Hormone Therapy Revisited: A New Era in Women’s Health

by Robert Duhaney, MD, FACP

Why menopause care is evolving — and what women should know

For many women, perimenopause and menopause can feel like an abrupt change in the body’s operating system: sleep becomes lighter, energy dips, mood shifts, weight distribution changes, and hot flashes or night sweats appear out of nowhere. For years, hormone therapy was often treated as a “last resort,” and many women were told to simply push through symptoms. But something has shifted.

In recent years, we’ve seen a renewed and more nuanced understanding of hormone replacement therapy (HRT)—a “new renaissance” in women’s health. It’s being discussed more openly on social media, supported by updated expert guidance, and increasingly offered by trained primary care teams (including many of us at One Medical) in a way that is safer, more personalized, and more evidence-based than in the past.

The conversation has changed: revisiting the Women’s Health Initiative (WHI)

A major reason HRT fell out of favor was the early reporting of the Women’s Health Initiative (WHI) trial in the early 2000s. Headlines understandably alarmed many women and clinicians, especially around risks like blood clots, stroke, and breast cancer.

What we understand better now is that the WHI data requires context:

• Many WHI participants were older (often well past the typical menopause transition)

• Many started hormones later, not near the onset of menopause symptoms

• The formulations used then were not always the same as the options we commonly use today

In other words, HRT isn’t “one-size-fits-all,” and risk/benefit looks different depending on age, timing, health history, and the specific hormone formulation and route.

Women are talking about menopause more openly now

Menopause has finally entered the mainstream conversation—and that’s a good thing. Women are sharing real experiences about:

• insomnia and early morning awakening

• hot flashes and night sweats

• anxiety, irritability, and mood changes

• brain fog and memory concerns

• sexual health changes (low libido, vaginal dryness, pain)

• joint aches and shifting body composition

This increased visibility has helped many women realize:“This isn’t just me. This is common, and it’s treatable.” And most importantly - their doctors are finally listening!

What HRT can help with

Most evidence-supported benefits of hormone therapy are for the following:

• Hot flashes and night sweats

• Sleep disruption related to vasomotor symptoms

• Vaginal dryness and discomfort (especially with local estrogen therapy)

• Quality of life and daily functioning for symptomatic women

  
  

Beyond the hot flashes and night sweats, research has also shown HRT can lead to:

• a 30% reduction in overall mortality

• a 50% reduction in heart disease risk (when started within 10 years of menopause)

• Protection against bone loss and fractures

• Reduced risk of diabetes

  
  

What “safe and effective” HRT looks like in 2026

Modern menopause care focuses on personalization and safety, including:

• Right patient selection (benefits must outweigh risks)

• Right timing (often best when started near the menopause transition for symptoms)

• Right formulation

  • systemic estrogen ± progesterone when needed

  • local vaginal estrogen when symptoms are primarily genitourinary

• Right route

  • transdermal options (patch/gel) can be helpful for many women, especially those with certain risk factors

• Lowest effective dose, adjusted over time

• Ongoing monitoring and follow-up, not “set it and forget it”

Just as importantly, today’s approach includes clear guidance on when HRT may not be appropriate, and what alternatives exist.

What HRT is not

HRT is not:

• a universal anti-aging cure

• a substitute for strength training, nutrition, and sleep health

• something to start casually without medical review

• a perfect fit for every woman

It’s a powerful tool—but it needs to be used thoughtfully.

Primary care is stepping up and why that matters

For a long time, many women were told they needed a specialist just to have a menopause conversation - mostly an OB/GYN but sometimes a Urologist or more rarely an Endocrinologist. Even functional doctors made this a focal point. While specialists remain incredibly important, the reality is that menopause care should be accessible, and primary care is uniquely positioned to help.

At One Medical (and increasingly across primary care in general), more clinicians are pursuing additional training in:

• evidence-based menopause care

• safe prescribing and monitoring

• shared decision-making and individualized risk assessment

That means women can often get high-quality guidance and treatment without long delays—and with a clinician who also understands their full medical history including certification from the The Menopause Society.

A practical next step if you’re wondering, “Is HRT right for me?”

