Building a Better Menopause System: Insights from One Medical’s Dr. Erin Duralde
about the episode
On this episode of Innovate & Elevate, Sharon speaks with Dr. Erin Duralde, Medical Director for Women’s Health and Menopause Care at One Medical, about a question that keeps coming up in midlife healthcare: now that we know more, where do people actually go for menopause care?
Recorded shortly after the FDA removed the long-standing black box warning on estrogen therapies, this conversation explores how menopause and perimenopause care can be integrated into primary care, what a modern menopause visit should look like, and how clinicians can better listen to symptoms, history, and lived experience to guide care.
What You’ll Learn from this Episode:
How Dr. Duralde’s early work as a patient advocate at the UCSF Breast Care Center shaped her approach to menopause care and clinical decision-making
Why menopause education was largely missing from medical training following misinterpretations of the Women’s Health Initiative, and how that legacy still affects care today
What patients can expect from a dedicated menopause or perimenopause visit at One Medical
How intake surveys and symptom tracking help clinicians better understand what matters most to each patient
The wide range of symptoms that can appear during perimenopause, beyond hot flashes and night sweats
How clinicians think through treatment options in perimenopause, including hormonal and non-hormonal approaches
The difference between menopausal hormone therapy and combined hormonal contraception, and why timing and symptoms matter
How testosterone is used in post-menopause, why dosing matters, and how safety is monitored
How primary care providers are being trained at scale to deliver evidence-based menopause care
About Dr. Erin Duralde
Dr. Erin Duralde is a primary care physician and Medical Director of Women’s Health and Menopause Care at One Medical. She previously practiced at Brigham and Women’s Hospital’s Menopause and Midlife Clinic and earned her MD from the University of California, San Francisco, with an MPH from Harvard. Board-certified in internal medicine and a Menopause Society Certified Practitioner, her work focuses on improving access to evidence-based, patient-centered menopause care.
Connect with her on LinkedIn.
Episode Outline
00:00 – Why Access to Menopause Care Keeps Coming Up
01:00 – Introducing Dr. Erin Duralde and Her Path into Menopause Care
03:30 – How Misinterpretations of the WHI Shaped Medical Training
06:30 – What a Modern Menopause Visit Should Look Like
09:30 – Why Intake Surveys Change the Quality of Care
12:00 – The Range of Perimenopause Symptoms
14:30 – Hormonal and Non-Hormonal Treatment Options
18:00 – Testosterone Therapy: Safety, Dosing, and Expectations
22:00 – Labs, Symptoms, and Clinical Judgment
25:00 – Scaling Menopause Care Through Primary Care
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Sharon Kedar, CFA: I wanted to share with everyone today an option. 'Cause everyone's asking about, how do you actually access an appointment in midlife for perimenopause, menopause.
We are recording this less than two weeks after the FDA took off the black box warning on hormone therapies. And I'm super excited to welcome Dr. Erin Duralde to the podcast.
Dr. Erin Duralde: Thanks so much for having me, Sharon.
Sharon Kedar, CFA: It is a pleasure. Can you talk a little bit about your new menopause, perimenopause offering and however you wanna introduce yourself and One Medical.
Dr. Erin Duralde: I'm Medical Director for Women's Health and Menopause Care at One Medical. I actually came into menopause care, I think in an interesting way. I came to working at the UCSF Breast Care Center before med school where I was a patient advocate for folks with breast cancer. Yeah. And it was a really informative experience to be an advocate and sit with people and understand what are the questions that matter?
What are our values? How do treatment decisions impact our choices in healthcare? And then what is all of life after that?
Sharon Kedar, CFA: And that's where you went to medical school, as well, was UCSF.
Dr. Erin Duralde: I did. I chose a residency where I was able to do one-on-one mentorships across the women's health spectrum. I started to learn the foundation of menopause care.
There was no one venue where I learned hormone therapy is actually safe for most people. I didn't get that during residency.
I would say at the time there wasn't education on menopause. I think we briefly talked about the physiology of it, but we were in that era after the misinterpretations of the Women's Health Initiative trial, where hormone therapy was not considered a viable option.
So it might have been mentioned or whispered: if someone has severe symptoms, you could consider this. Otherwise it's too high risk.
Sharon Kedar, CFA: Was it the study or the readout that was the problem or both?
