The sleep that stopped being restorative. The hot flashes that show up in meetings. The fog, the mood, the libido, the body that doesn't quite respond the way it used to. We bring estradiol, progesterone, and — when your labs and symptoms call for it — testosterone back into the range a healthy version of you would live in. Pellet, cream, oral, or vaginal — the route follows your physiology, not a one-size protocol.
You come in tired. Not sleeping the way you used to. Maybe you're 42 and your cycles have started doing odd things, or you're 55 and the night sweats are wearing you down, or you're a few years past menopause and the joint aches and brain fog are louder than anyone warned you they'd be. We draw blood, sit down with the numbers, and build a plan around the three hormones that quietly run the show for women: estradiol, progesterone, and testosterone.
Estradiol is the workhorse — it drives sleep architecture, vasomotor stability (the hot flashes), cognition, bone, cardiovascular tone, vaginal and urinary tissue health, and skin. Across the menopause transition, estradiol falls dramatically — and that decline is what most of the classic symptoms track to. Progesterone protects the uterine lining when estradiol is on board, and on its own tends to help sleep and anxiety. Testosterone — yes, women make it too — falls earlier and matters for libido, energy, mood, mental clarity, and lean mass. When the panel and your symptoms line up, we add it in, often as a low-dose pellet.
EvexiPEL® pellet — the set-it-and-forget-it route. A rice-grain pellet (estradiol, testosterone, or both) is placed under the skin in a five-minute office visit, under local. It dissolves quietly over 3 to 4 months in women, so your levels stay even — no daily peaks and valleys, nothing to remember.
Compounded cream — the dial-it-in route. A daily cream made for your exact dose of estradiol, testosterone, or both. Easy to start, easy to adjust, easy to stop. A good first step if you'd like to feel the change before committing to longer-acting delivery.
Oral micronized progesterone at bedtime — this is the standard when you have a uterus and are taking systemic estradiol. Many women find it helps sleep on its own.
Vaginal estradiol — local cream, tablet, or ring for genitourinary symptoms (dryness, painful intimacy, recurrent UTIs, urinary urgency). Very little systemic absorption. Often used alongside systemic HRT because systemic dosing doesn't always reach the tissue.
About the so-called window of opportunity: the cardiovascular, bone, and cognitive signal for HRT is strongest when therapy is started within roughly ten years of your final period. That doesn't mean later is off the table — it means earlier is generally better, and waiting has a cost.
Compounded preparations are individually formulated and are not FDA-approved finished drug products; brand-name FDA-approved options are offered when clinically appropriate. The agent, the route, and the dose follow your diagnostics — never the other way around.
Who it helps.
You're not chasing a number on a chart — you're chasing how you feel. The labs are how we know we're getting there, and how we keep getting there. Learn about our diagnostics →
Falling asleep, staying asleep, waking without the 3 a.m. roulette. Often the first thing to shift, often within the first few weeks.
The vasomotor symptoms — daytime flashes, nighttime drenching — are what estradiol addresses most directly. For most women, noticeable in weeks, not months.
Word-finding, focus, the sense of being mentally sharper than yesterday. Cognition tracks closely with estradiol — and with the sleep that comes back first.
Desire, arousal, vaginal comfort. Often a combination — systemic estradiol and (when indicated) testosterone for the desire side, vaginal estradiol for the tissue side.
Less of the flat-affect, irritable, unmoored feeling. Progesterone often helps the anxiety component; estradiol helps the depressive lean.
Slower-moving — months, not weeks — but the midsection weight tends to redistribute and lean mass becomes easier to hold when hormones, sleep, and protein intake are all in range.
The arc is the same for most women — sleep first, vasomotor symptoms next, the slower-moving body and mood changes after that. Here is what a real first half-year on HRT looks like at Bespoke.
Comprehensive lab draw, personal and family history, symptom timeline. Your provider sits with the panel and recommends a starting plan and route.
Estradiol begins (pellet, cream, or patch); progesterone at bedtime if indicated. Sleep and mood often start to move within the first month. Your team is one message away.
Repeat hormone panel against baseline. Dose and route adjusted to what your body is actually doing — not the protocol everyone else is on. Testosterone added if the panel calls for it.
