Advice about whether women undergoing menopause should take hormone replacement therapy (HRT) has oscillated between two extremes in the past couple decades.
At first, doctors rubber-stamped HRT for the vast number of women with symptoms such as hot flashes, night sweats, sleep apnea, vaginal atrophy, and cognitive decline. Then a slight uptick in the risk of breast cancer among one of two cohorts in) a 2002 study by the Women’s Health Initiative (WHI) halted HRT recommendations.
Media headlines stirred up panic among women and doctors who believed there were more harms than benefits to HRT—a message that is beginning to flip. As a clearer picture emerges, doctors are better able to identify who should get HRT and who should not.
“We really need to get this across to women because they’re searching for that answer for these really debilitating symptoms,” Karen Martel, a nutritionist and weight loss coach, told The Epoch Times. ”They’re trying every supplement under the sun, and they’re exercising, and they’re eating perfectly, and yet they can still suffer immensely.”
Martel, now a certified hormone specialist, described herself as a perfect eater who managed to gain 15 pounds rapidly when menopause symptoms began.
“I had hot flashes and night sweats, no libido, and dry vagina,” she said.“I had every symptom, and I could not get myself out of that until I replaced the hormones.
“For some women, it’s an important piece.”
Nuances of Hormone Treatment
One consequence of the WHI has been a more nuanced approach to HRT, according to Dr. Joel Evans, an OB-GYN and founder and director of the Center for Functional Medicine. It’s not a universal green-light therapy, he said.
For instance, some women shouldn’t take HRT at all, and for everyone else, it’s vital to take the right hormones, sourced the correct way, and at the right time.
“I’ve been trying to simplify the HRT story forever, and it’s really a challenge,” Evans told The Epoch Times. “HRT has been a pendulum.
“The truth is somewhere in the middle ... but it’s more toward it’s a good thing. The general recommendation is for most women that are at average risk of breast cancer, hormones are safe.”
There are two main types of HRT, according to The Menopause Society:
- Estrogen/progestogen: The combination therapy is for women who still have a uterus, as progestogens prevent cell growth in the uterus that can lead to cancer. The Menopause Society guidelines state that this combination may slightly increase risk of breast cancer if taken for more than four to five years. Progestogen (or progestins) is a synthetic hormone. Evans and other doctors may recommend bioidentical progesterone, meaning it’s chemically identical to progesterone your body produces—often sourced from plants.
- Estrogen Only: Women who have no uterus take only estrogen therapy.
In either case, the organization recommends using the lowest dose of estrogen that relieves hot flashes.
HRT Messaging
Today’s mid-life women are navigating their menopausal terrain with motherly advice ringing in their ears that HRT is too risky. The previous generation was likely taken off HRT or told it was unsafe.
Newer messaging is often contradictory. News media, social media, and celebrities have heightened demand for hormone therapy, according to a July review in The Annals of the New York Society of Sciences.
Recent critiques of the original WHI study suggest it was flawed regarding the age at which a woman should begin HRT, and that it didn’t adequately acknowledge that the specific types of hormones used make a difference. In short, HRT could help menopausal symptoms like hot flashes among women who began before age 60 and didn’t have any contraindications.
Additionally, the WHI’s underreported findings included a lowered breast cancer risk in the study’s second cohort. The WHI breast cancer finding that showed a doubled risk of breast cancer—two cases per 1,000 versus one per 1,000—remained rare.
Critics have noted that the WHI largely ignored premenopausal women. The study included women up to age 79, and about 83 percent of the participants were more than five years past menopause.
Menopause Society guidelines on hormone therapy state that the benefits of HRT outweigh the risks for healthy women who are younger than 60 and within 10 years of menopause.
Beyond Hot Flashes
Evans said that hormones also help prevent top women’s health issues such as
heart disease,
dementia, and thinning bones or
osteoporosis.
“Now we know, for instance, hot flashes are bad for the heart,” he said. Night sweats interrupt sleep, and interrupted sleep is physically problematic for women.
“The belief to just grin and bear it and tough it out may have been true for your mother’s menopause, but it’s not true for your menopause.”
Most of the risks associated with HRT are uncommon, according to The Menopause Society, though its guidelines note that there’s a slightly increased risk of heart disease if you begin hormone therapy further from menopause or after age 60.
