Initiating Menopausal Hormone Therapy in Primary Care: Where to Start, With Harvard's Caroline Mitchell, MD, MPH

During The Menopause Society 2025 Annual Meeting, Patient Care© had the chance to speak with Caroline Mitchell, MD, MPH, associate professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School, on a range of women's health issues related to menopause.

Up to 80% of women experience vasomotor and other disturbing symtpoms during menopause. However, despite evidence supporting the safety and efficacy of hormone therapy for appropriate candidates, recent data show it was prescribed in only 3.8% of US ambulatory care visits by midlife and older women from 2018 to 2019.1 Additionally, only 6.8% of graduating residents across family medicine, internal medicine, and OB/GYN programs feel adequately prepared to manage menopause.2 With those statistics in mind and the knowledge that the population of women entering the climacteric will continue to grow with the aging population, we asked Mitchell to describe what initiating hormone therapy would entail in a primary care setting and also to clarify safety considerations about vaginal estrogen prescribing.

The following transcript has been lightly edited for flow.

Patient Care: What would be a practical first-line treatment algorithm for primary care? Should they begin with hormonal treatment, start with non-hormonal treatment, or does it depend on the individual?

Mitchell: I think the lovely thing about the interventions available is that they all work for some people. It really is guided by patient preference—both how they feel about hormones and what form of treatment they prefer. Do they want to use a gel, a tablet, a ring? Something daily, or something just for sex? There’s a range of reasonable options to start with, and the key is matching the approach to the individual’s needs and comfort.

PC: Are there any misconceptions or prescribing errors with vaginal estrogen that you observe in primary care?

Mitchell: I think there are a couple of important points about vaginal estrogen.

First, it is safe for just about everyone, including breast cancer survivors, people with cardiac disease, and probably even those with a history of DVT or pulmonary embolus, because the change in circulating estrogen levels with vaginal estrogen is minimal. It’s almost negligible. So that’s the first thing: it’s safe.

Second, you do not need to use a progestin to protect the endometrium when using low-dose vaginal estrogen. Low-dose includes the Estring, vaginal estrogen tablets, or estrogen creams, typically in the range of about half a gram to one gram twice weekly. All of those are considered low-dose, and they do not require progestin.

References

1. Sobel TH, Lisha NE, Huang AJ. Menopause hormone therapy prescribing in ambulatory care visits among midlife and older U.S. women from 2018 to 2019. Maturitas. 2024;184:107997. doi: 10.1016/j.maturitas.2024.107997
2. Allen JT. Effective menopause education methods: addressing the needs of current medical trainees. Menopause. 2024;31(2):89-90. doi:10.1097/GME.0000000000002308