The truth about menopausal hormone therapy (MHT/HRT): Moving beyond the panacea vs poison debate
MHT has been labelled both poison and cure-all for years - the reality is far more nuanced than ‘bad’ or ‘good’
Key Points Summary
• The Pendulum Effect: MHT has swung from being marketed as an anti-ageing miracle cure to being feared after major clinical trials revealed cardiovascular and cognitive risks, particularly in older women
• Understanding the Evidence: The Women's Health Initiative trials found MHT with synthetic progestins increases risks of cardiovascular disease, stroke, and dementia in older postmenopausal women, though younger symptomatic women show lower cardiovascular risk. Critically, these trials tested synthetic progestins (particularly medroxyprogesterone acetate), not body-identical progesterone, which appears to have a more favourable safety profile
• Beyond Hormone Therapy: Menopause is a complex multisystem transition affecting sleep, cognition, mood, and sexual health—not simply an oestrogen deficiency requiring hormone replacement
The Training Gap: Fewer than 1 in 10 (American) medical graduates feel confident managing menopausal health, leaving women vulnerable to self-medicating with supplements and questionable online advice. Doctors generally not well-educated in herbal medicines and supplements often defer to incorrect information varying between the 'expensive urine' and 'ineffective' narratives. This often results in valuable, gentle strategies which support the body's own mechanisms for balance are avoided, and harder-hitting (sometimes unnecessary) pharmaceuticals are used first. Many women find a combination of both provides more effective, gentle and faster results.
• Comprehensive Care Approach: Evidence-based menopause management requires individualised, and holistic treatment plans, proper clinician training, and a toolkit of hormonal, non-hormonal, and behavioural strategies
The Women’s Health Initiative (WHI) trials were prematurely stopped due to adverse results.
This research has since been found to be flawed in multiple ways - but not before it caused fear, and confusion for practitioners and women alike!
The conversation around menopausal hormone therapy has always been loaded with emotion, cultural baggage, and conflicting medical opinions. For decades, hormone therapy has sparked heated debates about women's health, ageing, and what constitutes appropriate medical care during midlife. The story (now that we are openly talking about menopause!) has swung wildly—from miracle cure to dangerous drug—leaving many women confused, under-treated, and struggling to navigate one of life's most significant transitions.
Let's examine what the evidence actually tells us, why this matters for women's health, and how we can move towards a more balanced, comprehensive approach to menopause care.
The Rise and Fall of Hormone Therapy as a Miracle Cure
Throughout much of the mid to late 20th century, menopausal hormone therapy was promoted as nothing short of miraculous. Women were told it would help them remain "feminine forever," (1) prevent weight gain, keep their skin youthful, ward off heart disease, and even prevent dementia. Hormone therapy was marketed as a complete solution to ageing itself—a pharmaceutical fountain of youth.
The problem? These sweeping claims existed without large-scale clinical trials using actual health outcomes to back them up. The enthusiasm for hormone therapy outpaced the evidence, and millions of women began taking these medications based on theories and smaller observational studies rather than rigorous clinical testing. (1)
This all changed with the Women's Health Initiative (WHI) trials, which followed more than 25,000 postmenopausal women for up to 20 years. These groundbreaking studies tested specific hormone combinations to determine whether the claimed disease prevention effects actually held up under scrutiny. (2)
The results shocked both the medical community and the public. The trials were stopped prematurely, between 2002 and 2004 because of evidence of harm. Whilst hormone therapy did reduce the risk of bone fractures, diabetes, and colon cancer, it also increased long-term heart disease risk. Both types of therapy tested increased the risk of stroke, blood clots, and dementia—particularly in older women. (2)
The pendulum swung dramatically. Women stopped taking hormone therapy in record numbers, and what had been promoted as a miracle cure was suddenly feared as a dangerous drug.
Understanding What the Trials Actually Tested: The Critical Difference Nobody Talks About
Here's where things get complicated—and where much of the confusion about hormone therapy originates. The WHI trials specifically tested synthetic versions of hormones called "progestins," not the body-identical hormone called progesterone. This distinction is absolutely crucial, yet it's been muddled for decades by terminology that treats these substances as the same thing when they're fundamentally different.