Dr. Erin Duralde: I would say the interpretation. The study was actually asking the question of, does hormone therapy prevent chronic disease? Which is a little different than the way we might look at things now.
It missed the concept of, how about in people who need it to treat very significant symptoms. And also, it was designed to look at post-menopausal women only. Nowadays, we're very commonly doing hormone modulation in perimenopause, which is at a younger age.
So the research question was well designed at the time with information they had.
We have a lot more nuanced understanding now. For us at One Medical, I have hundreds of providers that wanna learn this information.
So the opportunity is now to train people who are practicing and on the job. That's what we've been working on is making perimenopause and menopause care part of primary care.
Sharon Kedar, CFA: I think it's really exciting for people that this is available to them through One Medical.
Dr. Erin Duralde: Yes. Let's have everyone who comes in with these concerns be affirmed in their experience.
Let's hear what's really going on with them. Let's take that history we should be taking: which is understanding what's their cardiovascular health like? Is there a risk of breast cancer? Has there been breast cancer? These are important things in helping somebody to live their healthiest. They also affect what types of treatments we may or may not wanna guide them to.
But the first steps are really not that hard. We can really raise up the base everywhere, I think, pretty quickly.
Sharon Kedar, CFA: You are one of the few people who has said that we can raise up the base pretty quickly.
I think a lot about how are we gonna catch up the system. Can you talk a little bit about what someone should expect at a One Medical appointment like that?
Dr. Erin Duralde: Yeah. So we started with a pilot: L.A. and San Francisco. We had 1,000 patients that we were able to work with, 2024 into 2025.
And it was really successful. Patients told us, we really appreciate this. A lot of folks were feeling a lot better. A lot of people got on hormone therapy, some on non-hormone therapy. And being in primary care, we were able to also say, hey, thanks for coming in. You actually haven't had an annual visit in a while, or you're not up to date on this or that screening; can we help you get up to date on that?
So it was a really nice opportunity.
And we were able to get organization-wide support because so many folks in the leadership really believed this is a gap. We have to do better.
Sharon Kedar, CFA: When you say organization-wide, is it a One Medical or Amazon support?
Dr. Erin Duralde: We're part of Amazon Health Services. So we have a really multidisciplinary team. And that's what it takes to bring something like this together to really create a meaningful service at scale. We created this visit type that you could book. We created an intake survey that we're really proud of to help people come in ready for their visit. The provider's more ready for their visit.
Sharon Kedar, CFA: It sounds like you've created at One Medical an intake. And I know,
you all are, from my understanding, data-driven. 'Cause that's the thing about like perimenopause and menopause care is part of making it great is the process and the data.
So if you could just speak to that.
Dr. Erin Duralde: Yeah. I agree. We are collecting data in a lot of different ways, and one of them is through the survey. The survey's greatest importance is to clinical care at the moment, though. So it's having our patients and providers be a little more primed and ready to have a great discussion. Some of the background information we wanna ascertain, it could feel like rotely collecting information. Let's get that ahead of time. Have you had breast cancer? Have you had a blood clot before? How was that treated? Things like that. But then also we like to ask questions about 15 different common menopause symptoms.
So we can start to get our arms around, hey, what's this person's constellation of symptoms like? Sometimes when we come into the visit, I can say, as a patient myself, I can forget some of my most important questions that I have or concerns. So we are finding that this survey is inviting people to talk about a lot of these things that maybe they hadn't realized were connected.
Sharon Kedar, CFA: When you're there, it's like, of course, five things came up beforehand and you forget. Your blood pressure's up. It's the hospital lighting. You said there's 15 symptoms. What are they?
Dr. Erin Duralde: Of course the most classic cardinal vasomotor symptoms. So hot flashes, night sweats... But then other things like palpitations, we ask about. Feeling nervous, anxious, irritable, on edge, low mood, low motivation. We ask about sleep difficulties, waking up easily in the middle of the night, having trouble falling asleep.
Vaginal and genital symptoms. Bladder symptoms, headaches. So many, unfortunately, different symptoms people can experience as they're going through the menopause transition.
Sharon Kedar, CFA: It's amazing for the listeners and viewers to hear that 'cause the old rules are that symptoms start in menopause and it's hot flashes and night sweats. But the new rules... and this really got me when I heard about the heart palpitations. All women deserve to know whether their heart palpitations are serious. And if they are, that's really important to know. Or treatable for perimenopause, menopause. But a lot of people don't realize some of these symptoms.