If you’re experiencing symptoms that are affecting your quality of life, a good starting point is a structured conversation around:

• What symptoms are most disruptive (sleep, hot flashes, mood, sexual health)

• Your personal and family history (breast cancer, clotting history, migraines, etc.)

• Your cardiovascular risk profile

• Whether you still have a uterus (affects progesterone needs)

• Your preferences and comfort level

• A plan for follow-up and monitoring

  
  

Bottom line

We are in a new era of women’s health—one that takes menopause symptoms seriously and treats them with compassion, clarity, and evidence-based options. HRT is being re-evaluated not because the risks disappeared, but because we now understand how to use hormone therapy more safely, more thoughtfully, and more individually than ever before.

If you’re curious about your options, talk to your healthcare provider about what you’re experiencing and build a plan that fits your body, your goals, and your risk profile. Check out my FAQs below for more information.

Frequently Asked Questions (FAQ): Menopause & Hormone Therapy (HRT)

1) How do I know if I’m in perimenopause?

Perimenopause is the transition period leading up to menopause. Many women notice:

• irregular or changing periods

• new or worsening PMS symptoms

• hot flashes or night sweats

• sleep disruption (especially early morning awakening)

• mood changes (anxiety, irritability, low mood)

• brain fog or difficulty concentrating

• weight redistribution (especially around the midsection)

  
  

While your healthcare provider may want to get baseline metabolic and hormonal labs, we don’t need a speficic lab test to diagnose perimenopause — your constellation of symptoms and cycle changes are often the most helpful clues by themselves.

2) Do I need hormone testing to start treatment?

Not always. For many women, menopause care is primarily based on symptoms and history, not just hormone levels. Hormone levels can fluctuate significantly during perimenopause, so a “normal” value does not necessarily mean you aren’t in the transition.

That said, we sometimes check labs to evaluate other causes of symptoms (like thyroid issues, anemia, vitamin deficiencies, or insulin resistance).

3) What symptoms does HRT help the most?

HRT is most effective for:

• hot flashes

• night sweats

• sleep disruption related to vasomotor symptoms

• vaginal dryness / discomfort

• pain with sex related to low estrogen

• 
  

Many women also notice improvements in quality of life, energy, and mood stability — though results vary.

4) Will HRT make me gain weight?

HRT is not a weight-loss medication, but it does not automatically cause weight gain either. Many women gain weight during midlife due to:

• hormonal shifts

• muscle loss with age

• sleep disruption

• stress and cortisol changes

• changes in activity level and metabolism

For some women, treating menopause symptoms (especially sleep and hot flashes) can make it easier to exercise consistently and eat well — which helps long-term weight and body composition.

5) What’s the difference between estrogen and progesterone?

• Estrogen helps with hot flashes, night sweats, vaginal dryness, and more.

• Progesterone is usually needed if you still have a uterus, to protect the uterine lining from overgrowth when using systemic estrogen.

If you’ve had a hysterectomy, you may not need progesterone (depending on your specific situation).

6) What about testosterone for women?

Testosterone is often thought of as a “male hormone,” but women naturally produce testosterone too—and it can play an important role in sexual desire, arousal, energy, and overall well-being.

For some women, especially in peri- or post-menopause, testosterone therapy may be considered when there is:

• persistent low libido that feels distressing or “not like you,” and

• symptoms have not improved with addressing other common factors (sleep, stress, relationship dynamics, depression/anxiety, vaginal dryness, medication side effects, etc.)

  
  

What testosterone may help with:

• hypoactive sexual desire (low libido) in appropriately selected patients

• sometimes improved sexual satisfaction and responsiveness

What testosterone is not reliably proven to fix:

• general fatigue

• brain fog

• weight loss

• mood issues (in most cases)

• muscle gain without lifestyle changes

  
  

How it’s used safely (when appropriate):

• While there is currently no FDA approved testosterone formulations for women, if the decision to use it is made, a compounded version can be prepared aiming for physiologic dosing (bringing levels into a healthy female range—not “bodybuilding” levels)

• You would be monitored for any improvement in symptoms, any side effects, and labs over time

• Overly high dosing and “set-it-and-forget-it” approaches are avoided

  
  

Potential side effects (especially if dose is too high):

• acne or oily skin

• increased facial/body hair

• scalp hair thinning

• voice deepening (can be irreversible)

• mood changes/irritability

• changes in cholesterol patterns

  
  

Important note about formulations: Testosterone therapy for women requires careful dosing. Some delivery methods (especially pellets or high-dose compounded products) can lead to unpredictably high levels, which increases the risk of side effects. So when used, topical creams are preferred.

