Hormone Replacement Therapy
Myths, Facts, and the Case for Estrogen and Progesterone
Do you experience night sweats, hot flashes and have just been told that’s just “part of peri/menopause?”
While many women experience these symptoms during this transition phase of life, that doesn’t mean there’s nothing that can be done to help!
Hormone Therapy (HT) or Hormone Replacement Therapy (HRT), also known as menopausal hormone therapy, involves the use of estrogen—alone or in combination with progesterone—for the treatment of symptoms related to perimenopause and post menopause. It remains the most effective intervention for managing vasomotor symptoms (e.g., hot flashes, night sweats), urogenital atrophy, and osteoporosis prevention (North American Menopause Society [NAMS], 2022).
Despite its benefits, HRT has been widely misunderstood—largely due to misinterpretations of the Women’s Health Initiative (WHI) study in 2002. This article explores the evidence behind modern HRT, clears up persistent myths, and offers a clearer understanding of its safety and utility.
As always, these articles are designed to help inform and empower. This is not saying that hormone replacement therapy is the only solution to your symptoms. I highly encourage you to find a provider that will work with you to decide on what treatment approach is best for you.
Benefits of Estrogen and Progesterone
Technically estrogen is FDA approved to treat four things: hot flashes, night sweats, genitourinary syndrome of menopause (GSM), and osteopenia.
While FDA approval/oversight is a good thing, there are still many other research-backed benefits of HRT. The main reason it’s only “approved” for those four items is that the FDA requires studies to be performed in certain ways (like having decades worth of data that we just don’t have time to complete).
What’s important to note is that many prescriptions are technically “off-label,” meaning they are intended to treat one thing, but actually treat something else.
For example, many doctors may prescribe SSRIs (anti-depressants) to help with menopause symptoms before prescribing HRT. Similarly, Gabapentin (FDA approved to treat seizures) is commonly used for pain, neuropathy, and even anxiety.
This is not to say that we shouldn’t care about the FDA approval (we should), it’s just to point out that even if you’re experiencing other symptoms of perimenopause/menopause, hormone therapy may still be highly beneficial.
That being said, let’s look at what HRT can help with.
Symptom Relief & Quality of Life
Estrogen therapy has been shown to significantly reduce the severity and frequency of hot flashes, improves sleep, reduces vaginal dryness, and improves quality of life (Manson et al., 2013). Also, improvements in sexual health and improved ability to work longer and feel better have been found as clinical benefits (Hirsch, 2025).For women with an intact uterus, progesterone is prescribed alongside estrogen to protect the endometrium.
Bone Health
Both systemic estrogen and estrogen-progestin therapies have been shown to preserve bone mineral density and reduce the incidence of osteoporotic fractures (NAMS, 2022).
Cardiovascular Health
When initiated in women under 60 or within 10 years of menopause onset, HRT is associated with a reduced risk of coronary heart disease and all-cause mortality (Manson et al., 2017; Hodis et al., 2016).
This is HUGE! Heart disease is the #1 killer of women. Estrogen plays a vital role in controlling our blood vessels and when we lose estrogen, our risk of heart issues significantly increases.
Another important note on cardiovascular health is the “10 year rule”. Many, many studies, doctors, etc. will talk about this “within 10 years of menopause” being critical to starting HRT.
While that may be when it’s most effective in terms of prevention, that doesn’t mean you can’t get on HRT if you’re older than 60 and beyond 10 years of menopause (Hirsch, 2025). This is another reason I advocate to find a provider who really listens to you and enables you to be the driver in decision making.
Brain and Mood
While the evidence is mixed, some studies suggest that estrogen therapy started soon after menopause may reduce the risk of cognitive decline and improve mood (Shuster et al., 2010).
Similar to our discussion about FDA approval, the research here is a little inconclusive because we just don’t have the research study that looks at two, randomized groups over the course of decades to see how HRT did or didn’t impact dementia.
So while HRT technically doesn’t “prevent dementia” per research, we do know that estrogen also plays a huge role in brain health, so it makes sense that HRT could have an impact on maintaining that healthy brain for our lifespans.