Full lab redraw and symptom review against your starting point. Maintenance cadence set — visits land where your numbers and your life need them, not on a contract calendar.
HRT is a longer conversation than most visits — here are the questions that come up first.
You don't have to wait until your periods stop. Perimenopause — the four-to-ten-year stretch leading up to menopause — is often when symptoms are loudest and when therapy is most useful. If sleep, mood, cycles, or hot flashes have shifted, we can run a panel and talk about what fits. The window of opportunity from large trials sits within roughly ten years of your final period; starting earlier in that window is generally where the cardiovascular and bone signal is strongest.
The 2002 WHI headline is one of the most misread results in modern medicine. The studied women averaged 63, were a decade or more past menopause, and were given oral conjugated equine estrogen with synthetic progestin — not the bioidentical estradiol and micronized progesterone we use today. Re-analyses show women who started therapy within ten years of menopause had a different — and largely favorable — risk profile. We review your personal and family history (including breast, clotting, and cardiovascular history) before anything is prescribed, and we re-check on a schedule afterward.
It can be — but the conversation is more individual. Starting fresh in your sixties without prior HRT carries a different risk profile than continuing therapy that began earlier; transdermal routes (cream, pellet) avoid the first-pass liver effects that drive most of the clotting signal seen with oral estrogen. We weigh symptom burden, cardiovascular and breast history, bone status, and what life looks like for you — then decide together.
For endometrial protection, no — progesterone's classic job is protecting the uterine lining from unopposed estrogen, and if there's no uterus there's no lining to protect. That said, many women feel meaningfully better on micronized progesterone anyway; it tends to help sleep and anxiety. We talk through whether it belongs in your plan.
Yes — women make testosterone too, and levels fall through the menopause transition (and earlier than most women realize). When labs and symptoms line up, low-dose testosterone — often pellet, sometimes cream — can help libido, energy, mental clarity, and lean mass. It's not standard for every woman and it's not necessarily a starting point; it's a tool we add when your panel and your symptoms point to it.
Local vaginal estradiol (cream, tablet, or ring) treats genitourinary symptoms — dryness, painful intimacy, recurrent UTIs, urinary urgency — with very little systemic absorption. Many women use it alone; many use it alongside systemic HRT because systemic dosing alone doesn't always reach the tissue. They solve different problems and they're often used together.
The signal in the WHI was small in absolute terms, was driven primarily by the synthetic progestin arm (not estrogen alone, which actually trended lower in some analyses), and looks different with bioidentical micronized progesterone in more recent data. Personal and family history change the calculus — we review yours carefully, and we don't proceed if the risk-benefit doesn't make sense for you.
Bioidentical means the molecule is structurally identical to what your body makes — 17-beta estradiol and micronized progesterone rather than conjugated equine estrogens and synthetic progestins. We use FDA-approved bioidentical preparations where appropriate and compounded preparations when a custom dose or route is clinically warranted.
Most plans combine routes. Systemic estradiol is usually pellet or cream; oral micronized progesterone goes at bedtime if you have a uterus; vaginal estradiol is added when genitourinary symptoms are part of the picture. Pellet is hands-off and steady-state; cream is the easiest to adjust. We walk through trade-offs at the consult.
Sleep and mood often shift in the first two to four weeks. Hot flashes typically calm in weeks two to six. Libido, vaginal comfort, and the slower-moving symptoms — body composition, joint aches, skin and hair — take two to four months, which is also when we re-test and tune. It's a curve, not a switch.
Two things, mostly. First, your dose is built from a comprehensive panel that we draw and read in person — not a symptom quiz. Second, your care team works from one chart in one clinic: the clinician titrating your dose can see the labs, the notes, the pellet placement, and everything else we've done with you. When something feels off, you're not starting over with a stranger on a portal.
We're a cash-pay clinic — labs, the consult, and the medication itself are billed transparently up front, with no surprise fees. Many patients submit lab work to their insurance for reimbursement; we can provide the documentation. Cherry financing and our membership plans are available if you'd like to spread the cost.
No prescription is written before diagnostics. Your first visit is a structured clinical interview and blood draw.
Plus: how we’d use a summer with the schedule on your side. One page, refreshed each month.
Read this month →