risk than oral estrogen. Expect light spotting in the first six months of continuous therapy. Progesterone causes drowsiness, which is why you take it at night.
The conditions below end the intake. We will not prescribe systemic hormones online if any apply, and the intake tells you where to go instead.
- A history of breast cancer, including DCIS, or any estrogen-sensitive cancer. Hormone therapy after breast cancer is managed with your oncology team.
- A blood clot in a leg or lung (DVT or PE), or a known clotting disorder such as factor V Leiden or antiphospholipid syndrome. Systemic estrogen raises clot risk.
- A heart attack, stroke, TIA or coronary artery disease or angina. See your primary care clinician or cardiology.
- Unexplained vaginal bleeding in the past 12 months, or any bleeding after a year with no period. This needs evaluation first, usually an ultrasound or biopsy.
- Active liver disease.
- Pregnancy or breastfeeding.
- Under 40 or 70 and over. Under 40 needs a primary ovarian insufficiency workup. Over 70 needs in-person menopause care.
The vaginal estradiol arm stays open for some of these (clot history, prior cardiovascular events) because it acts locally with little absorption. A breast cancer history blocks even the vaginal arm at intake; that decision belongs to your oncology team.
Several things flag for clinician review rather than end the intake: migraine with aura, current smoking, BMI 35 or higher, blood pressure at or above 140/90, diabetes or two-plus cardiovascular risk factors, a strong family history. None of these is an automatic no. Each one means a clinician thinks before prescribing.
How it works here
You answer an intake. Questions about your symptoms, your menstrual and gynecologic history and your cancer and clotting history. About ten minutes. A clinician needs these answers to prescribe safely.
A licensed clinician reviews it. A clinician licensed in your state reviews your intake. If you qualify, they write the prescription. If something needs a closer look, such as your blood pressure or your timing relative to menopause, they message you or move you to a video visit. A start at 60 or older, or more than ten years past menopause, always requires a video visit first.
The pharmacy ships. Your patch or gel and your progesterone ship to your door. The first fill is a three-month supply. After a three-month reassessment, refills run up to twelve months in three-month increments.
You usually need no bloodwork. In women 45 and older with classic symptoms, the menopause transition is diagnosed on history, because no single hormone level can rule menopause in or out. We order labs only for ages 40 to 44, ambiguous histories or a flagged triglyceride or liver question.
Price
Two flat charges: the visit and the medication. No membership.
| Clinical visit and prescription (per intake / at annual renewal) | $49 / $39 |
|---|---|
| Estradiol patch (three-month supply) | $45 |
| Estradiol gel (three-month supply) | $55 |
| Micronized progesterone (three-month supply) | $35 |
| Vaginal estradiol (three-month supply) | $49 |
These are generic FDA-approved medications. If your insurance covers the drug, your pharmacy copay may be lower than our cash price, and we will tell you that.
FAQ
Does the 2025 label change mean estrogen is risk-free now?
No. Removing a warning is a reread of existing data, not new proof of safety. The Menopause Society reaffirmed that real risk remains for older women and those starting many years after menopause. Estrogen alone in a woman with a uterus still raises endometrial cancer risk. That warning stayed in the box.
Why do I have to take progesterone if I have a uterus?
Estrogen tells the uterine lining to grow. Unopposed, it can overgrow into hyperplasia and, over time, cancer. Progesterone opposes that growth. If you have a uterus, you take both. If you have had a hysterectomy, you take estrogen alone.
Why transdermal and not a pill?
A patch or gel goes through your skin and skips the first pass through the liver. That route carries a lower clot and stroke risk than swallowed estrogen. It is the preferred route with obesity, high triglycerides or migraine, so we made it the only systemic route we offer.
Do I need bloodwork to start?
Usually no. In women 45 and older with typical symptoms, menopause is diagnosed on history. We order labs only for ages 40 to 44, ambiguous cases or a flagged triglyceride or liver question.
Will this work for vaginal dryness if hot flashes are not my problem?
Yes. Genitourinary symptoms route to low-dose vaginal estradiol, which acts locally. It does not require progesterone alongside it.
Can I start HRT if I am over 60 or more than ten years past menopause?
Sometimes, but never through the standard online flow. A late or older start has a less favorable benefit-risk profile, so it requires a video visit and a documented shared decision before any prescription.
Is migraine with aura a hard stop?
No. Unlike combined hormonal contraception, transdermal estradiol at replacement doses is considered acceptable with migraine with aura. We prefer steady-state transdermal delivery and ask you to report any new neurologic symptoms. It routes to clinician review, not a block.
Will HRT prevent pregnancy?
No. If you are still having any periods, use non-hormonal contraception or talk to us.
What about compounded "bioidentical" hormones?
We do not prescribe them. Compounded hormones have inconsistent potency and lack endometrial-protection data. The major societies advise against them when an FDA-approved equivalent exists. We use the regulated products.
What happens if I get unexpected bleeding once I am on therapy?
Light spotting in the first six months on continuous therapy is expected. Bleeding that persists past six months, or that starts after a settled no-bleeding pattern, gets referred for an endometrial workup. We hold your dose steady until it clears.
The rest of the catalog
The same rules apply to every medication we carry: a structured intake, a licensed clinician on every review, flat prices and FDA-approved generics only.
From the catalog · Hormones & menopause
Start your intake
Answer the intake and a licensed clinician reviews it, usually within one business day.
Clinical content reviewed by [Reviewer name], MD. Last clinically reviewed 2026-06-10.