By Michele Promaulayko
When my sister mentioned that her gynecologist—a man—told her she didn’t need hormone replacement therapy (HRT) because her menopause symptoms were “mild,” I had to put the phone down and take a deep breath. First, it’s never OK to ask a woman to quietly tolerate any amount of needless suffering. Second, and more importantly, her doctor’s comment revealed a dangerous blind spot in mainstream medicine: HRT is not just about managing symptoms, such as hot flashes and mood swings; it’s about protecting your heart, brain, bones and more for the next 30-plus years.
In fact, HRT (now commonly referred to simply as hormone therapy) is one of the most evidence-backed treatments in women’s health. And sadly, a generation of women was deprived of its remarkable benefits because of one deeply flawed report.
The Study That Got It Wrong
National prescribing data shows that between 1995 and 2002, roughly 15 million women were using HRT. Then, in 2002, the Women’s Health Initiative (WHI), a landmark government-funded study, announced it was stopping its combined hormone therapy trial early, citing increased risks of breast cancer and cardiovascular disease. Overnight, HRT became a pariah—doctors stopped recommending it, and women stopped asking for it.
After the WHI study was halted, HRT use cratered, dropping from roughly 1 in 4 American women to fewer than 1 in 20. But as we now know from countless documented sources, the study didn’t hold up. Robin Berzin, M.D., founder and CEO of Parsley Health, explains: “The WHI study used the wrong hormones, given to the wrong women, at the wrong time.”
The average age of participants was 63, well over a decade past the average onset of menopause at age 51 for American women. (Today, guidelines recommend starting HRT within 10 years of the final menstrual period for an ideal risk-benefit window.) The synthetic hormones used—conjugated equine estrogen paired with a synthetic progestin—behaved very differently in the body than the bioidentical hormones most commonly prescribed today. And crucially, the reported 26 percent increased risk of breast cancer amounted to eight additional cases per 10,000 women, a statistic not widely publicized.
The fallout: One study estimates as many as 91,000 American women died prematurely between 2002 and 2011 from conditions that HRT might have helped prevent. But this study only looked at women who’d had a hysterectomy and were between the ages of 50 and 59 during those years, so that number likely grossly underestimates the real toll.
The Reckoning
In November 2025, after a review of scientific literature, an expert panel and a public comment period, the FDA removed the black box warning (its most severe safety label) from HRT products for menopause.
“Tragically, tens of millions of women have been denied the life-changing and long-term health benefits of hormone replacement therapy because of a medical dogma rooted in a distortion of risk,” FDA commissioner Marty Makary, M.D., said when the rollback was announced.
The updated HRT labels went into effect in February 2026, but the work of undoing more than two decades of entrenched misinformation, fear-mongering and demonization is far from over.
The Whole Health Story
The tropes of menopause focus on midlife hot flashes and midsection weight gain; the truth is much more complex. “Estrogen is important throughout our lives, not just during the reproductive years, because it supports every major organ system in our body,” explains Amy Killen, M.D., a women’s health and longevity specialist and chief medical officer and co-founder of Humanaut Health.
Here, a few of the many ways HRT can improve your health span:
Brain Health
Estrogen supports mood, memory and cognition through its effects on serotonin, dopamine and brain-derived neurotrophic factor (BDNF)—the protein responsible for growing and maintaining the neural connections that keep thinking sharp. Its loss, notes Berzin, “is linked to brain fog and higher Alzheimer’s risk.”
This connection is no small thing: Alzheimer’s affects nearly twice as many women as men, and researchers increasingly believe the hormonal cliff of menopause is part of the reason why. Women who begin HRT close to the onset of menopause, rather than years later, show greater neuroprotective benefit.
Another aspect of HRT’s impact on the brain relates to mental health. Some research shows that approximately 10 percent of menopausal women may experience suicidal ideation. For many more, foreign feelings of anxiety and rage appear out of nowhere. These women are often handed a prescription for an antidepressant medication instead of being told their brain is undergoing a neurochemical upheaval driven by declining estrogen.
Bone Density
We built an entire milk-guzzling culture with marketing campaigns about calcium while largely ignoring the hormone that actually governs how bones are made and maintained. Estrogen regulates osteoblasts, the cells that build bone, so when estrogen drops, bone breakdown accelerates. “Women can lose up to 20 percent of bone density within five years of menopause without HRT,” says Berzin, who calls the standard guideline recommending a DEXA bone density scan only at age 65 a travesty.
You can head off serious conditions, such as osteopenia and osteoporosis, by getting a baseline DEXA scan in your 40s. “HRT initiated early can increase bone mineral density by 10 percent and meaningfully reduce fracture risk,” says Berzin.
Heart Health
Cardiovascular disease is the No. 1 killer of women. Read that again. “Research shows that when estrogen is started within 10 years of menopause, it can cut the risk of cardiovascular disease significantly by helping to maintain flexible arteries and healthy cholesterol,” says Killen. Timing, however, is important. “Unlike the skeletal and other systems, emerging research shows that starting estrogen late—when you’re already solidly in menopause—does not appear to be as protective to the cardiovascular system as starting in perimenopause,” says Berzin.