Have you found that intake really helps the doctors? And when a patient actually shows up, does that intake form actually help the system to get ready for what that visit might look like?
Dr. Erin Duralde: Yeah, it helps a lot. Because not only do we ask, are you experiencing this, but we also say, how much is it bothering you? And that can already help because then when my patient comes in, if I haven't met her before, I can say, hey, you mentioned that you are newly having these really severe headaches.
Is that the thing that's most important or what's coming to the surface for you? Because if we could fix one thing, what would really make the biggest difference for you? And so it helps to prompt those conversations. It also helps me as a provider to start thinking, okay, they mentioned heavy vaginal bleeding and cramping and headaches.
I'm already starting to think about which combinations of treatments might be more useful for this person. Because especially in perimenopause, there are a lot of different treatment choices and what works for you know, someone's friend or mom or sister may not be what's right for them.
Sharon Kedar, CFA: What does that mean?
When you say there's options, can you just lay out just a little bit of the menu? This is not medical advice, this is just an introduction to an offering to consider.
I don't think the audience even understands 'cause, by the way, they don't even know when they're in perimenopause. It's not like it announces itself on December 10th.
Dr. Erin Duralde: In perimenopause, there's so much we can do. So one of the first things we like to think about with treatment... So I'm understanding what's bothering my patient most. And, let's say for somebody, it's that they're having really bothersome, heavier, irregular bleeding, for example. And we're gonna think about is there anything that's atypical about this that requires a deeper investigation?
But let's say we're able to chalk it up to, this is probably related to fluctuating hormones. Then we'll think about different treatment options. So in perimenopause, one of the biggest break points is, are we trying to wrangle heavy or irregular periods or not? For a lot of people, that's not bothersome for them.
They don't experience that. Okay. Another thing we think about is contraception. Does this person want to prevent a pregnancy? Because that's going to influence what might be some of the best choices. And then we're also thinking about, and I'm not sure if you've seen this diagram drawn before, but a lot of us clinicians will show that before perimenopausal hormones are just pretty much up and down clockwork. And then in perimenopause we start to see more irregularity. And so that estrogen, if we just hone in on one hormone, can be higher than it ever used to be and lower. The intervals, right? So if somebody's symptoms seem related to more of that hormonal chaos, the kind of high amplitude of up and down, that can also direct us towards certain treatments more than others.
And so then on the menu is what we call menopausal hormone therapy. So that's gonna be estrogens. And for people with a uterus, progestogen; that's the whole family with progesterone, progestins. And then we also can use combined hormonal contraception, which is going to take hold of the system more.
It's gonna override that communication between the brain and the ovary, prevent ovulation. That's how it prevents fertility. Can be useful for thinning the uterine lining, decreasing cramping, all of that. So there's strong reasons why someone might wanna go down one path or the other. And then within menopausal hormone therapy, this is for perimenopause and post menopause, so many options. You described that you have multiple of those. So for estrogens, patches, pills, vaginal rings, creams, gels.
Sharon Kedar, CFA: It can be so overwhelming. There were some comments of people saying like, where do I go? Is the menu of estrogen, progesterone, testosterone, vaginal estrogen...
are those all things that someone can get at One Medical?
Dr. Erin Duralde: Yeah, absolutely. Testosterone we hadn't touched on in detail, but we're prescribing that for low libido, post menopause for the most part. That's what various clinical society guidelines have been putting forth. You mentioned it's not FDA approved, which is true. We keep it in a safe range. You mentioned pellets, which is a method that unfortunately the studies have shown can result in really high levels in people and can cause more side effect. Certainly I've had patients who have had them from other providers and they really liked them.
But on average from the research, probably not the safest approach.
Sharon Kedar, CFA: So when you prescribe testosterone, what range do you guys do for people?
Dr. Erin Duralde: We use transdermal - through the skin - testosterone, 'cause that's gonna be the most physiologic, the least chance of side effects like blood clots. And we're targeting keeping the blood level within the premenopausal range. So the range will be different based on the lab.
At our lab it goes up to 55 (ng/fL depending on lab) for premenopausal range. So we're generally trying to keep folks within that range. But the testosterone therapy really is dosed to maximize someone's benefit while minimizing any harm, as long as we stay within the safe blood level range.
Sharon Kedar, CFA: Dr. Kelly Casperson, she's talked about how some women described to her, their brains turning back on. She talked about women starting businesses.