Debunking the Myths: What the 2002 WHI Study Got Wrong
The 2002 Women’s Health Initiative (WHI) study is one you may have heard of.
This study was great in that it included thousands of women. It was initially designed to look at coronary heart disease, non-fatal heart attack, and coronary heart disease death, not for the management of menopause (Hirsch, 2025).
The study had two groups:
Group A took oral conjugated equine estrogen (CEE) and medroxyprogesterone acetate (MPA)-which is a form of progesterone- versus a placebo group
Group B was made up of women who had previously had a hysterectomy so they took oral CEE alone versus a placebo group
The study was stopped early due to an “increased risk” of breast cancer in Group A.
This led to widespread fear of HRT and had women flushing their hormones down the toilet.
But here’s the thing… those results were not significant! Meaning that there wasn’t a significant increase in breast cancer beyond the normal risk. Additionally, there were other key limitations:
Age bias: The average age of participants was 63, well beyond typical menopause onset. Those in the 70-79 age range made up 21% of the study (Hirsch, 2025).
Formulation: The study used older, synthetic hormone formulations not representative of today's low-dose transdermal or bioidentical options.
Overgeneralization: Results were applied to all postmenopausal women, regardless of age or symptom severity.
Reanalysis of WHI data and follow-up trials have shown that starting HRT in younger (50-59), newly menopausal women (within 10 years of menopause onset) results in significantly lower risks of cardiovascular disease, all-cause mortality, reduction in menopausal symptoms, improved quality of life, osteoporosis prevention, and prevention of new onset of diabetes. (Manson et al., 2017; Hodis et al., 2016; Hirsch, 2025).
What Are the Real Risks?
While no treatment is entirely risk-free, the risks of modern HRT are often small and manageable, particularly with individualized dosing and delivery methods.
Breast cancer
Slightly increased with combined HRT, but the absolute risk is about 3 additional cases per 1,000 women over 5 years (Chlebowski et al., 2020). Estrogen-only HRT may even lower risk in women with prior hysterectomy (Manson et al., 2013).
When it comes to breast cancer risk, I want to acknowledge that it is very scary and don’t want to downplay that.
However, it’s important to note that HRT does not carry the highest risk of increasing breast cancer- there are many other things that contribute to one’s risk.
Just one example is alcohol consumption. Those who drink one glass of alcohol per day have an 13.3% absolute risk, compared to 11.3% risk for those who have less than one drink per week. Said another way, the absolute risk of those who drink one glass of alcohol per day is 18 additional cases per 1,000 women (Breastcancer.org, 2025).
Endometrial cancer
Unopposed estrogen increases risk, but this is eliminated with adequate progesterone (Beral et al., 2005).
Blood clots
Oral estrogen increases the risk of venous thromboembolism. Transdermal routes do not appear to increase this risk (NAMS, 2022).
Once again, I want to highlight that the risk is very low. Lower, in fact, than the risk of blood clot associated with oral birth control pills.
HRT can still be prescribed for women with a history of blood clot, so once again, find a provider who listens to you and will talk out the best options for you.
Who Shouldn’t Be on HRT?
At the risk of sounding like a broken record, choosing to go on HRT is 100% your decision, so I’m truly not advocating for this being the only route. In future articles we will discuss other treatment options.
However, there are still myths out there about how things like family history play into receiving a prescription for HRT, so I just want to lay some of those to rest as well.
Lastly, remember to talk to your provider- even if you think you may fall into one of the following categories- because you may actually be surprised what treatments are still available to you.
Contraindications (Hirsch, 2025):
Estrogen receptor-positive breast cancer
Active liver disease (cirrhosis)
Prior stroke or life-threatening clot
Prior hormone-induced clots (due to pregnancy or previous HRT, for example)
High-risk endometrial/ovarian cancer
Recent heart attack
Unexplained vaginal bleeding (this mostly needs to be checked by your doctor, not necessarily a contraindication)
Note that family history of breast cancer or blood clot are not on this list. So again, for the people in the back, please speak with your provider.
