Case: a 51-year-old healthy woman presents to the office. She has two children, 24 and 21 years of age, both delivered by cesarean section for fetal distress. Following the second delivery, she had a bilateral tubal ligation for contraception. She has had no other medical conditions. She reports that her menses have changed over the past year, becoming shorter and lighter. She occasionally skips a period altogether. She reports hot flushes, palpitations, and some sleep disruption. She believes that the sleep disruption has led to fatigue and some mild cognitive changes, which are beginning to interfere with her work performance. She has no personal or family history of breast cancer, coronary artery disease, or thromboembolic disease. She does have a family history of osteoporosis. She is a non-smoker, drinks two beers weekly, and exercises inconsistently. Her best friend had been on hormone therapy but stopped with the recent news concerning adverse effects. She wants to know whether she should consider hormonal therapy for her hot flushes and sleeping difficulty or if there is anything “safer.”