What's your perspective on what testosterone can do?
Dr. Erin Duralde: Yeah. And it's not approved by our FDA, but it is approved in, I believe, five countries internationally by their equivalent of the FDA. And I think what our FDA would need to see is enough efficacy data and enough safety data to feel comfortable moving forward with that. And I hope they'll be considered in the coming years.
But I've had some real success with prescribing testosterone. While there's probably a bell curve around the types of benefits somebody could anticipate, some people are going to get just libidos, some might have energy or other improvements.
It's probably a question of dosing too. So right now, based on the existing research, we're trying to keep it relatively low dose to avoid things like unwanted voice changes and hair loss on the head, which I have seen these things unfortunately occur.
Sharon Kedar, CFA: It's really interesting to me, just from the problem solving lens, that some people need a tiny amount, some people need more.
Dr. Erin Duralde: I think probably some of that mystery lies in the pharmacogenetics. Our different receptor types and every which piece downstream for that. And if we could understand that more, could that then open up, hey, for patient Anne, she's gonna need this amount of dose and whereas, Beth needs much less. I think we would love to see that kind of information.
Sharon Kedar, CFA: If a patient comes in, do they get blood work for estrogen, progesterone, and testosterone? Or just depends?
Dr. Erin Duralde: Yeah. So what I think is so interesting about this type of medicine is that, coming from an internal medicine background, we make a lot of decisions based on lab tests. We can trust them. A equals A. This is the definition; this is the diagnosis. In menopause care, because there are so many interpersonal differences, the actual circulating blood level of a lot of these hormones, I consider it sometimes a hint or a clue towards what will be the best treatment, but it's rare that it's the answer. The guidelines are very clear. Do not treat toward a testosterone blood level target..
Sharon Kedar, CFA: Which is why the questionnaire matters so much and the training matters so much to listen to a woman's symptoms.
Dr. Erin Duralde: Which in a lot of ways is reaffirming. Your story is the most important thing to me when I'm treating. So lab values, again, they're really important in certain situations. They can help us understand if someone's in premature menopause. We cannot miss that. That's the case where it's so essential to start hormone therapy as early as possible to prevent heart disease and cognitive decline, all of that.
The labs during the perimenopause window when someone who's a more standard age to be experiencing perimenopause sometimes can give us clues. It's really important if I'm thinking, is it PCOS? Is this a thyroid? What's going on? I don't understand what's going on. It can be part of a process of elimination sometimes.
So that's okay.
Sharon Kedar, CFA: And Dr. Duralde, when someone comes to One Medical for an appointment, could it be anything from an internist to an OB-GYN to urology, orthopedic surgery... is it someone who is a One Medical doctor who's taken your training?
Dr. Erin Duralde: We are entirely a primary care organization. So patients who come to us could see internists, family medicine, trained docs, NPs and PAs who are primary care experts. But all of them have undergone the training. If you sign up for a menopause visit, you'll see one of these providers who has undergone the training and is really passionate about this care.
Sharon Kedar, CFA: And does someone have to do blood work to get the prescriptions or no?
Dr. Erin Duralde: No. We only would recommend blood work if it's gonna actually help inform what's the best treatment choice. A lot of times we're helping people catch up on blood work. What are their blood sugars? Where's cholesterol? We are really helping people get up to date on their whole health picture because we know that perimenopause and menopause, this is a major inflection point in our overall health.
So this is the time to pay attention to everything. And so if our opportunity is, you're coming in because these bothersome changes are happening or something's confusing, great. Let's use that as a chance to help you feel better and help you be your healthiest self.
Sharon Kedar, CFA: How many perimenopause, menopause specialists are there at One Medical?
Dr. Erin Duralde: We have several hundred now. Almost 300.
Sharon Kedar, CFA: So it's a really big deal. It's probably one of the biggest perimenopause menopause practices, then.
Dr. Erin Duralde: Yeah. I know there are other companies, especially telehealth companies. We're just really proud to get to be part of this movement of saying people deserve this care. And we also get to do it in person too, which I think can be really nice for some folks who like to come, see their provider, get any labs done, same day in our clinic.
It's a nice service for some people, but we also provide telehealth for convenience too.
Sharon Kedar, CFA: Yeah, I mean that all makes terrific sense. Where do you all stand on the topic of vaginal estrogen?
