Explore this Article
How does the body respond to the decline in reproductive hormones?
What are the safety concerns about supplemental estrogen?
What is the relationship between estrogen and cancer?
Who is — and is not — a good candidate for HRT?
I choose not to use HRT: Does this also involve risk?
In 2020, George Keller was 52 years old and deep in perimenopause. The Minneapolis-based actor recalls a night of lying sleepless on her couch, timing her hot flashes like they were labor contractions, then recording the times in her notes app: 10:47, 11:30, 12:02, 12:45, 1:00, 2:30 . . .
This can’t be normal, she thought.
These hot flashes were nothing like her body’s usual response to heat or exercise.
“It feels like you’re going to spontaneously combust,” Keller recalls. “I remember standing outside in my bare feet when it was 14 below zero and feeling the ice melt beneath my feet.”
She had heard about hormone replacement therapy in her online circles and wondered if it might help. Yet when she asked her doctor about HRT, her doctor suggested antidepressants.
Keller was not convinced that mood medications were the answer. If hormones were contributing to her struggles, she wanted to know if they could also be part of the solution.
Eventually, her doctor agreed to prescribe HRT: in her case, a low-dose estradiol patch paired with oral progesterone. Keller’s hot flashes became less frequent, and as she slowly increased her estradiol dose, they disappeared. Her sleep improved, as did her mood and energy.
Though Keller welcomed the relief she got from HRT, she didn’t make her decision lightly.
“Of course, I questioned whether there would be a connection between HRT and cancer,” she says. Her half-sister died of breast cancer that spread to her brain, her mother had colon cancer, and two of her grandparents died of cancer later in life.
After researching further, Keller made a personal calculation. “I’d rather enjoy my life and feel like a complete human being,” she says. She didn’t want to just endure her symptoms out of fear of risk to her future health. She also wonders whether the risk may have been overstated.
The decision about whether to use HRT is one that millions of perimenopausal and menopausal women now find themselves facing.
Over the past two decades, the pendulum of public opinion about HRT has swung dramatically. In the early 2000s, there was widespread alarm about findings in the Women’s Health Initiative study, which showed a connection between HRT and increased breast cancer risk. And so in 2003, the U.S. Food and Drug Administration applied black-box warnings to HRT products. Today, newer studies suggest that the benefits of HRT may outweigh the risks — at least for some women.
In November 2025, the FDA tempered the black-box warning for hormone therapies for menopause to reflect updated science. The agency stated that the original caution had been based largely on research involving older women taking hormone formulations that differed significantly from most of those prescribed today.
Confusion about the safety of HRT remains. Even with the FDA’s about-face, the Menopause Society reported in 2024 that less than 4 percent of women between ages 50 and 60 use hormone therapy. Meanwhile, telehealth platforms, social media influencers, and hormone-focused clinics are promoting hormonal treatments for menopause more aggressively than ever — often presenting HRT as a long-overdue solution to a slew of aging-related conditions and complaints.
It can be hard to know what to believe, so we sought help from specialists to answer some common questions surrounding HRT — including how it works, what the real risks are, and how to decide whether it’s right for you.
What is HRT?
Hormone replacement therapy is a medical treatment that supplements the body’s own hormones — most commonly estrogen and progesterone, and sometimes testosterone. The therapy delivers these hormones in various forms: pills, skin patches, gels, sprays, or vaginal creams and tablets.
During the years leading up to menopause (a phase called perimenopause), estrogen and progesterone levels fluctuate and decline. This volatility can trigger a wide range of physical and emotional symptoms, including hot flashes, night sweats, weight gain, vaginal dryness, irregular periods, irritability, and insomnia.
At menopause, estrogen levels drop to a permanently lower baseline, laying the groundwork for bone loss as well as cardiovascular and metabolic changes. This is why many healthcare professionals recommend HRT to replace estrogen as it declines.
“Not everybody needs the same hormone in the same dose at the same time.”
Estrogen may be the most commonly prescribed hormone for menopause and perimenopause; it directly addresses most of their hallmark symptoms, particularly hot flashes and night sweats. For women who still have a uterus, progesterone is typically prescribed alongside estrogen to help protect the uterine lining from excessive growth, which is associated with endometrial (uterine) cancer. Progesterone can also influence the brain’s GABA receptors, helping promote relaxation and relief for menopause-related anxiety and insomnia.
