If you’ve started hormone therapy and noticed bleeding you weren’t expecting, I want you to take a breath before you spiral into worst-case scenarios. This is one of the most common questions I get from patients and from the women who follow me online, and it’s also one of the most anxiety-provoking, mostly because nobody has walked you through why it happens. The good news? It’s likely nothing more than an annoyance. Now remember, this is medical education only. Please be sure to consult with your clinician on your bleeding, as each case is individual.

The fear everyone jumps to first. The moment bleeding shows up, most women assume the worst-case scenario: uterine cancer. In my practice, that is the least likely explanation by far. I understand why the fear is so loud. Bleeding feels like a warning sign, and the medical system tends to respond to it with ultrasounds, biopsies, and sometimes a recommendation to stop hormone therapy altogether. Warnings are all over social media. But there are several far more common reasons for bleeding, and once you understand them, most of the fear dissolves on its own.

If you’re still in perimenopause: Irregular bleeding is a hallmark of this stage, not an exception to it. You might skip a period for six months, then have one at three months, then again three weeks later, then nothing for nine months, then a period heavier than anything you’ve had in years. That unpredictability is perimenopause doing exactly what perimenopause does. My advice to patients here is simple: track your bleeding and spotting. An old-fashioned calendar or a phone app both work. Knowing your own pattern, even a messy one, gives you and your clinician useful information and takes some of the fear out of the unknown. Most uterine cancer is in postmenopausal women, so being in perimenopause makes the worst-case, least likely scenario even less likely.

If you’re postmenopausal and it’s been at least twelve months since your last period:

This changes the calculus, and I’ll walk through what matters most below. But even here, several benign explanations are far more common than cancer. Know this, that bleeding in the first four to six months after starting hormone therapy, or after changing the dose, route, or formulation, is considered so normal that no workup needs to be done. Read below to critically think through what could be happening in your body.

Ovulation can still happen: Menopause means your ovaries have gone quiet, but starting hormone therapy can bring them back to life, even for just a small amount of time. I’ve seen this more times than I can count in over a decade of prescribing. Unless your ovaries have been surgically removed, they are still capable of releasing an egg, even one, two, or three years after your last period. Your body senses that estrogen again and occasionally decides to give it one more ovulatory try. If you noticed breast tenderness, a mood shift, and then bleeding that felt like an actual period, this may be exactly what happened. It’s hard to confirm after the fact, since we can’t go back and check for a developing follicle, but it is common, and it is not a red flag.

Fibroids and polyps respond to hormones too: These are extra tissue surface areas that were built to respond to shifting estrogen and progesterone, and hormone therapy gives them more of what they’re designed to respond to. Polyps in particular are extremely vascular, meaning they have a lot of blood vessels supplying and sometimes sustaining their growth. When those vessels open back up under estrogen, bleeding is a fairly predictable result. It doesn’t mean something is wrong with your uterus. It means the tissue is doing what vascular tissue is supposed to do. Bring fresh blood supply to the area.

Bleeding after intercourse has its own explanations: A cervical polyp can get bumped during sex and bleed brightly. Or you may be dealing with vaginal or uterine atrophy, where the tissue is thinner and more fragile, and small microtears can occur. Atrophy isn’t a comfortable word, but it is the single most common reason women bleed after menopause, and it is entirely benign.

Sometimes it’s just hormonal bleeding. This is the least dramatic explanation and also one of the most common one I see in my own patients. Your uterus is simply being a good student, responding to hormones we are giving your body (assuming you are on FDA-approved hormone therapy) the way it always did before menopause. There is nothing wrong with you and nothing wrong with your uterus when this happens. Is it annoying? Yes. Is it anxiety-provoking if it keeps happening month after month? Absolutely. But it is not dangerous, and it is very often the first thing I address when a patient calls me about bleeding, because it is usually solvable with a fairly small adjustment.

What you can actually do about it. If the bleeding is benign, you do not need to stop your hormone therapy. You have real options, and this is where individualized care matters and where I spend most of my time with patients. Sometimes lowering your estrogen dose helps, though it can occasionally bring back the very symptoms you started hormone therapy to treat in the first place, so this is a trade-off worth talking through with your clinician rather than doing on your own. Increasing progesterone is another option. Progesterone acts as the conductor of the uterine lining, keeping it steady rather than letting it build up and shed unpredictably. If oral micronized progesterone causes too much drowsiness at a higher dose, then a synthetic progestin such as norethindrone acetate or medroxyprogesterone acetate often controls bleeding more effectively, which is another strategy to combat the bleeding.

