What 30 Years of Bioidentical Hormone Therapy Has Taught Me About Hormone Optimization

• By Maryann Simpson, NP
• Folsom, California

I’ve been working with bioidentical hormone replacement therapy for more than 30 years. When I began regularly implementing bioidentical hormones at UC Davis, hormone optimization looked different than it does today. There wasn’t nearly as much public awareness, and many of the conversations we’re having about hormones now simply weren’t happening.

After three decades of caring for patients, one lesson stands above almost everything else: hormone therapy should never be about treating a lab result. It should be about treating the person sitting in front of you.

Labs are important. We use comprehensive blood testing at Embody Wellness, and those results give us valuable information. But they’re guideposts. How a patient feels, the symptoms they’re experiencing, their medical history and how they respond to treatment are all important parts of determining whether we’re moving in the right direction.

Hormonal changes can affect many aspects of how we feel and function — including energy, sleep, mood, motivation, sexual health, muscle and bone health, cognition and skin. But hormones are only one part of the picture. Over the years, I’ve come to think about healthy aging around several foundations: sleep, nutrition, hormones, detoxification, exercise, purpose and contribution.

One of the biggest mistakes in hormone management is assuming there is one perfect number that every patient should reach. There isn’t.

Two women can have similar laboratory results and feel completely different. One may be sleeping well, exercising and feeling great. The other may be experiencing fatigue, poor sleep, changes in mood or motivation and feeling nothing like herself.

That’s why I don’t make decisions from laboratory results alone. I use comprehensive blood testing, but I also want to know: How are you sleeping? How is your energy? How is your mood? Are you motivated? Are you maintaining muscle? How is your cognition? And most importantly — do you feel like yourself?

The lab helps guide us. The patient tells us whether the treatment is working.

After 30 years, I’ve learned that hormone replacement should not be a one-size-fits-all protocol.

For many of my female patients, I use individualized compounded bioidentical hormone creams that may include estradiol, estriol and testosterone, depending on the patient’s needs. This is often part of a broader conversation about menopause and perimenopause and overall women’s health.

Progesterone may be incorporated differently depending on the individual. For some women, oral micronized progesterone may be appropriate. Because it can cause drowsiness in some patients, nighttime dosing may fit particularly well for certain women. That can allow a patient to use her hormone cream earlier in the day and take progesterone before bed.

Other patients require a different approach. This ability to adjust the dose and delivery method over time is one reason I generally prefer therapies that give me flexibility rather than relying on a treatment that is difficult to modify once it has been administered.

Your hormone needs today may not be exactly the same a year from now. Your treatment should be able to evolve with you.

The same individualized philosophy applies to men.

At Embody Wellness, we often use small, frequent subcutaneous testosterone injections rather than automatically relying on larger, less-frequent injections. The goal is to provide steadier hormone exposure and avoid unnecessarily large peaks and troughs.

We also pay attention to estradiol and the patient’s symptoms rather than reflexively adding another medication simply because someone is receiving testosterone. When possible, our philosophy is to optimize the testosterone regimen itself and avoid unnecessary medications, including routine use of estrogen-blocking medications.

Again, the treatment should fit the patient — not the other way around.

This is something experience teaches you.

If someone was doing well and then begins experiencing symptoms again, simply increasing the hormone dose isn’t always the right answer. I want to know what changed.

We look at the bigger picture, including nutrition, lifestyle, environmental exposures and the body’s normal processes for metabolizing and eliminating hormones. At Embody Wellness, we may incorporate individualized nutritional and lifestyle strategies designed to support healthy hormone metabolism as part of our broader approach.

The lesson is simple: when a treatment that was working stops working as well, don’t automatically prescribe more. Find out why.

Gut health is another piece of the broader health picture that I don’t like to overlook.

The digestive system and gut microbiome are involved in many processes that influence overall health, including nutrient absorption and the metabolism and elimination of hormones. When clinically appropriate, we may look at digestive health, nutrition and gut function as part of understanding why a patient isn’t feeling or responding the way we would expect.

This doesn’t mean every hormone symptom comes from the gut. It means hormone optimization works best when we remember that the body’s systems are interconnected.

Another lesson I’ve learned is that symptoms overlap. A patient may come in saying: “My hormones must be off again because I’m exhausted.”

Maybe. But fatigue can have many potential contributors.

Thyroid health is one of the areas we may investigate. When clinically appropriate, our thyroid evaluation can go beyond looking only at TSH. We consider a broader laboratory picture along with the patient’s symptoms and history.

That doesn’t mean every tired patient has a thyroid problem. It means we shouldn’t assume every symptom in a hormone patient requires more hormone. Our job is to ask why.

Hormone therapy is often discussed in terms of a few well-known symptoms. But after decades of working with patients, I think the conversation should be much broader.

As hormones change with age, patients may notice changes in sleep, mood, motivation, energy, sexual health and cognition.

Maintaining muscle and bone health also becomes increasingly important as we age. Muscle isn’t just about appearance — maintaining strength and lean mass is an important component of remaining active and independent.

Hormonal changes can also affect the skin. Declining estrogen is associated with changes in collagen, skin thickness and elasticity.

These are all pieces of a larger goal: maintaining function and quality of life as we get older.

If 30 years of hormone therapy has taught me anything, it’s that there is no prescription that replaces the fundamentals of health.

I think about healthy aging around seven areas: sleep, nutrition, hormones, detoxification and healthy metabolism, exercise, purpose, and contribution.

You can have excellent hormone levels and still neglect your sleep. And health isn’t only physical. Having purpose, relationships and a reason to remain engaged with life matters too.

My goal isn’t simply to help patients have better numbers. It’s to help them continue living well.

Bioidentical hormone replacement therapy has changed considerably since I first began working with it more than 30 years ago. But my fundamental approach hasn’t changed very much.

Listen to the patient. Use laboratory testing as an important tool. Individualize the treatment. Make adjustments when necessary. And don’t assume every symptom can be solved by simply prescribing more hormones.

The best hormone program should be part of a much bigger conversation about how someone wants to feel, function and live as they age. That’s what hormone optimization means to me.

Maryann Simpson, NP, has spent more than three decades caring for hormone patients. Her background includes approximately 20 years at UC Davis and extensive experience in women’s health before joining Embody Wellness. She was the first provider at UC Davis to regularly implement bioidentical hormone replacement therapy as part of ongoing patient care.

Her approach combines comprehensive laboratory testing with symptoms, clinical history and individualized treatment, with the goal of helping patients maintain health, function and quality of life as they age.

Embody Wellness provides individualized hormone evaluation and treatment for women and men in Folsom, California, with comprehensive laboratory testing and ongoing monitoring.

Hormone therapy is not appropriate for every patient. Treatment recommendations should be individualized based on medical history, symptoms, laboratory testing and clinical evaluation. This article is for educational purposes and is not a substitute for medical advice.