Proponents of HRT note that the therapy can be useful for more than just menopausal symptoms.
“Estrogen has more than 400 purposes in the body,” says Karen Kaufman, MD, a board-certified obstetrician and gynecologist, and the medical director of MIORA in Colorado. “It’s involved in bone health, joint health, brain health, heart health, vaginal health — really almost every system.”
Most experts agree that HRT works best and is least risky when clinicians prescribe the lowest effective doses, tailoring treatment to a person’s symptoms, health history, and risk factors. In practice, that means hormone therapy is rarely a one-size-fits-all prescription.
“It’s really a personalized approach,” Kaufman says. “Not everybody needs the same hormone in the same dose at the same time.”
How does the body respond to the decline in reproductive hormones?
Hormones affect our health in many ways.
Libido: Reproductive hormones play a direct role in sexual desire, arousal, and pleasure. As estrogen drops, vaginal tissues can become thinner and drier. Changes in testosterone levels can also influence sexual interest.
Supplemental hormones can be used to treat all these symptoms. “Some women respond better to estrogen for libido, and others respond better to testosterone,” Kaufman says, stressing the need for individualized treatment.
Libido isn’t purely hormonal, though. Sexual interest is also affected by stress, sleep, relationship dynamics, and overall health. For some women, restoring hormone levels can improve comfort and desire; for others, addressing lifestyle or emotional factors may be just as important.
Bone health: Estrogen, progesterone, and testosterone all help stimulate and maintain bone tissue. When they decline, bone loss can accelerate. According to the Bone Health & Osteoporosis Foundation, half of women over 50 will break a bone because of osteoporosis.
“The hormone drop-off is absolutely one of the reasons for bone-health issues like osteopenia and osteoporosis postmenopause,” Kaufman says. “Without estrogen, progesterone, and testosterone, we start to lose bone density.”
She adds that supplementing with these three hormones can have profound effects on bone strength.
Brain health: Estrogen plays a role in glucose metabolism in the brain. Low levels can lead to brain fog, including concentration and memory problems. These issues are common enough to have their own nickname: menopause brain.
“Women in particular really need estrogen for their brain health.”
“Women in particular really need estrogen for their brain health,” Kaufman says, noting that the hormone can help prevent cognitive decline by protecting the brain from the plaque associated with Alzheimer’s.
Studies have found that menopause may lead to reductions in the brain’s gray-matter volume. Yet there’s also evidence that this volume may partially recover after menopause — and there’s no evidence that menopausal brain fog is associated with a subsequent risk of dementia.
Joint health: Some women experience joint pain for the first time during perimenopause and menopause. Because estrogen can act as a natural anti-inflammatory and lubricant for the body, declining levels can lead to systemic inflammation, thinning cartilage, and reduced collagen production in the joints.
Activity level, prior injuries, muscle loss, and inflammatory conditions each play their own role in joint health. Yet when joint symptoms appear or worsen alongside other menopausal changes, hormone therapy may help relieve discomfort, especially when combined with strength training and anti-inflammatory nutrition.
Mental and emotional well-being: Estrogen and progesterone help regulate mood, stress, and sleep. When these hormones decline, many women experience more anxiety, irritability, and emotional volatility. Still others experience a loss of emotional range, says Kaufman. “People will say, ‘I just feel flat. I can’t explain it. I’m just not myself.’”
Antidepressants are often prescribed for these symptoms, but Kaufman says hormonal changes are frequently at play and that it can be more effective to address them first.
What are the safety concerns about supplemental estrogen?
Concerns about supplemental estrogen stem largely from the Women’s Health Initiative (WHI) study results that were released in 2002. Prior to the study, hormone therapy was considered the gold standard for menopausal symptom relief, but the WHI showed an increase in the risk of breast cancer, cardiovascular disease, and stroke. The 1998 HERS study also contributed to a wave of concern that has caused many to shy away from HRT in the years since.
Now, researchers have pointed out serious flaws in both studies. Specifically, WHI and HERS focused on older women — a mean age of 63 to 67. In the HERS study, all participants already had cardiovascular disease. About 70 percent of subjects in the WHI trial were overweight or obese, half were current or former smokers, and the majority were a decade or more past menopause.
“The risks and benefits of hormone therapy depend heavily on timing, formulation, and the individual patient’s health profile.”
These study participants were given oral conjugated equine estrogen, derived from the urine of pregnant horses, along with a synthetic progestin that differs markedly from the bioidentical progesterone that’s more widely used today.