A progestin-releasing IUD is another route I use often in my own practice. Brands like the Mirena slowly release a progestin directly to the uterine lining, thinning it over time so there is less tissue available to build up and shed. Used for five years, it can also lower uterine cancer risk while it’s doing that work. And for women who can take oral estrogen, a combination medication called Duavee, which pairs conjugated equine estrogen with bazedoxifene, has a genuinely strong track record for controlling bleeding. I’ve used it plenty of times when nothing else fit a patient’s needs.

The point I want you to leave with is this: bleeding on hormone therapy is common, and in my experience it is very likely to be normal. The first move is rarely to stop your hormone therapy. It’s to adjust it. If your bleeding is hormonal, which it often is, that usually means increasing your progesterone, decreasing your estrogen, or moving to something like Duavee or a progestin IUD. There are a lot of levers to pull before anyone should be talking about stopping the treatment that is actually helping you feel like yourself again.

When cancer risk actually matters. Statistically, uterine cancer from postmenopausal bleeding is most associated with women in their sixties who are not on hormone therapy and who carry the following risk factors: diabetes, hypertension, high cholesterol, untreated PMOS (formerly known as PCOS), a family history of uterine cancer, smoking, tamoxifen use, or obesity. Higher if any of those diagnoses are combined. A history of any of these might prompt an earlier workup.

Women taking hormone therapy with adequate progesterone alongside their estrogen actually carry a lower risk of uterine cancer overall, because progesterone protects the uterine lining. If none of those risk factors apply to you, keep that context in mind the next time bleeding sends you into a panic.

I do want to flag the newer ACOG guidelines, which now recommend both an ultrasound and a biopsy for postmenopausal bleeding instead of the ultrasound first, and then proceeding with a biopsy if the uterine lining is> 5 mm. This has been debated among experts.

In my practice, this conversation comes up constantly, and it is almost always more manageable than the fear around it suggests. You don’t have to choose between treating your symptoms and feeling safe in your body. Most of the time, you can have both; you just need the right adjustment and a long-term game plan.

Looking for more?

If you’re looking for this level of care from a knowledgeable clinician, my private telemedicine practice, The Collaborative, is where my team and I see patients. Members don’t just get unlimited visits with their clinician. They get access to an incredible community that I host, along with a copy of my menopause masterclass, plus our wellness partners who teach on various topics such as nutrition, sexual health, mental health, fitness, and more. Check us out at jointhecollaborative.com.

And if you’re a clinician who wants to become more confident in menopause medicine, prescribing hormone therapy, and caring for women in midlife, explore the educational programs available through the Academy for Advanced Women’s Health Medicine.

The conversation is growing. My goal is to ensure that both women and clinicians have the information they need to participate fully.

Stay Proactive

Dr. Heather Hirsch

Every day, women ask me questions that should have been answered years ago. Is this perimenopause? Are my symptoms really related to hormones? Is hormone therapy safe for me? Is it too late to start? Why does my doctor keep ordering hormone tests when I still do not have an explanation for what is happening?

The questions vary, but underneath them is usually the same concern: Something has changed in my body, and I do not feel like anyone is helping me understand it.

That is why I created this Substack.

I’m Heather Hirsch, MD, MS, MSCP. I am a board-certified internal medicine physician and a Menopause Society Certified Practitioner, and I have spent more than a decade focused on women’s midlife health. I completed advanced fellowship training in women’s health at the Cleveland Clinic, founded the Menopause and Midlife Clinic at Brigham and Women’s Hospital, and served on the faculty at Harvard Medical School. Today, I am the founder and CEO of The Collaborative, my telemedicine practice for women navigating perimenopause and menopause, and the founder of The Academy for Advanced Women’s Health Medicine, where I train clinicians to provide better, more thoughtful, thorough care to women in midlife.

I have also had opportunities that a younger version of me would have had a hard time imagining. I have stood on stage with Oprah Winfrey to talk about menopause, sat down with Drew Barrymore, and appeared regularly on the Today show and Live with Kelly and Mark. My work has been featured in The New York Times, The Washington Post, NPR, Oprah Daily, and other national outlets. I have written two books, Unlock Your Menopause Type and The Perimenopause Survival Guide, because I wanted women to have the information they need before they are sitting in an exam room trying to explain a complicated story in a 15-minute appointment.

I am incredibly grateful for the reach those platforms have given me. But television segments are short. Social media is even shorter. A 60-second video can tell you that progesterone may affect sleep or that a normal hormone test does not rule out perimenopause, but it cannot fully explain why. It cannot walk through the evidence, the clinical nuance, or the questions I would want you to ask before making a decision about your health.

