Beyond One-Size HRT

What If the Reason Your HRT Is Not Working Is Not You, But the Assumption That All Women Absorb Hormones the Same Way?

Is the “One Size Fits All” HRT Model Failing Women, Or Simply Being Poorly Applied?

In 2026, women are more informed than ever about menopause. Prescriptions have risen. Conversations are louder. Awareness is improving. Yet many women still describe feeling dismissed, confused, under-dosed, over-dosed or simply unsure whether their treatment is truly tailored to them.

For many women, HRT has been transformative. It restores sleep, reduces anxiety, protects bone density and improves quality of life. When prescribed appropriately, it remains one of the most effective treatments we have for moderate to severe menopausal symptoms.

The North American Menopause Society states clearly:

“For women aged younger than 60 years or within 10 years of menopause onset and without contraindications, the benefits of hormone therapy outweigh the risks.”

Notice the precision in that statement. Age. Timing. Contraindications. That is not universal medicine. That is stratified medicine.

Yet a growing body of research tells us something important. Menopause care cannot be uniform in practice.

The Women’s Health Initiative 20-year follow-up made it clear that the risks and benefits of hormone therapy vary depending on a woman’s age and the timing of initiation relative to menopause. Starting therapy early in the menopausal transition carries a different cardiovascular and metabolic profile compared to starting it a decade later.

Context matters.

Meanwhile, UK research examining 1,508 women using identical doses of transdermal estradiol found absorption ranged from under 30 pg/mL to over 250 pg/mL. That variation is clinically meaningful. It means two women using the same patch or gel may experience very different biological effects.

This does not mean HRT is inherently flawed. It means women are not biologically identical.

Individual Response Is Not Linear

Even within formal guidance, individualisation is already the stated goal.

NICE advises clinicians to offer hormone replacement therapy after discussing risks and benefits, “taking into account the woman’s individual circumstances.”

The British Menopause Society reinforces this further, stating that:

“Hormone replacement therapy should be individualised according to a woman’s symptoms, medical history and risk factors.”

The science is not calling for one size fits all care. It is calling for merit, nuance and difference.

The challenge often lies in implementation. In busy clinical settings, decision trees can become simplified. Follow-up can be inconsistent. Adjustments may not occur quickly enough.

Estradiol absorption varies due to skin structure, body mass index, liver metabolism, genetics and age. Progesterone type matters. Oral micronised progesterone behaves differently from synthetic progestogens. Oral estrogen carries a different clotting risk compared to transdermal formulations.

Some women may benefit from testosterone support. Others cannot take systemic hormones at all and require non-hormonal options such as selective serotonin re-uptake inhibitors or cognitive behavioural therapy-based approaches.

Menopause care is not a single prescription. It is a layered plan that evolves over time.

Where Equity Enters the Conversation

When we widen the lens to ethnicity and culture, the conversation deepens further.

Research including the SWAN study shows differences in symptom patterns and experiences across Black, Asian, Hispanic and white women.

UK prescribing data indicates that Black women are significantly less likely to receive HRT prescriptions than white women, with Asian women also less likely to be prescribed. These disparities demand thoughtful examination.

Are they driven by cultural hesitancy around hormones? GP confidence levels? Historical mistrust of medical systems? Communication barriers? Under-representation in clinical trials?

It is rarely one factor alone. But it highlights a structural reality. If research populations are narrow, treatment models risk reflecting that narrowness.

Balancing Risk Without Amplifying Fear

The United States Food and Drug Administration advisory panels have reinforced that hormone therapy decisions should be based on an “individual benefit-risk assessment rather than routine or universal prescribing.”

This is a critical point.

For many women under sixty or within ten years of menopause onset, the benefit–risk profile is favourable when properly assessed. The absolute risks are often smaller than public perception suggests.

However, timing, cardiovascular health, personal cancer history, route of administration and co-existing medical conditions all influence that balance.

Precision is not panic. It is responsible medicine.

Reframing the Narrative

There is no “average woman” for whom menopause care was perfectly designed. Clinical trials rely on population data. Guidelines are constructed around statistical models. But you do not live inside a model. You live inside a body shaped by genetics, stress exposure, reproductive history, ethnicity, sleep patterns, metabolic health and lived experience.

Your physiology is dynamic, not fixed.

When medicine defaults to averages, it attempts safety through standardisation. But safety and sameness are not identical. A model built on the “typical” woman will inevitably underserve the woman who is early menopausal, late menopausal, navigating autoimmune disease, managing cardiovascular risk or coming from a community underrepresented in research.

The issue is not that women are complicated. It is that menopause is biologically variable.

Hormones fluctuate. Receptors respond differently. Absorption shifts. Risk profiles evolve. An older model that sought neat categories was always going to struggle with something inherently fluid.

Menopause is not a pathology to be fixed. It is a transition to be supported. That distinction matters psychologically as well as medically. When we treat it solely as disease, women feel broken. When we treat it as transition, women feel guided.

The goal is not a perfect prescription. It is informed, adaptive care.

How to Advocate for Yourself Practically

If you are navigating HRT or considering it, here are grounded steps:

1. Ask for a full health context discussion, including cardiovascular risk, family history and timing since menopause.

2. If symptoms remain unchanged after six to eight weeks, request review. Dose or delivery route may need adjustment.

3. Ask about oral versus transdermal differences. They are not interchangeable in risk profile.

4. If you feel dismissed, request referral to a menopause specialist.

5. If you cannot or choose not to take HRT, discuss evidence-based non-hormonal options rather than being told to simply cope.

6. Keep a symptom log. Data supports better decision-making for you and your clinician.

The Future of Menopause Care Starts Here

The science does not call for fear. It calls for nuance.

Major governing bodies already agree that hormone therapy must be individualised. The North American Menopause Society emphasises timing and age. NICE requires consideration of individual circumstances. The British Menopause Society reinforces personalisation based on symptoms and risk profile. The evidence is not divided on this point.

What varies is how consistently that precision is delivered in real-world care.

The future of menopause care will not be built on louder debates or polarised opinions. It will be built on better conversations between women and clinicians. It will be built on research that reflects diverse populations. It will be built on follow-up, monitoring and adjustment rather than one-off prescribing.

Most importantly, it will be built on women understanding that they are not difficult, not failing and not “average.”

You are navigating a biological transition that is dynamic and deeply individual. The goal is not to endure it quietly. The goal is to move through it with informed, adaptive support.

Personalised care is not a luxury. It is what respectful medicine looks like.

That shift begins with informed questions, shared knowledge and women refusing to accept oversimplified answers.

If this has clarified something for you, stay in the conversation. Share your experiences or questions below. When women speak with information and confidence, systems evolve.

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If you feel comfortable, share your experiences or questions below. Your voice matters more than you realise. Conversations like this do not create panic. They create progress.

Menopause care should be individualised, evidence-led and respectful of women’s diversity. If you agree, like this post so it reaches more women who may still be navigating in silence.

Add your perspective in the comments. Share it with someone who needs reassurance that she is not alone and certainly not “average.”

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Disclaimer

This article is intended for educational and informational purposes only. It does not constitute medical advice, diagnosis or treatment. Hormone replacement therapy decisions should always be made in consultation with a qualified healthcare professional who can assess your individual medical history, risk factors and current health status.

Menopause care is highly individual and what is appropriate for one woman may not be suitable for another. If you are experiencing new, worsening or concerning symptoms, please seek guidance from your general practitioner, menopause specialist or relevant healthcare provider.

The information shared here reflects current research and guideline perspectives at the time of writing but should not replace personalised clinical assessment.