The “Test, Don’t Guess” Trope: What We’re Getting Wrong About Hormone Testing

That blank stare paired with the pregnant pause.

I can see the bubble plainly above my patient’s head… Is she f@#$%^& serious?

I have just recommended starting menopausal hormone therapy without testing her hormones. The horror!!!!

At best this lands as unsettling, at worst … ludicrous. I’ve just said something that goes against everything you’ve been told to believe about high quality mid-life menopause care.

RED FLAG!!!!

To be completely frank, I’ve thought more times than I can count: It would be SO much easier if I just tested everyone. Before. During. After. Every year. For the rest of their freaking lives.

It would make my job simpler, I would meet expectations, I would make more money.

“Test, don’t guess” has become a shorthand for good medicine in the menopause space. Responsible. Measured. Reassuring in a time of life where absolutely nothing feels normal—your body, your mind, even your medical care. Testing? Hell YES! Finally something will make sense! You’re not alone in wanting something to anchor to, in wanting answers.

DUTCH, blood, saliva, genetics—all of it, hundreds and hundreds of times. For over 15 years now I am frequently referred complex cases, which has meant I have gone down every rabbit hole and have spent a lot of time with all manner of testing. I have studied and used every type of testing we’ve got in search of meaning and answers that could help me, help YOU.

Subsequently, I now know when these tests will be useful or useless. I do order tests—of course—but only when I need more puzzle pieces that will actually change clinical management. I will not push you through an expensive and largely senseless array of testing and pretend it means something to make you feel better.

At this point—to be very clear—we do not have evidence to support routine measurement of estradiol or progesterone to guide treatment in midlife or beyond. There is no established level for symptom control, “optimization,” or what is framed as “balance.” Two women can have the same estradiol level—one feels well, the other feels horrible. I've seen dozens shift from "tested but still suffering" to thriving on symptom-guided MHT—no labs needed. The number alone doesn’t tell us how the body is experiencing the hormone. Are there scenarios where I test hormone levels? Of course, too many to list here.

In perimenopause, hormones fluctuate within days, hell, within the hour. A single lab value is a snapshot of a moment, not a pattern—and it is in the pattern that the answer lies. In postmenopause, estrogen levels are expected to be low, and if on MHT and there is confusion about dose or absorption, then testing is wise. Despite what you see on Instagram, the gold standard when prescribing menopausal hormone therapy—per both The Menopause Society and the European Society of Endocrinology—is that we are not titrating to a number. We are treating symptoms, function, and quality of life. I will absolutely be the first to let you know if there is a rational, evidence-based reason to change this approach.

This is critical in terms of bone health. The Instagram narrative? "Hit xxxpg/mL estradiol to save your bones." Logical. Proactive. Unsupported by data. As the brand new 2025 European Society of Endocrinology guideline confirms, we do not have an agreed-upon serum estradiol threshold that confers bone protection, nor do we have data showing that adjusting therapy to reach a specific number improves fracture outcomes. We know estrogen plays an important role in bone physiology, and we know that appropriately prescribed hormone therapy will reduce bone loss and fracture risk. Even ultra-low-dose topical estrogen slashes fracture risk—no target number required.

The reality is that extensive testing is easy to package and … sell. It looks thorough, feels scientific, and positions the clinician as specialized and data-driven—avoiding the complex conversation about why testing isn’t always, in reality… helpful. And yes, it can meet a real emotional need. It helps women feel seen, validated, and more in control.

So, what to do? I handle it on a case-by-case basis and to this point have opted out of blanket testing. I test when I need a puzzle piece (or if the patient wants to test) and use listening to patients and 20+ years of pattern recognition as core to problem solving.

This area of medicine is truly not for the faint of heart. It asks a lot more of us as clinicians on the front line than most women realize. You have to be willing to listen to patients, and that takes time. You have to be comfortable working in a space that isn’t clean or algorithm-driven, where there isn’t always a clear protocol to lean on, and where a lot of women are in rough shape emotionally and physically.

We are working with incomplete research and guidelines that are evolving too slowly and are too narrow in what they address. The highest-quality data we do have doesn’t always answer the questions that matter most to the woman sitting in front of you. We are very much in the wild, dear sisters.

Meanwhile… there’s a massive glut of information—some of it helpful, much of it not—that she, YOU, are grappling with.

My patients? Yeah well, they aren’t exactly coming in feeling even medium. They arrive feeling confused, dismissed, or minimized at some point along the way. Why would they trust the system, the evidence, the guidelines, or even the person sitting across from them, or even… me? It does beg the question.

Being a woman, as far as I can tell, is extra. Wouldn’t trade it for the world, but also, let’s just be honest here people.

Experience matters. Discernment matters. Labs and intuition matter. A willingness to be okay with being in the wild is a prerequisite of doing this work, or frankly you won’t be working here for long.

Dr. Kirsten Smith, ND, MSCP

References

Personal clinical experience with DUTCH, saliva, blood, and genetic hormone testing (2009–2026).

The Menopause Society (formerly NAMS) 2022 Hormone Therapy Position Statement. Menopause. 2022;29(7):767-794.

European Society of Endocrinology clinical practice guideline for evaluation and management of menopause and the perimenopause. European Journal of Endocrinology. 2025;193(4):G49–G71.

Santoro N. Declining ovarian function and the pathophysiology of menopausal symptoms. Best Practice & Research Clinical Endocrinology & Metabolism. 2016;30(4):473-484.

Writing Group for the Women's Health Initiative Investigators. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy. JAMA. 2004;291(14):1701-1712.

Cauley JA. Estrogen and bone health in men and women. Steroids. 2011;76(12):1349-1354.

The PEPI Trial: Postmenopausal Estrogen/Progestin Interventions. JAMA. 1995;273(3):199-208.