Access to Evolving Estrogen Therapy Remains Uneven in Vermont

When Kirsten Berggren stopped feeling like herself after a major ankle surgery in 2016, she assumed the slump would pass once she was back on her feet.

The normally energetic family medicine nurse practitioner was sleeping poorly, increasingly irritable and slogging through days that felt inexplicably hard. The symptoms lingered after her ankle healed. Then came the COVID-19 pandemic: long shifts in urgent care, aging parents who needed more support, children preparing to leave home. There always seemed to be another explanation for the then-49-year-old woman’s exhaustion, stress and a growing sense that something was off.

Perimenopause — the hormonal transition leading to menopause — never crossed her mind.

It wasn’t until she ran into a colleague around her age at a conference that she began to consider a different explanation. The woman looked rested and healthy, Berggren recalled. Her colleague credited menopausal hormone therapy. Berggren followed up with her primary care provider, who agreed she was a good candidate for an estrogen patch.

She felt the difference within three days.

“It was like the shades lifted,” Berggren said. “I didn’t know how bad I was feeling until I started feeling better.”

Stories such as Berggren’s have become increasingly prominent as a generation of women enters midlife armed with new research, online networks and renewed interest in hormone therapy, following decades of clinical caution that pushed treatment to the margins. Demand has risen as medical guidance came around in recent years, but the health care system — including medical providers and drug manufacturers — has struggled to keep pace.

Across Vermont, women describe searching for informed clinicians, waiting weeks or months for appointments, and, at times, calling multiple pharmacies to locate medications. Providers say gaps in training and uneven adoption of updated guidance have left diagnosis and treatment inconsistent. The result is perimenopausal care often shaped less by symptoms than geography, clinical experience and access to specialized care. 

Perimenopause often begins in a woman’s forties, though it can start earlier as ovaries gradually produce less estrogen. Unlike menopause, defined as 12 consecutive months without a menstrual period, perimenopause can last years and produce a wide range of symptoms, including anxiety, brain fog, irregular cycles, hot flashes, joint pain, mood swings, sleep disruption, urinary changes and vaginal dryness.

Much of today’s debate over hormone therapy traces back to the federal Women’s Health Initiative, a series of clinical studies focused on women after menopause. Researchers halted a central component of the study’s hormone therapy clinical trial in 2002, after analysis showed that women taking estrogen and progestin faced higher risks of breast cancer, stroke and blood clots. The conclusion sharply reduced prescribing and led millions of women to stop estrogen therapy almost overnight. It also shaped how a generation of clinicians was trained.

In the years since, researchers have refined those conclusions. Current guidelines now say that for many healthy women under 60 or within 10 years of menopause — a group that was underrepresented in the WHI’s largely older population — the benefits of hormone therapy often outweigh the risks. In contrast, for women 60 and older, hormone therapy is generally less recommended to start, because the risk of blood clots rises with age and the passage of time after menopause. Whether an older patient should continue therapy is a decision best made by the patient and her clinician based on symptoms, health history and other factors, Berggren said.

Earlier this year, the U.S. Food and Drug Administration updated labeling on certain estrogen products, including patches that administer the potent hormone estradiol, easing the long-standing black-boxed warning on risks tied to menopause hormone therapy.

“A health care system worthy of public trust tells the truth, updates its guidance as science evolves and respects women’s ability to make informed choices about their own health,” Health and Human Services Secretary Robert F. Kennedy Jr. said in February.

Estrogen therapy is now available in patches, gels, sprays, pills and vaginal preparations. Patches, which offer a lower risk of blood clots than oral estrogen, have proven particularly popular in recent years. In addition to relieving perimenopausal symptoms, these medications can also help slow the bone loss that accelerates post-menopause and have been associated in some studies with lower cardiovascular and diabetes risk when started in younger, otherwise healthy women. If a patient has a uterus, then an intrauterine device or the drug progesterone should be used with estrogen therapy to protect against the increased risk of endometrial cancer that can occur when estrogen is used alone.

Dr. Jennie Lowell, a gynecologist with Maitri Health Care in South Burlington, said she spends some patient visits correcting outdated assumptions tied to estrogen, though that work is easing as public understanding evolves. Lowell, who was among the providers trained when the Women’s Health Initiative set the standard, was prescribed estrogen therapy several years ago when she was navigating severe perimenopause symptoms that she says almost ended her marriage.

Still, estrogen therapy is not appropriate for everyone, Lowell cautioned, and treatment decisions should be made in conversations with a patient’s own provider, weighing symptoms, risks and medical history.

Diagnostic decisions related to perimenopause remain difficult in part because no single definitive test exists. Berggren, the family medicine nurse practitioner, compared hormone testing to a photograph taken mid-roller coaster ride. It captures a snapshot, not the changes that drive symptoms.

A common refrain among Berggren’s perimenopausal patients at Central Vermont Medical Center’s family medicine practice, an affiliate of University of Vermont Health, is: “I just don’t feel like myself.”

Dr. Colleen Horan, an ob-gyn at Central Vermont Medical Center, said patients entering perimenopause today — often members of Generation X — are more likely to question recommendations, research options and advocate for themselves. 

Prescriptions for menopausal hormone therapy rose more than 85 percent between 2021 and 2025, according to medical-record data analyzed by Epic Research, which is a subsidiary of Epic Systems. Drug manufacturers have scrambled to meet the demand. The FDA has not declared a shortage of estradiol, but the American Society of Health-System Pharmacists has identified shortages of several patch formulations as of July 1.