If you’re not having luck finding a provider who will talk these things out with you, check of Dr. Heather Hirsch’s directory HERE to find a menopause provider near you.
Evidence-Based Use: How to Minimize Risk
Start Early: Ideally within 10 years of menopause or before age 60 (Hodis et al., 2016).
Use the Lowest Effective Dose: Tailor dosing to symptom severity.
Choose the Safest Route: Transdermal estrogen reduces clot risk and bypasses first-pass liver metabolism (NAMS, 2022).
Add Progesterone if Uterus is Present: Prevents endometrial hyperplasia and cancer (Beral et al., 2005).
Reevaluate Regularly: Annual check-ins with your provider can help assess risks and benefits over time.
In Conclusion
The 2002 WHI study caused a cascade of fear that led many women and providers to abandon hormone therapy—often unnecessarily. Today, we know more.
Modern hormone therapy, when used thoughtfully, is safe, effective, and life-changing for many women.
As with any medical decision, HRT should be personalized. When started early, in the right candidate, and with appropriate formulations, the benefits of estrogen and progesterone often far outweigh the risks.
References
Beral, V., Reeves, G., Bull, D., & Green, J. (2005). Endometrial cancer and hormone-replacement therapy in the Million Women Study. The Lancet, 365(9470), 1543–1551. https://doi.org/10.1016/S0140-6736(05)66455-0
Chlebowski, R. T., Anderson, G. L., Aragaki, A. K., Manson, J. E., Stefanick, M. L., Pan, K., ... & Wactawski-Wende, J. (2020). Association of menopausal hormone therapy with breast cancer incidence and mortality during long-term follow-up of the Women's Health Initiative randomized clinical trials. JAMA, 324(4), 369–380. https://doi.org/10.1001/jama.2020.9482
Hodis, H. N., Mack, W. J., Henderson, V. W., Shoupe, D., Budoff, M. J., Hwang-Levine, J., ... & Azen, S. P. (2016). Vascular effects of early versus late postmenopausal treatment with estradiol. New England Journal of Medicine, 374(13), 1221–1231. https://doi.org/10.1056/NEJMoa1505241
Manson, J. E., Chlebowski, R. T., Stefanick, M. L., Aragaki, A. K., Rossouw, J. E., Prentice, R. L., ... & Anderson, G. (2013). Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women's Health Initiative randomized trials. JAMA, 310(13), 1353–1368. https://doi.org/10.1001/jama.2013.278040
Manson, J. E., Aragaki, A. K., Rossouw, J. E., Anderson, G. L., Prentice, R. L., LaCroix, A. Z., ... & Howard, B. V. (2017). Menopausal hormone therapy and long-term all-cause and cause-specific mortality: The Women's Health Initiative randomized trials. JAMA, 318(10), 927–938. https://doi.org/10.1001/jama.2017.11217
North American Menopause Society. (2022). The 2022 hormone therapy position statement of The North American Menopause Society. Menopause, 29(7), 767–794. https://doi.org/10.1097/GME.0000000000002028
Shuster, L. T., Rhodes, D. J., Gostout, B. S., Grossardt, B. R., & Rocca, W. A. (2010). Premature menopause or early menopause: Long-term health consequences. Maturitas, 65(2), 161–166. https://doi.org/10.1016/j.maturitas.2009.08.003
Writing Group for the Women’s Health Initiative Investigators. (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results from the Women’s Health Initiative randomized controlled trial. JAMA, 288(3), 321–333. https://doi.org/10.1001/jama.288.3.321
Breastcancer.org. (2025, May ?—update based on publication). Alcohol and breast cancer risk: Surgeon General advisory. Breastcancer.org. Retrieved July 15, 2025, from https://www.breastcancer.org/news/alcohol-breast-cancer-risk-surgeon-general-advisory
Hirsch, H. (2025). Allied health professionals course. Heather Hirsch Academy.https://www.heatherhirschmd.com/
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