Debunking HRT Myths: Why Hormone Therapy Should Be Standard of Care in Psychiatry

Hormone replacement therapy has long been taught as a last resort, something to prescribe cautiously, at the lowest dose, for the shortest possible time, if at all. That guidance is outdated, according to Nardin Valentin, DO.

Valentin, a general psychiatrist at Virtua Health in South Jersey who splits her time between inpatient and outpatient care, said that framing was baked into her own training. "In medical school, we were not taught anything about hormone replacement therapy. If anything, we were taught that it's not standard of care," she told Psychiatric Times in an interview. "And if you are going to treat anyone with hormone replacement therapy, it should be the smallest dose, shortest amount of time."

That thinking no longer holds, Valentin explained. The conversation has really shifted to hormone therapy as a " standard of care and should be offered to every patient," regardless of whether they present with psychiatric symptoms.

The Cancer and Stroke Myths That Still Shape Prescribing

Much of the lingering hesitancy among clinicians and patients traces back to a familiar set of fears, Valentin said.

"I think there's a lot of myths about hormone replacement therapy, that it's bad for you, that it causes cancer, that it causes strokes," she told Psychiatric Times. Layered onto training that treated HRT as a niche, last-resort intervention, those myths have left many psychiatrists without a framework for even raising the topic with patients moving through perimenopause and menopause.

Fracture Risk Links Menopause to Later-Life Mental Health

Valentin pointed to fracture risk as a concrete example of what is at stake when hormone therapy is withheld.

Fracture risk increases significantly in postmenopause, she said, and that physical vulnerability "can also contribute to depression, anxiety in later age." Offered in that context, hormone therapy can be very protective, she added, and is a benefit that holds whether or not a patient carries a psychiatric diagnosis.

From Boutique Clinics to Standard of Care

Valentin also pushed back on the perception of hormone therapy as an expensive, elective service out of reach for most patients.

The conversation, she said, has moved away from HRT being "something that you would get at a clinic where you pay like thousands and thousands of dollars" and toward it being something "that should be offered to everyone and should be part of their treatment plan."

How Fluctuating Estrogen Can Mimic ADHD or Antidepressant Nonresponse

Beyond mood symptoms, Valentin flagged an interaction psychiatrists may be missing when patients report new or worsening brain fog in their 40s and 50s. Estrogen modulates dopamine receptors, she said, and the hormonal fluctuations of perimenopause may help explain why ADHD medications or antidepressants that once worked well suddenly seem less effective. "It could be stress and it could be anxiety," Valentin said, but for patients already diagnosed with ADHD, she suggested clinicians consider whether fluctuating estrogen is "making their ADHD medications not as effective or their antidepressants not as effective."

Building Competency to Prescribe HRT

For psychiatrists who want to build competency in this area, Valentin pointed to 2 resources: the Menopause Society, which offers a menopause-certification credential along with information through its website and Instagram account, and the Endocrine Society, which offers its own continuing-education courses. Certification, she said, means "you have the knowledge base and know how to prescribe HRT," along with a fuller understanding of what perimenopause and menopause actually look like for patients.

Treating Psychiatry "From the Neck Up" No Longer Works

Underlying all of it, Valentin said, is a broader argument against compartmentalizing the brain from the rest of the endocrine system. "These hormones and these receptors and the endocrine system is really uniquely but also largely connected to the brain," she said. With depression, anxiety, and other mental illnesses notoriously difficult to treat, she added, "we want all the tools and all the avenues that we can to give the best treatment to our patients."

Dr Valentin is psychiatrist at Virtua Health in New Jersey.