Let me tell you what actually happened, and what we now know.
The WHI Controversy
In 2002, the Women’s Health Initiative study was halted early and its results announced in a press conference that terrified women and doctors alike. Headlines screamed about increased breast cancer, heart attacks, strokes.
Hormone therapy use plummeted by 50% overnight. An entire generation of women suffered through symptoms they didn’t need to suffer through.
Here’s what got lost in the panic:
The study population was wrong for the question. The average age of participants was 63. Many were more than a decade past menopause. This is completely different from treating a 48-year-old in perimenopause.
The hormones used were specific formulations. The study used only oral conjugated equine estrogen (Premarin) and medroxyprogesterone acetate (Provera). We now know these aren’t optimal—but the results were applied to all hormone therapy.
The absolute risks were small. The headlines focused on relative risk increases that sounded alarming but represented very small absolute numbers.
Benefits were ignored. The study actually showed decreased fractures, decreased colorectal cancer, and—in the estrogen-only arm—no increased breast cancer risk.
The Reassessment (2024-2025)
Twenty years of subsequent research, including major analyses from Nature, Yale, the Korean Society of Menopause, and the International Menopause Society, have dramatically shifted the picture:
The timing hypothesis is validated. Starting hormone therapy early—within 10 years of menopause, or under age 60—produces different effects than starting late. Early initiation is protective for the heart; late initiation may not be.
Transdermal estrogen is safer than oral. Patches, gels, and sprays bypass the liver, don’t increase clotting risk, and don’t raise blood pressure like oral estrogen can.
Micronized progesterone is preferred. Unlike synthetic progestins, micronized progesterone (Prometrium) has a better safety profile, helps with sleep, and may have a lower impact on breast cancer risk.
The FDA is changing its stance. As of 2025, the FDA is initiating removal of the boxed warnings that have scared women and providers for two decades.
Current Evidence
| Outcome | Finding | Timing Matters? |
|---|---|---|
| Cardiovascular | Protective if started early; potentially harmful if late | Yes—within 10 years of menopause |
| Breast cancer | Small absolute risk increase with combined estrogen + progestin; estrogen-only may not increase risk | Duration matters |
| Bone health | Prevents fractures; effect is maintained while taking HT | Any age |
| Cognition | May protect if early; may harm if late | Yes—under 60 |
| Depression | Effective for perimenopausal depression | During transition |
| Hot flashes | Most effective treatment available | Any stage |
| Vaginal symptoms | Highly effective; local estrogen is safe for most | Any stage |
Types of Hormone Therapy
Estrogen Delivery
Transdermal (patches, gels, sprays): Generally preferred. Lower risk of blood clots because it bypasses the liver.The Menopause Society. The 2022 Hormone Therapy Position Statement of The North American Menopause Society. Menopause. 2022;29(7):767-794. More stable blood levels than oral. Options include patches (Climara, Vivelle-Dot), gels (EstroGel, Divigel), and sprays (Evamist).
Oral pills: Higher risk of blood clots and stroke. Affects liver proteins (including clotting factors). May work better for some women; metabolism varies.
Vaginal (local): For vaginal and urinary symptoms specifically. Minimal systemic absorption—safe for many women who can’t take systemic hormones, including many breast cancer survivors.ACOG Committee Opinion No. 659. The Use of Vaginal Estrogen in Women with a History of Estrogen-Dependent Breast Cancer. Obstetrics & Gynecology. 2016;127(3):e93-e96. Comes as creams, tablets, rings, or suppositories.
Progestogen (required if you have a uterus)
If you have a uterus, you need progestogen to protect the uterine lining from estrogen stimulation. Without it, estrogen alone increases risk of endometrial cancer.
Micronized progesterone (Prometrium): Body-identical progesterone. Better side effect profile than synthetic progestins. May help sleep (take at bedtime). Probably lower breast cancer risk than synthetic progestins.
Synthetic progestins (MPA, norethindrone): More side effects—mood changes, bloating—for some women. The type used in the WHI study.
Hormonal IUD (Mirena): Provides local progestogen protection to the uterus. Can be combined with estrogen therapy. Good option if you also need contraception (yes, you may still need contraception during perimenopause).
Testosterone
Testosterone isn’t FDA-approved for women in the US, but it’s used off-label and prescribed routinely in other countries for low libido, fatigue, and wellbeing. If this interests you, discuss it with your provider—preferably one knowledgeable about menopause.
Who Can and Can’t Use Hormone Therapy
Generally good candidates:
- Women under 60 or within 10 years of menopause
- Significant symptoms affecting quality of life
- No contraindications (see below)
Absolute contraindications:
- History of breast cancer (though local vaginal estrogen is often still safe—discuss with your oncologist)
- History of blood clots (though transdermal may be considered)
- Active liver disease
- Unexplained vaginal bleeding
- Known or suspected pregnancy
Situations requiring careful consideration:
- Family history of breast cancer
- History of stroke or heart disease
- Migraine with aura
- Gallbladder disease
- High triglycerides
If you have a complex medical history, find a provider who specializes in menopause—not one who reflexively says no because they’re not comfortable with the nuances.
Starting Hormone Therapy
Some practical considerations:
It takes time to work. Full effect for hot flashes may take 4-8 weeks. Don’t give up too quickly.
Dosing may need adjustment. Many women start on a standard dose and adjust based on response. Some need more; some need less.
There may be side effects initially. Breast tenderness, bloating, spotting—these often settle within a few months.
You don’t have to stay on it forever. The decision about duration is individual. Some women use it for a few years during the worst of the transition; others stay on it longer. There’s no mandatory stop date.
Stopping should be gradual. Abruptly stopping can trigger a return of symptoms. Tapering is usually better.
Finding a Knowledgeable Provider
Many providers are still operating on outdated WHI-era fears. You deserve someone who:
- Understands the timing hypothesis
- Knows the difference between formulations
- Takes your symptoms seriously
- Discusses both risks AND benefits
- Treats you as a partner in decision-making
See Finding Care for how to find and advocate with providers.
I hold no allegiance to hormone therapy as the only answer. For some women, other approaches work better or are more appropriate. For others, hormones are exactly what they need. What I want is for you to have accurate information and the freedom to choose—not to be scared away from an effective treatment by twenty-year-old headlines.