This Substack is where I can do that.

I will write about the questions I hear every day from patients, clinicians, readers, and women who stop me after a talk. Here I will write about the difference between perimenopause and menopause, because that seemingly small distinction changes how I interpret symptoms and think about treatment. We will talk about hormone therapy, including timing, dosing, formulations, side effects, benefits, risks, and why it is rarely as simple as “hormones are good” or “hormones are dangerous.”

We will also talk about everything that gets left out when menopause is reduced to hot flashes. Brain fog. Sleep. Anxiety. Weight and metabolic changes. Joint pain. Sexual health. Vaginal estrogen. Cardiovascular risk. Bone health. The strange feeling that you are working just as hard as you always have, but your body is no longer responding in the same way.

I also want to examine what women are actually experiencing, not just what medical textbooks say they should be experiencing. In a recent survey I conducted with nearly 800 women, brain fog was reported more often than hot flashes. Eight out of ten estrogen users told us they had adjusted their own hormone therapy without explicit guidance from their prescriber. Those findings should get the attention of every clinician caring for women in midlife. Women are not waiting for the healthcare system to catch up. They are trying to figure this out themselves, often because the care they need is still too difficult to find.

I want to be direct about what you can expect from me here. I am not going to tell you that every symptom is caused by hormones. I certainly will not dismiss hormones simply because the research has not caught up with what women are reporting. I will tell you what the evidence shows, what it does not show, and where more clinical judgment is required. I will explain how I think through these questions after years of caring for real women whose bodies, medical histories, priorities, and tolerance for risk do not fit neatly into a single protocol.

Sometimes the answer will be clear. Sometimes the honest answer will be that we do not know yet. Uncertainty is allowed in medicine, but dismissal should not be.

My goal is not to tell you exactly what to do. My goal is to help you understand your body, recognize your options, and walk into your next appointment prepared to have a more informed and direct conversation. I want you to finish a post thinking, “Finally, this makes sense,” and knowing what question you want to ask next.

So now I want to hear from you. What do you want me to write about? What symptoms, treatments, studies, or health headlines are you trying to understand? What have you been told about perimenopause or menopause that does not quite make sense? Leave a comment and tell me what is on your mind. Your questions will help shape what I write about here.

Stay proactive,

Dr. Heather Hirsch

Every day, someone asks me whether they should start progesterone or estrogen, or how they should even begin treating a symptom that’s been dragging on for months. And I can’t actually answer that question until I know one thing first: What stage of the menopause transition are you in? It’s the single most important thing I teach the clinicians who trai…

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Polycystic Ovarian Syndrome was recently renamed, and I personally think the new name is perfect. The new termnology is PMOS, which stands for Polyendocrine Metabolic Ovarian Syndrome, and to me this is one of the most important shifts in women’s health this year.

I want to be clear about why this matters, because on the surface a name change can look li…

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Every young doctor learns some version of the same guiding principle: do no harm. It sounds simple, noble, unquestionably correct, and for most of my training I never thought to question it. But after more than a decade of caring for women in midlife, I have come to believe that our interpretation of “do no harm” has be…

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Vaginal estrogen is one of the most requested topics I get, and for good reason. During periods of low estrogen, whether that’s postpartum, perimenopause, or postmenopause, women can develop genitourinary syndrome of menopause, or GSM. What’s actually happening is that the tissue of the vagina, vulva, labia, vestibule, and clitoris shifts from an acidic…

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In this episode, I explain why I do not recommend hormone cycling after menopause, including the higher doses of progesterone often needed just to create an artificial bleed.

And if you’re looking for personalized, proactive care in midlife, you can work directly with me and my team at The Collaborative. Learn more at jointhecollaborative.com.

I ran a survey this spring called Menopause in 2026, and asked almost 800 women what they were feeling in their bodies right now. The answers did not match what menopause medicine spends most of its time talking about, and I think you should see the numbers yourself.

The Top Symptoms That Show Up Every Day

Brain fog topped the list at almost 72 percent. I…

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Some back story…

Back in January, when I was in Los Angeles, I was filming a podcast episode with actress and producer Jeannie Mai the day after the premiere of the Balance docuseries (available on apple TV and Prime Video). My friend and brilliant colleague, Dr. Sharon Malone, was there too. Jeannie asked each one of us to name the first word that came …

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The Hormone and GLP-1 Combo Nobody Warned You About (In a Good Way)

If you’re a woman somewhere in the perimenopause to menopause window, chances are you’ve had this exact conversation with yourself: “Should I start hormone therapy? Should I ask about Zepbound? Can I even do both at the same time?”