“The real safety concern is around toxic, synthetic progesterone that we know increases risk for heart disease, cognitive decline, and breast cancer,” Kaufman says. “I haven’t prescribed that in 25 years, and hopefully nobody is anymore.”
Timing matters, too. “Later reanalysis showed that starting hormones within 10 years of menopause produces very different outcomes than starting them decades later,” says Sara Szal, MD, author of Women, Food, and Hormones. “The risks and benefits of hormone therapy depend heavily on timing, formulation, and the individual patient’s health profile. The one-size-fits-all conclusion from 2002 doesn’t hold up today.”
In late 2025, when the FDA announced it would update the black-box warnings on menopause hormone therapies, it requested that companies remove references to increased risks of cardiovascular disease, breast cancer, and dementia.
What is the relationship between estrogen and cancer?
Concern about breast cancer risk is one of the most common reasons women hesitate to use hormone therapy. Again, much of that fear traces back to reports from the WHI study in the early 2000s.
Subsequent analyses suggest that the increased breast cancer risk seen in the study may have been partly driven by synthetic progestin rather than estrogen. “Estrogen alone appears neutral or protective against breast cancer in some studies,” Szal says.
Observational research studying estrogen paired with bioidentical progesterone has not shown the same risk associated with older synthetic formulations. But researchers note that more large randomized trials directly comparing different types of progesterone are still needed to confirm their safety profiles.
“It’s incredibly important to balance your estrogen and progesterone.”
Estrogen does stimulate tissue growth, including in the lining of the uterus, so women with a uterus are typically prescribed progesterone alongside estrogen therapy. The progesterone helps counterbalance estrogen’s growth-promoting effects and reduces the risk of certain cancers.
“When we think about something like uterus cancer, it’s incredibly important to balance your estrogen and progesterone,” Kaufman says.
Who is — and is not — a good candidate for HRT?
For many women, hormone therapy can be a safe and effective way to manage symptoms of perimenopause and menopause — particularly when started relatively early in the transition. But clinicians emphasize that it isn’t appropriate for everyone.
“Safe doesn’t mean risk-free,” Szal says. “Every therapy has a context, and women deserve counseling about their specific risks.”
In general, many healthy women under age 60 — or within about 10 years after their last menstrual period — may be good candidates for hormone therapy if they need help with symptoms like hot flashes, sleep disruption, mood changes, or vaginal dryness.
Yet it’s still important to consider your medical history and risk factors. “The conversation is always individualized,” Szal says. “Personal and family history, genetic risk, and metabolic health all matter.”
Some women may be advised to avoid systemic hormone therapy altogether (this includes any hormone treatments that enter the bloodstream). According to guidelines from major medical organizations, systemic hormone therapy is generally not recommended for women with certain conditions:
- a personal history of breast cancer or other estrogen-sensitive cancers
- unexplained vaginal bleeding
- active liver disease
- prior blood clots, stroke, or heart attack
- certain inherited clotting disorders
In these cases, nonhormonal therapies or lifestyle strategies may be safer options. Kaufman does note that those with a history of breast cancer may still be able to pursue some forms of HRT with careful guidance from an attentive provider.
Topical hormone therapies like vaginal suppositories are another option for symptom relief. Rather than raising hormone levels throughout the body, they act on the tissues of the vagina and pelvic floor to help with vaginal dryness, pain with sex, urinary urgency, and recurrent UTIs. Because they’re more targeted, they can be an option even for women who are not good candidates for full-body HRT.
I choose not to use HRT: Does this also involve risk?
Given the swing of the pendulum toward HRT, it can seem as if using HRT is the only responsible choice — and that not using it puts you at greater risk for a range of age-related concerns. Experts say that isn’t the case.
“What matters most is your values regarding aging, personal and family medical history, and overall metabolic and immune health,” says Szal. “Hormone therapy should never be one-size-fits-all.”
“Hormone therapy should never be one-size-fits-all.”
In other words, HRT is a tool. It’s not a requirement. Some women experience relatively mild menopause symptoms and prefer to manage them by improving sleep, building muscle, adjusting diet, and addressing stress and metabolic health.
For women disinclined to HRT, Kaufman says good nutrition and supplements that support the bones, brain, heart, breast tissue, and libido can help enhance quality of life throughout menopause and beyond.