Dr. Erin Duralde: Oh yeah, there's no debate. Vaginal estrogen is highly beneficial. It's the first line treatment. The American Urological Association put out a great guideline this year. It's the first line treatment for vaginal dryness and vaginal vulvar tissue changes from low estrogen. So we are big proponents of vaginal estrogen.
It's safe to use after breast cancer. It's really safe in so many scenarios. It's really the rare exception of certain gynecologic cancers or unexplained vaginal bleeding that hasn't been investigated yet. Those are the rare cases where we would say, hey we might need to hold off, but we have a lot of patients who are using vaginal estrogen now.
Sharon Kedar, CFA: Since perimenopause doesn't announce itself, when does someone sign up for an appointment? What's your sort of "ideal"?
Dr. Erin Duralde: I think there's really no "too soon." We culturally have anticipatory guidance about puberty, and that's gonna happen in the doctor's office, but also happens in school, and it happens in our communities. I think we need to be doing the same thing about menopause.
And so, as far as your question goes for seeking healthcare, we wanna try to make this standard that we start to ask women about it or give them at least some education starting in the mid to late thirties.
Sharon Kedar, CFA: I think the system is gonna take years to catch up. I think it's just so important. Is there anything that I didn't ask you that I should have asked you about?
Dr. Erin Duralde: I would just say overall, there's so much we can do. So even though sometimes I feel frustrated that maybe the science isn't where women deserve it to be, there's still so much we can do. And the vast majority of the people we work with do feel a lot better and do see improvements in their health.
So I just wanna kind of reassure people and let everyone know: you can come, you can be heard, whether it's with us, whether it's elsewhere. Ideally look for providers who are part of The Menopause Society in some way, shape, or form 'cause it's gonna be more evidence-based care. And let's keep pushing for more developments, but also let's avail ourselves of the good treatments that we have available already now. I think there's a lot of reason to be hopeful.
Sharon Kedar, CFA: What is the science that you want done?
Dr. Erin Duralde: . Yes. I would say better testing technologies to provide more precision care. Sometimes we have to try various things over time. Could we nail it on the first try with better technologies? Maybe. Bodies keep changing over time.
That's one. Really just everything towards how can we do the most personalized, precise care and there's so much more than tests though. It's so much about having the time and space to hear what matters to people to help them the most. But let's have testing technology that supports us too.
I think it's okay now. It could be better.
Sharon Kedar, CFA: if someone goes into your office and they're like, okay so estradiol, I know it's not horse estrogen and progesterone, but can we tell a woman that we have a study that for the next 50 years she's gonna be fine and not have side effects.
Like that study doesn't exist, does it?
Dr. Erin Duralde: Only in small studies. So we're always taking what we know and then trying to apply and extrapolate. I totally agree with you. I would love to see that, like a prospective longitudinal study of the most contemporary forms. Some are underway, some have already resulted, and that's how we've been able to get to the present moment of recommending what we do.
But yeah, I share that with you.
Sharon Kedar, CFA: Dr. Duralde, thank you for everything you're doing. This is a great time for health and for women's health. I think for all genders, this is really beneficial and appreciate you leading the way.
Dr. Erin Duralde: Thank you so much. Thanks for shining a light on this.
Additional Resources
Menopause Care, Guidelines & Professional Organizations Referenced:
The Menopause Society – https://www.menopause.org/
American College of Obstetricians and Gynecologists (ACOG) – https://www.acog.org/
American Urological Association (AUA) – https://www.auanet.org/
About Your Host
Sharon Kedar, CFA, is Co-Founder of Northpond Ventures. Northpond is a multi-billion-dollar science-driven venture capital firm with a portfolio of 60+ companies, along with key academic partnerships at Harvard’s Wyss Institute, MIT’s School of Engineering, and Stanford School of Medicine. Prior to Northpond, Sharon spent 15 years at Sands Capital, where she became their first Chief Financial Officer. Assets under management grew from $1.5 billion to $50 billion over her tenure, achieving more than 30x growth. Sharon is the co-author of two personal finance books for women. Sharon has an MBA from Harvard Business School, a B.A. in Economics from Rice University, and is a CFA charterholder. She lives in the Washington, DC area with her husband, Greg, and their three kids.
Connect with Sharon
Connect with Sharon on LinkedIn: Sharon Kedar
Follow with Sharon on Instagram: @sharonkedarcfa
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