You are not alone. This is one of the most common questio…

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I spent last week in London speaking at the inaugural Longevity Show, held at Tobacco Dock, and I boarded my flight home thinking about something I wasn’t expecting to think about at all.

It wasn’t a new supplement. It wasn’t a breakthrough technology. It wasn’t an exciting clinical trial or a fascinating wearable device. Those things were certainly ther…

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A Finding That Should Stop Every Menopause Clinician in Their Tracks

In a research survey I conducted this spring with 766 women participating (that you, by the way!), eight out of ten estrogen users reported adjusting their own hormone therapy without explicit prescriber guidance. Not a fringe behavior. Not a rare workaround. The modal experience of men…

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It’s Not a Quick Fix. It’s a Journey.

Every week my inbox fills with some version of the same confession. Am I the only one still struggling? Am I the only one who started hormone therapy and didn’t feel like a new woman in six weeks? Am I the only one whose plan keeps changing?

The answer, every single time, is no. After more than a decade treating wome…

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The science, the hope, and what every woman in menopause deserves to know.

Every few months, a headline makes the rounds on social media claiming that estrogen prevents Alzheimer’s disease. Within hours, my inbox fills with questions from patients, clinicians, and women trying to make sense of what they are reading online. Some want to know whether they …

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When I boarded a plane to Berlin to speak at a global longevity conference, I expected to encounter the usual mix of differences in healthcare systems, cultural attitudes toward menopause, and perhaps a few novel approaches I hadn’t come across before. What I didn’t expect was how deeply familiar the challenges would feel.

After delivering my Grand Round…

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In the free article, I shared the headline finding from our survey: among women using hormone therapy, a surprisingly large proportion are also using vaginal estrogen. But the deeper story is not simply that women are using two forms of estrogen. The deeper story is that many women appear to arrive at vaginal estrogen late, after persistent symptoms, incomplete counseling, unclear dosing instructions, cost barriers, and months or years of trying to solve genitourinary symptoms on their own.

Our survey, Menopause in 2026: Your Voice Can Advance Science, included 766 consenting respondents. Among hormone-therapy-experienced respondents, 86.1% reported systemic estrogen exposure and 61.5% reported vaginal estrogen exposure. Because the survey allowed multi-select answers but did not provide respondent-level cross-tabulation for this specific question, the exact overlap cannot be directly calculated. Epidemiologically, we can bound it. At minimum, 47.6% of HT-experienced women used both systemic and vaginal estrogen. At maximum, 61.5% did. The most plausible estimate is around 55%.

That means roughly one in two women in this hormone therapy cohort is using both routes of estrogen, and that number deserves more attention than it usually gets.

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The Menopause Revolution Is Missing Something Important

Menopause Is Not a Gynecologic Issue

There has been a lot of discussion lately about a menopause revolution, particularly following Melinda French Gates’ significant investment in women’s health. For someone who has spent nearly a decade building a career around menopause education and care, I find t…

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Women are figuring this out for themselves.

That’s the clearest takeaway from our new survey data - 766 women sharing what’s actually happening in their hormone therapy experience in 2026. And when it comes to vaginal estrogen specifically, the picture that emerges is one of under-prescribed, under-dosed, and under-taught medicine meeting a patient popul…

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Website → https://heatherhirschmd.com/

🩷The Collaborative:
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Website → https://jointhecollaborative.com/

🩷The Academy:
Instagram → https://www.instagram.com/heather.hirsch.academy/
Website → https://heather-hirsch-academy.kit.com/a0354f0b4a

🩷Disclaimer:
This video is not sponsored. Some product links are affiliate links, which means I may earn a small commission at no extra cost to you. This video was not created for children under the age of 13.

A deeper scientific analysis of what our survey revealed about levels, satisfaction, dosing, and the clinical gaps women are still navigating

In the free article I published, I focused on one central idea: many women may be told testosterone “doesn’t work” before they have ever reached a level that could reasonably be expected to help.

But the deeper I sit with this dataset, the more I realize that the story is bigger than undertreatment alone.

This is not simply a story about low testosterone. It is a story about a hormone therapy being used in real-world clinical practice without enough standardization, without enough patient access to laboratory data, without a female-specific FDA-approved product in the United States, and without enough clarity around what “response” actually means.

As a clinician, I find the data clinically useful. As a researcher, I find it hypothesis-generating. And as someone who listens to women every single day, I find it validating.

Because women are not just asking, “Can I take testosterone?”

They are asking a much more sophisticated question.

They are asking, “How do I know if this treatment is actually being optimized for me?”

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