“There are options,” she says. “It’s a very personal decision. And while there are health risks associated with low estrogen levels, estrogen therapy is not a must-have if a patient has weighed the alternatives with a trained provider.” (For more on natural alternatives to HRT, see “Making Peace With Menopause.”)
I’d like to try HRT. What’s the safest way to get started?
Get professional support. Experts say the safest way to begin HRT is to work with a knowledgeable clinician who can evaluate your symptoms, health history, and risk factors before prescribing anything.
Szal says that the right time to consider hormone therapy is when your symptoms start affecting your daily life. It can be helpful to keep a diary of symptoms to note trends over time and whether hot flashes, night sweats, insomnia, and mood changes are becoming more frequent.
“The safest approach is personalized care guided by symptoms, medical history, and appropriate testing,” Szal says. Some clinicians consider ordering lab testing to look at hormone levels, thyroid function, and metabolic health, though many providers rely primarily on symptoms to guide treatment.
A holistic approach can help you mitigate menopause symptoms.
Much also depends on which delivery method you choose — pills, patches, gels, sprays, or vaginal products. Each affects the body differently. For example, transdermal estrogen (absorbed through the skin) may carry a lower risk of blood clots than oral forms.
Once therapy begins, most clinicians recommend starting with the lowest effective doses and adjusting gradually.
“Hormone therapy is a personalized plan that requires ongoing monitoring and adjustment,” says Szal. She recommends checking hormone levels six to 12 weeks after starting HRT, then every six to 12 months. Tracking symptoms alongside lab results can give the clearest picture of what you need.
Whether you’re taking HRT or not, Szal emphasizes the importance of tending to diet, exercise, lifestyle, and stress. A holistic approach can help you mitigate menopause symptoms and support your overall health, during the transition and beyond.
What about TRT for men?
The term “andropause” is sometimes used as a male analog to menopause, but the comparison is far from exact. Hormone levels fall relatively abruptly and predictably at menopause. In males, hormone production generally declines more gradually — on average about 1 percent per year in midlife and beyond. Some don’t experience much of a decline at all, with testosterone levels staying in the normal range well into older age.
That means testosterone replacement therapy (TRT) is generally used for a narrower set of problems — most often clinically significant low testosterone, or hypogonadism — rather than as a broad response to one universal life stage.
The American Urological Association considers low blood testosterone to be less than 300 nanograms per deciliter for adult men. An estimated 39 percent of men age 45 and older have low testosterone.
In addition to age, other causes of hypogonadism include obesity, chronic stress, injuries to the brain or testes, sleep apnea, genetic disorders, and medication side effects. Symptoms may include low libido, erectile dysfunction, fatigue, reduced muscle mass, depressed mood, and low bone density. All of these can have other causes, making careful diagnosis crucial.
For men with symptomatic hypogonadism, TRT can help. Clinical trials generally show improvements in sexual desire, mood, and body composition, especially when paired with resistance training.
One of the biggest tradeoffs with TRT is fertility. When men take exogenous testosterone, the brain reduces production of luteinizing hormone and follicle-stimulating hormone, the signals that tell the testes to make testosterone and sperm. That can sharply reduce sperm count and shrink the testes.
For younger men who want to preserve fertility, clinicians may use strategies to stimulate the body’s own production of testosterone, along with recommending weight loss, resistance training, stress reduction, and better sleep. (See “11 Tips to Boost Your Testosterone” for more.)
Other downsides of TRT can include sleep apnea, acne, breast enlargement, and excessive red-blood-cell production; the latter increases the chance of blood clots.
Then there’s the prostate question. For decades, men have been warned that testosterone is fuel for prostate cancer. While it’s true that testosterone can influence prostate growth, that doesn’t automatically translate to cancer risk, says holistic urologist Geo Espinosa, ND, LAc, IFMCP.
According to current evidence, raising testosterone — whether through lifestyle measures or TRT — does not elevate prostate-cancer risk in otherwise appropriate candidates. Espinosa adds that while TRT can modestly increase prostate volume in some men, research suggests it doesn’t typically worsen lower-urinary-tract symptoms.
Like any form of hormone replacement, TRT is best undertaken with the guidance of a knowledgeable clinician who can monitor symptoms and lab markers over time to adjust treatment as needed.
This article originally appeared as “A Balanced Approach to HRT” in the September/October 2026 issue of Experience Life.
Comments (0)