CVS Pharmacy declined to provide data on estradiol use in Vermont, and a spokesperson for UVM Health said the health network was unable to access that information. Kinney Drugs did not respond to requests for comment.

But patients and providers in Vermont who spoke with Seven Days said demand has strained the supply of both estrogen patches and clinicians trained in menopause care, leaving many patients to navigate fragmented treatment.

Jen Hanussak, 45, of Morristown first noticed headaches and vaginal dryness in 2024. A topical cream prescribed by her gynecologist offered little relief. Within a year, unexplained allergic reactions sent her to urgent care. It wasn’t until she read The Perimenopause Survival Guide by Dr. Heather Hirsch, an internist and founder of a women’s health concierge medical practice, that she began to suspect perimenopause.

When she raised the question of estrogen therapy, Hanussak said her gynecologist responded like a “deer in headlights” and gave her little more than web printouts. 

Six months ago, she found a clinician through Hirsch’s online directory of hormone therapy-trained providers who wrote her a prescription for an estrogen patch. Within days of starting the medication, Hanussak’s allergic reactions subsided. Hanussak now describes herself as “loud and proud” about her experience, hoping to push back against social taboos that persist around perimenopause and women’s health. 

For other women, the most disruptive symptoms are emotional rather than physical. A 45-year-old Fair Haven woman described heightened anxiety, teary episodes, and sudden mood shifts that felt overwhelming and unfamiliar.

“Instead of being a blithe 13-year-old who just doesn’t understand, it’s 45-year-old me looking on at my actions in horror and unable to stop it,” she said. She asked not to be identified out of concern that the stigma surrounding perimenopause could impact her career as a professor.

Her gynecologist diagnosed her with early perimenopause and prescribed a low-dose estrogen patch that she said “has made a world of difference.” The diagnosis opened the door to books, family conversations and online communities that reframed an experience she had once thought she was facing by herself. Her takeaway, she said: “You’re not alone.”

Lowell and other clinicians have adapted in real time to the increase in demand while the supply chain catches up: sending prescriptions to multiple pharmacies; reducing the amount dispensed at one time; or adjusting doses when equivalents exist, such as using two lower-strength patches to deliver the desired amount of medication. Patients reported calling repeatedly or traveling farther to find medication.

Supply constraints have affected women such as Amy Zielinski, 49, of Underhill. Before using estrogen patches, she experienced months of anxiety, brain fog, itchy ears, tinnitus and a persistent sense that something was wrong. Therapy and antidepressants brought little relief.

Hot flashes eventually provided what she called the “ammunition” to ask whether perimenopause might be responsible. 

Once she received a prescription for estrogen patches, she called several pharmacies before finding a location with her prescribed strength in stock. Her hot flashes dissipated almost immediately. The accompanying progesterone prescription has also provided an added benefit, she said, with melatonin-like effects that have improved her sleep quality.

Aware that not every patient is able to get responsive care so quickly, some clinicians in Vermont are now trying to make it easier for women to access providers trained in perimenopause and menopause.

Alison Farr, a nurse practitioner and founder of Ascent Healthcare, a concierge medicine office in Shelburne, said the state needs more providers who are trained in menopause care to keep women healthy and in the workforce. Researchers at the Mayo Clinic estimated that the United States loses $1.8 billion annually because of workdays missed due to menopause symptoms.

Hormone therapy is not a difficult area of medicine to practice, Farr added. 

“This is not neurosurgery,” she said. “This is understanding human physiology, then listening to women, how they’re feeling, and knowing how to help.”

This fall, the UVM Larner College of Medicine will host its first conference dedicated exclusively to menopause, bringing together clinicians for continuing education on treating patients through the menopausal transition. For Julie Dumas, a researcher and professor of psychiatry at the UVM Larner College of Medicine, the event is also a reminder of how much remains unknown. Women live a third longer than they did a century ago, she noted, yet medical research still dedicates relatively few resources to women over 60. She’s trying to close that gap. 

Dumas and colleagues published a study earlier this year in the journal Menopause that linked changes in brain connectivity after menopause to declining estrogen rather than aging alone, adding to a growing body of research exploring how hormonal changes shape brain health over time.

A group from UVM has also applied to establish a dedicated menopause center affiliated with the medical center that would conduct clinical care, training, research and community outreach. A proposal is under review. Berggren, who is involved in the effort, said Vermont’s size makes it a practical testing ground for broader change.

With these efforts under way, Berggren has taken on another challenge: making sure clinicians are up-to-date on the latest recommendations for menopausal hormone therapy. Berggren has partnered with another clinician to develop continuing medical education coursework on perimenopause and menopause. Created with the support of the UVM Larner College of Medicine and available nationally, the course is designed to help providers update training that, in many cases, still reflects older standards of care rooted in the Women’s Health Initiative. 

Uptake has been modest since its rollout, she said, though early responses have been positive. Berggren hopes the material will spread through clinical networks, shifting practice not only through individual providers but also through shared habits of care inside clinics.

After a recent presentation, a clinician told her she wished she could revisit earlier patients — women she had once dismissed as overreacting to vague symptoms — now that she better understood perimenopause and its treatment options.

The words struck a chord with Berggren, in light of both her own experience during perimenopause and her work treating menopausal patients. To address a biological reality that will affect roughly half the population, Berggren has no doubt the need for better perimenopause and menopause care exists. The challenge now, she said, is building a health care system prepared to meet it. ➆

The original print version of this article was headlined “Patch Work | Awareness of estrogen therapy has evolved, but access to care in Vermont and elsewhere remains uneven”

This article appears in The Cartoon Issue • 2026.

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