Few words in medicine have been colonised by marketing as thoroughly as “hormones”. A real field — how thyroid function, sex steroids and metabolism change with age — has become a pretext for selling “hormone optimisation” to anyone over 40 who feels tired.
Feeling tired is real. The question is whether hormones are the cause, and whether treating them will help. Here is a sober map of what has genuine evidence, what is mostly commerce, and how to approach it like a physician rather than a customer.
First principle: symptoms are not a diagnosis
Fatigue, weight gain, low mood, poor sleep, reduced libido, brain fog — the standard list on every hormone clinic’s website — are among the most common and least specific symptoms in medicine. Each has dozens of possible causes, most of them not hormonal: sleep apnoea, depression, iron deficiency, medications, alcohol, or simply too little sleep and too much stress.
The wellness model runs the logic backwards: it starts from a product and matches your symptoms to it. Evidence-based medicine runs the other way — history first, a targeted test for a specific question, treatment only if the result changes what you would do. It is the same filter we apply to longevity biomarkers.
What has real evidence
Thyroid: test TSH, interpret it calmly
Hypothyroidism is common, rises with age — particularly in women — and a TSH blood test answers the first question cheaply and reliably. If it is abnormal, free T4 completes the picture, and levothyroxine is one of the best-evidenced treatments in endocrinology.
Two nuances matter. First, mildly elevated TSH with normal T4 (“subclinical hypothyroidism”) is very common after 60 and often needs no treatment — guidelines generally suggest treating only above a TSH around 10 mIU/L. Second, thyroid results fluctuate; repeat a borderline value before acting on it. Treating a normal TSH because “your optimal is different” is optimisation theatre, not endocrinology.
Menopause: the real conversation about HRT
Menopause is the one area where hormones genuinely and predictably change, and where treatment has been confused by decades of fear in both directions. The current evidence, in brief:
- Hormone therapy (MHT/HRT) is the most effective treatment for hot flushes and night sweats, and also helps genitourinary symptoms and bone protection.
- The risk-benefit balance depends on age and timing. For healthy women starting within roughly ten years of menopause or before 60, major guidelines (NICE, the menopause societies) consider the benefits of appropriately chosen HRT to generally outweigh the risks.
- Risks are not zero and not uniform. Combined oestrogen-progestogen therapy slightly raises breast cancer risk with longer use; oral oestrogen raises clotting risk, which transdermal patches largely avoid; women with a uterus need a progestogen alongside oestrogen.
In short: HRT is neither the danger it was portrayed as after 2002, nor the “longevity elixir” some clinics now sell — it is a good treatment for specific indications, chosen dose by dose, woman by woman, not a proven way to prevent dementia or heart disease.
Testosterone in men: treat deficiency, not birthdays
Testosterone declines gradually with age — roughly one percent per year — and much of that tracks with weight gain and metabolic health rather than age itself. Genuine deficiency (hypogonadism) exists and is worth treating: men with compatible symptoms and consistently low morning testosterone on at least two properly timed measurements can benefit, with monitoring of haematocrit and PSA on treatment.
But the indication is confirmed deficiency with symptoms — not a low-normal number, not tiredness alone, and certainly not a birthday. Many “low T” prescriptions in the wellness market go to men whose levels are normal; for them the honest first-line treatment is weight, sleep, alcohol and strength training, all of which measurably raise testosterone.
What is mostly marketing
A few flags reliably identify commerce dressed as endocrinology:
- “Adrenal fatigue.” Not a recognised diagnosis. Real adrenal insufficiency is rare and diagnosable with specific tests; the “adrenal fatigue” construct exists to explain non-specific tiredness and sell supplements and saliva tests. The finding to act on is usually sleep, stress or depression — which deserve proper attention, not a glandular storyline.
- Testosterone pellets and mega-dose protocols. Pellets are sold as convenience but remove dose control: once implanted, the dose cannot be adjusted or stopped when side effects appear. There is no evidence that supraphysiological testosterone adds health — and real concerns about haematocrit, fertility and the prostate.
- Massive hormone panels for everyone. Thirty-hormone “optimisation panels” guarantee abnormal results by pure statistics: test enough values and some fall outside reference ranges by chance, and each then justifies a treatment. Good endocrinology tests one hypothesis at a time.
- “Bioidentical” as a magic word. The hormones in regulated, guideline-endorsed HRT — 17β-estradiol, micronised progesterone — are already bioidentical, which is precisely why guidelines prefer them. When a clinic uses the word to sell compounded, unregulated mixtures, it is selling less quality control at a higher price, not more nature.
A sensible way to approach it
- Start with the boring causes. Before any hormone panel: sleep quality (screen for apnoea if you snore), mood, alcohol, medications, iron and B12, activity. These explain most midlife fatigue.
- Test to answer a question. TSH if thyroid is plausible; morning testosterone twice if deficiency is plausible; nothing “just to see”.
- Interpret in context. Reference ranges are population statistics, not personal targets. A result matters alongside symptoms, history and repeat measurements — not on its own.
- If treatment is indicated, use regulated medicine with follow-up. Defined molecule, lowest effective dose, scheduled monitoring, and a clear answer to “how will we know if this is working?”
- Get a second opinion before long-term hormone therapy from a clinic that profits from it. An independent second medical opinion from a specialist with nothing to sell you is the cheapest filter in this field.
A well-designed check-up — such as an executive health check-up in Barcelona — already covers the metabolic layer (glucose, lipids, blood pressure, body composition) behind most of what hormone marketing promises to fix, and gives you a baseline for discussing hormone questions from evidence, not anxiety.
The bottom line
Hormones after 40 are a real medical topic with three legitimate territories — thyroid, menopause, and genuine testosterone deficiency. Around them sits a much larger market that monetises the universal experience of getting older. The dividing line is not the molecule; it is the method: diagnosis before treatment, guidelines before enthusiasm, monitoring after prescription.
At Vensavita we help clients navigate exactly this — arranging consultations with serious endocrinologists and gynaecologists in Barcelona, organising the right tests rather than the biggest panel, and translating results into plain language. The first conversation is free. And whatever you read — including this article — hormone decisions belong with a physician who knows your full history; this is information, not medical advice.