7) Is an estrogen patch safer than a pill?

For many women, transdermal estrogen (patch/gel/spray) can be a great option and may have a lower risk of certain side effects compared with oral estrogen—especially in women with risk factors like migraines, higher clot risk, or elevated triglycerides.

The “best” route depends on your history, symptoms, and preferences.

8) Does HRT increase breast cancer risk?

Breast cancer risk depends on the type of hormones used and how long they’re taken—some older studies showed a small increase in risk with estrogen plus synthetic progestins, especially with longer use.

However, when progesterone is needed (for women who still have a uterus), our preference is micronized progesterone, because it appears to have a more favorable breast safety profile than synthetic progestins. The goal is always to use the lowest effective dose, reassess regularly, and tailor treatment to your personal risk factors and symptoms.

9) Who should NOT take systemic HRT?

Systemic HRT may not be appropriate for women with a history of:

• certain types of breast cancer

• blood clots (DVT/PE) or significant clotting disorders

• stroke or high-risk cardiovascular disease

• unexplained vaginal bleeding

• active liver disease (in some cases)

  
  

Even in higher-risk situations, there are often non-hormonal options and/or local therapies that can help.

10) Is vaginal estrogen safe?

For many women, local vaginal estrogen is considered low-risk and very effective for:

• vaginal dryness

• burning/irritation

• painful sex

• urinary symptoms related to menopause

It works locally with minimal systemic absorption for most patients. It can be a great option even for women who aren’t candidates for systemic HRT (though special cases should be individualized).

11) How long can I stay on HRT?

There isn’t one universal answer. Many women use HRT for a few years, while others benefit longer. The best approach is:

• start within 10 years of your last menstural cycle

• use the lowest effective dose

• reassess symptoms and goals periodically

• continue only as long as the benefits outweigh the risks for you

  
  

12) If I don’t want hormones, what else can help?

Great question — and you have options. Depending on your symptoms, alternatives may include:

• lifestyle strategies (sleep, exercise, strength training, nutrition)

• non-hormonal medications for hot flashes

• cognitive behavioral therapy for insomnia (CBT-I)

• vaginal moisturizers/lubricants and non-hormonal therapies

• targeted mental health support when anxiety/depression is part of the picture

You deserve relief, and your provider can build a plan that fits your comfort level.

13) What should I expect at a menopause-focused visit?

A high-quality menopause visit usually includes:

• symptom review (sleep, mood, hot flashes, libido, cycle changes)

• personal + family history

• medication review and risk assessment

• discussion of treatment options (hormonal and non-hormonal)

• a clear follow-up plan to adjust treatment safely

14) What’s the difference between “bio-identical,” compounded hormones, pellets, and retail brand HRT?

Bio-identical simply means the hormone has the same chemical structure as what your body naturally makes—most commonly estradiol and micronized progesterone. The key point is that many FDA-approved (“retail brand”) hormone therapies are already bio-identical, so bio-identical does not automatically mean compounded, and it does not automatically mean safer.

FDA-approved products are made under strict quality standards with consistent dosing, proven stability, and clear safety labeling.

Compounded hormones are custom-mixed by a compounding pharmacy and may be helpful in select situations (like ingredient allergies or uncommon dosing needs), but they are not FDA-approved and can have more variable absorption and dosing consistency. We commonly use this route if topical testosterone is to be considered.

Pellet therapy involves hormone implants placed under the skin; while some women feel better on pellets, dosing can be harder to adjust, levels can run higher than intended, and side effects may last longer.

Bottom line: for most women, the safest starting point is usually FDA-approved estradiol + micronized progesterone (when progesterone is needed) at the lowest effective dose, with thoughtful follow-up—rather than choosing a product based on marketing terms like “natural” or “bio-identical.”