Hormone Therapy Can Be Life-Changing—And You Can Start It Sooner Than You Think
By now, you've probably heard the negative messaging around hormone therapy (also known as hormone replacement therapy or HRT). It's dangerous! It causes breast cancer! It'll make you gain weight! Except these are half-truths. Hormone therapy can actually be life-changing for menopausal women—and provide the most benefits, with the lowest risks, for perimenopausal women.
When we talk about hormone therapy, we're typically referring to low doses of estradiol (the primary form of estrogen in your body during your reproductive years) and progesterone. Unlike the hormones commonly found in birth control, these aren't synthetic hormones—they are known as bioidentical hormones, which have the same chemical makeup as the hormones in our body. Hormone therapy is FDA-approved to alleviate symptoms like hot flashes, night sweats, vaginal dryness, painful sex, and recurrent UTIs. It also offers some pretty amazing benefits, such as preserving bone health, improving heart health, and lowering the risk of diabetes. If a woman doesn't have a uterus, then she typically only takes estrogen, but if she does, she takes both estrogen and progesterone to protect the lining of the uterus from excess thickening.
In perimenopause, estrogen and progesterone fluctuate wildly, which can make it a little tricky to find the right dosage (usually you start on the lowest dose and go up based on response, tolerability, and efficacy). This is why ob-gyns will often recommend birth control pills or a progestin IUD—potentially with an added low dose of estradiol—as a first course of action to alleviate symptoms. The birth control can turn off the crazy fluctuating hormones (therefore controlling irregular periods and, in some cases, eliminating them completely). It also provides contraception since you can still get pregnant while in perimenopause.
But for perimenopausal women who haven't had great experiences with birth control, are experiencing bothersome symptoms, and aren't planning to get pregnant, experts agree that hormone therapy can be a good option for them.
'For young people who are having [perimenopausal] symptoms, unless they have an absolute contraindication like breast cancer, the benefits are going to outweigh the risks,' says Jan Shifren, MD, a gynecologist, reproductive endocrinologist, and director of the Mass General Hospital Midlife Women's Health Center. Some other contraindications are a history of coronary heart disease (CHD), stroke, liver disease, estrogen-sensitive cancers, and unexplained vaginal bleeding. 'Once you are in your 50s, then you have to be a little bit more concerned about risks than a young person does.'
For women over 60 who take estrogen and progesterone for more than four years, research has shown there's a slight increase in breast cancer risk—1 out of every 1,000 women—as well as an increased risk of heart disease, stroke, and dementia (more on that in 'The Great Hormone Therapy Comeback' here). To experience the most benefits with the lowest risks, it's ideal to start hormone therapy before you turn 60 or within 10 years of your last period.
That said, you can begin as early as your 30s. In fact, there are young patients with premature ovarian insufficiency (when a woman's ovaries stop working before she's 40) who require hormone therapy much earlier than others going through natural menopause. However, Dr. Shifren says perimenopausal women shouldn't start hormone therapy to prevent symptoms. Rather, they should think of hormone therapy as a potential treatment option for symptoms affecting their quality of life. Determining when to stop taking it, if at all, depends on your goals for the therapy weighed against potential side effects and risks. Make sure to discuss this with a certified menopause practitioner.
Testosterone Enters the Chat
Spoiler alert: Women produce three times more testosterone than estrogen before menopause. Testosterone gradually declines as we age, and that can impact mood, energy level, libido (a.k.a. sex drive), bone health, and muscle mass. As menopause has gone mainstream, some female urologists are advocating that women add testosterone to their hormone therapy regimen. The problem? There are zero FDA-approved testosterone products for women, which makes it difficult for us to access and afford it.
'The role of testosterone is just a lesson in gender bias,' says Kelly Casperson, MD, a urologist. 'Because 100 percent of women will have low testosterone and there's zero FDA-approved products. About 20 percent of men will have low testosterone and there are plenty of FDA-approved products.'
Not all health care practitioners agree that women should be prescribed testosterone, though. Dr. Shifren, a gynecologist, notes that the actual benefit of testosterone above that of a placebo is very small—though she acknowledges a placebo works—and she prefers to get to the root cause of symptoms like low libido.
'Low libido is incredibly common for women, and it's often due to things like fatigue, stress, relationship conflict, depression, anxiety, and painful sex,' she explains. 'It's much easier to write prescriptions for off-label compounded testosterone and send someone on their way. But when you really take a thorough look at their history, you find a lot of things that people can improve to make their lives better.'
Dr. Casperson argues that, placebo effect or not, there isn't harm in prescribing women low-dose testosterone—five milligrams per day in the form of a gel or a cream—if it improves their symptoms and they monitor their levels. (Though it's not recommended to go on T if you can or are planning to get pregnant, as it could affect the baby.) Consult a health care professional to discuss potential side effects and risks.
This story appears in the Summer 2025 issue of Women's Health.
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