What Your HRT Clinic Is Trying to Add - And Whether You Need It

Educational only. Not medical advice. Some add-on treatments have legitimate clinical indications. Others are marketed without evidence. Evaluate each addition based on your specific clinical picture, not a protocol that includes everything for everyone.

You signed up for HRT. Your hot flashes improved. Then the clinic suggested testosterone “for energy and libido.” Then DHEA “for adrenal health.” Then a thyroid panel that showed levels “slightly suboptimal.” Then a supplement bundle. Each addition came with a clinical-sounding rationale and a monthly charge.

Some of these additions are evidence-based for specific patients. Others lack strong evidence and may not be necessary for your individual situation. The difference is not always obvious, which is why understanding what the evidence supports helps you evaluate whether each addition on your protocol is clinically justified.

• Estrogen and progesterone are the evidence-based foundation of HRT. Everything else is an add-on that requires its own clinical justification
• Testosterone has evidence for one specific indication in women: HSDD (low desire causing distress). It has no evidence for fatigue, energy, cognition, or general wellness in women
• DHEA supplementation in women is supported for one specific use: intravaginal DHEA (Intrarosa/prasterone) for vaginal atrophy. Oral DHEA for general “hormonal balance” lacks evidence
• “Adrenal fatigue” is not a recognized medical diagnosis. Supplements marketed for adrenal support have no evidence for menopausal symptoms
• Thyroid “optimization” beyond treating diagnosed thyroid disease is not evidence-based. A TSH of 2.5 does not need treatment
• Salivary hormone testing is not recommended by NAMS for HRT management. It is often used to justify frequent dose adjustments and refills

For each common add-on: what the evidence supports, what it does not support, and when to be skeptical.

Evidence supports: treatment of HSDD in postmenopausal women already on estrogen therapy, after other causes of low desire have been evaluated and addressed (medications, relationship factors, depression, pain with intercourse). The 2019 Global Consensus Statement endorses this specific indication.

Evidence does NOT support: testosterone for fatigue, low energy, cognitive function, mood, bone density, muscle strength, or general “vitality” in women. These are commonly marketed indications without adequate supporting evidence.

When to be skeptical: when testosterone is offered at the first visit before your primary symptoms are even evaluated. When it is included as a default part of every woman’s HRT protocol. When the clinic monitors with salivary testosterone rather than serum testing. When the dose produces serum testosterone above the female physiologic range.

Fair price: compounded topical testosterone $30 to 100 per month. If your clinic charges significantly more, compare to compounding pharmacy direct pricing.

Evidence supports: intravaginal DHEA (prasterone/Intrarosa) for moderate-to-severe vaginal dryness and pain during intercourse. FDA-approved for this indication. Works locally to restore vaginal tissue.

Evidence does NOT support: oral DHEA supplementation for energy, mood, cognition, weight management, or general hormonal balance in menopausal women. The studies are inconsistent, and NAMS does not recommend oral DHEA as part of standard HRT.

When to be skeptical: when oral DHEA is included in a compounded multi-hormone preparation as a default ingredient. When DHEA is prescribed based on a serum DHEA-S level without a specific clinical indication beyond “it is low for your age.”

Evidence supports: testing thyroid function (TSH) as part of baseline evaluation because hypothyroidism mimics menopausal symptoms. Treating diagnosed hypothyroidism or hyperthyroidism with appropriate medication.

Evidence does NOT support: treating a TSH of 2.0-3.5 as “suboptimal” and prescribing thyroid hormone to “optimize” it. Prescribing combination T3/T4 therapy or compounded thyroid preparations when standard levothyroxine is adequate. Using thyroid supplementation for fatigue or weight management in women with normal thyroid function.

When to be skeptical: when a clinic flags your TSH of 2.5 as “suboptimal” and offers to prescribe desiccated thyroid or a T3/T4 compound. When thyroid treatment is bundled into an HRT package rather than evaluated independently.

Evidence supports: essentially nothing in the menopausal context. Pregnenolone is a steroid hormone precursor. It is marketed as a “mother hormone” that supports all downstream hormone production.

Evidence does NOT support: pregnenolone supplementation for any menopausal indication. There are no quality randomized trials demonstrating benefit for menopausal symptoms.

When to be skeptical: whenever it appears in a compounded HRT formulation.

“Adrenal fatigue” is not a diagnosis recognized by any major endocrine organization. The symptoms attributed to it (fatigue, brain fog, difficulty coping with stress) are real, but they are caused by menopause, sleep deprivation, depression, thyroid disorders, or other identifiable conditions - not by adrenal insufficiency.

True adrenal insufficiency (Addison’s disease) is rare, serious, and diagnosed with specific tests (cortisol, ACTH stimulation). It requires medical treatment, not supplements.

Supplements marketed for “adrenal support” (ashwagandha, rhodiola, adrenal glandular extracts) have no evidence for menopausal symptoms and no role in HRT management.

NAMS explicitly recommends against salivary hormone testing for HRT monitoring. Salivary hormone levels do not reliably correlate with serum levels or clinical response. They fluctuate based on time of day, hydration, food intake, and collection technique.

Clinics that use salivary testing may test frequently, find apparent "imbalances," and adjust doses accordingly. In practice, this approach is based on unreliable measurement and can lead to unnecessary dose changes. NAMS recommends serum testing when hormone levels need to be checked, and clinical response as the primary guide for HRT dosing.

Serum (blood) testing for estradiol is the standard for monitoring HRT when levels need to be checked. Clinical response (symptom control) is the primary measure of HRT adequacy.

A standard HRT regimen (estradiol + progesterone): $20 to 65 per month generic. Adding testosterone: +$30 to 100 per month. Adding DHEA: +$20 to 50 per month. Adding thyroid: +$15 to 50 per month. Adding pregnenolone: +$15 to 30 per month. Adding supplement bundle: +$30 to 100 per month.

A woman on “optimized” multi-hormone therapy with supplements can easily spend $200 to 400 per month when her actual evidence-based HRT need costs $25 to 65. Every add-on should be evaluated individually: does this specific addition address a specific diagnosed condition that has not responded to standard treatment?

• What is the specific clinical indication for each medication or supplement you are recommending?
• Is this add-on evidence-based for my diagnosed condition, or is it part of a standard protocol?
• What would happen if we started with just estrogen and progesterone and added other things only if needed?
• Are you using serum or salivary testing for monitoring, and why?
• How does the cost of this protocol compare to standard FDA-approved HRT?