Sleep Quality
Restorative sleep is often a casualty of menopause. Estrogen has been shown to reduce waking throughout the night, and increase total sleep time, in part because it stabilizes core body temperature, thwarting the night sweats that jolt so many women awake. Progesterone acts like a sedative by stimulating GABA receptors in the brain—the same receptors targeted by sleep and antianxiety medications. Together, the two hormones form what Killen calls the body’s natural “build and balance” system: estrogen to energize and strengthen, progesterone to calm and regulate. “Unopposed estrogen for long periods can be problematic,” warns Killen, “so it’s important to balance estrogen with progesterone if you have a uterus.”
Sex Drive
A decimated libido isn’t an inevitable fact of aging; it’s frequently a hormonal issue with a hormonal solution. “Estrogen influences sexual desire and physical arousal by supporting blood flow and nitric oxide production,” explains Killen. “Testosterone, frequently underprescribed for women, can fuel libido as well as muscle strength and motivation.”
But desire is only half the equation. For many women, it’s not that they don’t want sex, it’s that sex has become uncomfortable or painful. That’s where vaginal estrogen comes in. It can address physical changes, such dryness, by binding to estrogen receptors in the vaginal walls, rebuilding a thicker, more elastic, better‑lubricated lining. More upside: It doesn’t increase systemic blood levels of estrogen, so you can use it alone or in concert with your primary HRT.
Skin Health
Over-the-counter topical beauty products accomplish what estrogen does from the inside out. Estrogen stimulates fibroblasts to produce collagen, the structural protein that gives skin its firmness and elasticity. During menopause, collagen production declines by about 30 percent within the first five years, and it keeps dropping from there. Estrogen also drives hyaluronic acid production, the molecule responsible for skin’s plumpness, moisture retention and structural integrity.
Weight Management
“Estrogen is the master regulator of female longevity,” says Berzin. “It acts as a systemic anti-inflammatory; without it, cellular aging accelerates.” That includes a metabolic dimension, since estrogen helps support insulin sensitivity and lean muscle mass; when it dips, the risk of metabolic syndrome and diabetes rises.
About the Big C
An analysis of 30 trials encompassing more than 26,000 women found that HRT was not associated with increased cancer mortality. And women taking estrogen alone (the therapy used for those without a uterus) actually showed a 24 percent reduction in breast cancer.
Finding a Menopause-Literate Doctor
The FDA’s HRT label update is only as useful as the physicians implementing it — and many haven’t gotten the memo yet. Killen notes that “fewer than 7 percent of the doctors most likely to see menopausal women feel prepared to treat them.” Berzin backs this up: “Most OB-GYNs and PCPs have, unfortunately, had limited training in MHT (menopausal hormone therapy),” she says, adding, “Many doctors still believe HRT is dangerous, despite strong evidence to the contrary.” A few tips for finding a doc who gets it:
1. Search The Menopause Society’s (formerly NAMS) directory of certified menopause practitioners at menopause.org. These clinicians have passed a certification exam based on current evidence-based guidelines.
2. Use telehealth platforms such as Alloy Health (myalloy.com) and Midi Health (joinmidi.com), which are staffed by practitioners who are trained in menopause medicine.
3. Have your blood labs drawn independently, then reviewed by a practice versed in analyzing hormonal health. Parsley Health offers this service. If a doctor downplays your symptoms or cites HRT risks without acknowledging current data-driven guidelines, find a physician whose goal is to support your long-term vitality.
Delivery Menu
Following, the safest, most prescribed forms of HRT. Always consult with your personal menopause-literate doctor to decide which vehicle and dosages are best for you.
Estrogen
Transdermal patch: applied to the skin (typically the abdomen or thighs) and changed once or twice a week
Topical gel: rubbed into the skin daily, usually on the arm or thigh
Topical spray (Evamist): spritzed onto the inner forearm daily
Vaginal Estrogen
Cream: applied directly to vaginal tissue with an applicator
Ring (Estring): a soft, flexible ring inserted into the vagina that releases a low, steady dose of estrogen for up to 90 days
Tablet/suppository (Vagifem): a small insert placed in the vagina with an applicator, typically used twice a week after an initial daily loading period of two weeks
Progesterone
Oral micronized progesterone: a pill taken at bedtime; the micronized form is body-identical, safer and better tolerated than older synthetic progestins
Testosterone
Topical cream: compounded and applied to the skin daily, typically in very low doses calibrated for female physiology
Topical gel: similar to cream; applied to the inner arm or thigh and absorbed transdermally
Injection: administered by a health care provider; less commonly used for women, but an option for those individuals who don’t absorb topical forms well.
Disclaimer: The information in this article is for educational purposes only and is not intended as medical advice. Consult a qualified health care provider—ideally one trained in menopause medicine—before starting, stopping or changing any hormone therapy