HRT is not associated with weight gain, according to The Menopause Society, and may lower women’s chances of developing Type 2 diabetes.
Despite estrogen’s many benefits, Martel said, it’s not a panacea. For women in the second half of life, she added, foundational lifestyle changes—such as prioritizing protein in their diets, lifting weights, and practicing intermittent fasting—are ever more important.
“Hormones are not the miracle things that are going to solve all these problems,” she said.“You can’t take a hormone and think you’re not going to get Type 2 diabetes while you’re eating like crap.
“But the hormones do something that those [lifestyle] things can’t do.”
Smart Shoppers
The WHI study involved a conjugated estrogen derived from pregnant horse urine. Known by the brand name
Premarin, the drug contains a number of types of estrogen with only a very small amount of estradiol.
Some have questioned whether the horses used for the drug’s production are treated well. Others have concerns that Premarin doesn’t match up well with human estrogen.
Evans prefers using a bioidentical form of estradiol, the type of estrogen that’s common in women of reproductive age. Estrogen can be delivered in different forms such as pills, patches, gels, and creams.
There’s also a difference between compounded hormones and conventional hormones, which only come in a set dosing. All ingredients are approved by the Food and Drug Administration, but compounded hormones are the only ones that can be customized.
According to Dr. Wendy Warner, functional medicine gynecologist and hormone expert, the problem with conventional doses is that “some will be getting too much or not enough.”
She said some could argue, however, that compounded hormones leave patients vulnerable to human error or suboptimal ingredients. Mayo Clinic has stated that there’s no clinical evidence that compounded hormones are more effective or safer.
A 2024 opinion article in Frontiers in Reproductive Health raises concerns that compounded hormones prey on past fears over HRT and ought to be studied with the same rigor as FDA-approved products.
However, the personalized approach of compounded hormones could benefit some women, according to Mayo Clinic. Compounding pharmacies make up doses the way doctors prescribe them—something Warner said allows her to also include other hormones.
While estrogen and progesterone are the dominant ones used in HRT, there are others that boost overall health, Warner said. Testosterone and DHEA also decline in menopause and are sometimes included in more personalized hormone therapies.
Stoplight System
Warner said she uses a functional medicine “stoplight” approach when it comes to prescribing HRT to her patients.
Green Light: HRT is strongly encouraged for women who are going through menopause before age 40 and have no contraindications.
“If that woman doesn’t go on hormones, she is at such high risk for osteoporosis and heart disease and cognitive decline because she’s missing out on 15 years’ worth of hormones,” Warner said. “I don’t push things on people very often, but I very strongly encourage hormones for those people.”
Red Light: She would not consider HRT for women with undiagnosed abnormal bleeding or with newly diagnosed breast cancer, especially when the cancer contains estrogen receptors.
Evans takes that a step further. For women who have high estrogen levels and a family history of breast cancer, he prescribes other options first. Women with a history of strokes, blood clots, or clotting disorders should also avoid orally prescribed HRT.
Both the red and green light groups represent a small number of women, Warner said, with the vast majority of women in a proceed-with-caution group.
Yellow Light: Women who have menopausal symptoms can consider using HRT depending on the severity of symptoms, balanced with the other benefits they’re seeking and the risks they’re willing to take.
Warner said this is the area in which conversations about HRT have evolved during the years she’s practiced medicine.
“We can do it for hot flashes and night sweats, but I have a lot of other tools in my toolkit. If you want to work on the vasomotor symptoms some other way with herbs and things, we can do that,” she said.
“But just remember you could be getting these other benefits of improved cognition, bone health, and heart protection from hormones as well.”
When Hormones Aren’t Enough
Tools such as dietary and lifestyle changes are not only beneficial for those women who cannot take HRT, but also a good way to address symptoms that aren’t entirely alleviated with hormones, Evans added.
While HRT dosing varies widely, it should not exceed recommended standards, Evans said. Yet some doctors may continue to increase estrogen for women who are still uncomfortable on HRT.
“I believe, as long as you’re on the standard dose, you can try to get rid of any symptoms that are remaining with non-hormonal approaches. Those can be herbs, medication, acupuncture, reiki, and all sorts of other things that can be beneficial,” he said.
“The real sweet spot for these things is when you’re on the dose of HRT that we know is protective—you don’t have enough relief and you bring the other things in.”