Think of it this way: progesterone is the actual hormone your body makes naturally. Progestins are synthetic laboratory-created compounds that were designed to mimic some of progesterone's effects but have a different chemical structure. It's a bit like comparing real butter to margarine—they might serve similar purposes, but they're not the same substance and don't behave identically in your body.
As naturopath and hormone specialist Lara Briden explains, the confusion has deep historical roots. When progesterone was first discovered, scientists couldn't create a version that could be absorbed well when taken orally, so they developed synthetic alternatives—progestins—that could be made into pills. Body-identical progesterone in an absorbable oral form didn't become widely available until the 1990s. By then, decades of research had been conducted on progestins, and the terms "progesterone" and "progestin" had become incorrectly used interchangeably in medical literature and clinical practice.
This linguistic mix-up has had serious consequences. When research showed that the synthetic progestin called medroxyprogesterone acetate (MPA) increased risks of breast cancer and heart problems, many people—including healthcare providers—incorrectly assumed these risks applied equally to natural progesterone. The safety profiles of these substances, however, appear quite different.
The structure of the progestin molecule used in MHT is more like testosterone, than progesterone!
The Crucial Distinction: Body-Identical Hormones vs Synthetic Versions
Research now shows that not all hormone formulations carry the same risks. A comprehensive review comparing progesterone with synthetic progestins found that when combined with oestrogen, progesterone was associated with a 33% lower risk of breast cancer compared to synthetic progestins. (9) Studies from France that followed over 80,000 postmenopausal women found that combining natural progesterone with skin-patch oestrogen showed no increase in breast cancer risk, whilst synthetic progestins did increase this risk. (10)
Laboratory research has revealed why these differences exist. MPA, the synthetic progestin used in the WHI trials, has properties similar to both progesterone and testosterone. Studies on breast cancer cells show that MPA's effects overlap significantly with testosterone, which helps explain why it promotes breast cell growth. In contrast, natural progesterone appears to have protective effects on breast tissue, encouraging cells to mature properly rather than multiply uncontrollably.
The heart health story follows a similar pattern. Research demonstrates that progesterone and MPA have distinctly different effects on the cardiovascular system. (11) Whilst MPA may negatively affect cholesterol levels and blood vessel function, progesterone appears to have neutral or potentially beneficial effects on heart health.
Dr Leah Hechtman (PhD), a leading naturopathic researcher specialising in reproductive health, emphasises the importance of understanding these hormonal differences when supporting women through menopause. Her work in integrative reproductive medicine highlights how body-identical hormones interact differently with the body's hormone receptors compared to synthetic alternatives.
Briden notes that many progestins are actually more chemically similar to testosterone than to progesterone. Levonorgestrel, for instance, which is used in many contraceptives and the morning-after pill, is structurally closer to the male hormone testosterone. (8) This structural difference explains why some progestins can cause side effects like hair loss and weight gain, whilst natural progesterone tends to have the opposite effects.
As Briden powerfully states, progestins and progesterone are "not cousins, not twins, not even friendly look-alikes"—they're fundamentally different molecules with different effects in the body. (8)
The Unintended Consequences: When the Pendulum Swung Too Far
The backlash against hormone therapy created its own set of problems—made worse by the failure to distinguish between different hormone formulations. The unfavourable risk-to-benefit ratio for disease prevention with synthetic hormones led many women—and their healthcare providers—to avoid all forms of hormone therapy entirely, even body-identical options and even for managing severe symptoms. (2)
Women experiencing difficult menopausal symptoms found themselves with few treatment options. Many simply suffered through their hot flushes, sleep disruption, and other menopausal changes that significantly impacted their quality of life. The fear generated by the WHI findings meant that even women who might have safely benefited from body-identical hormone therapy for symptom relief were left without effective treatment.
This represents a significant gap in women's healthcare. When we consider that women comprise over half the world's population and will spend almost half their lives in their peri- or postmenopausal years, the impact of under-treatment becomes clear. Most women experience menopausal symptoms to varying degrees, and many could benefit from appropriate, evidence-based care.
The Pendulum Swings Back: A Resurgence of Interest
In recent years, interest in hormone therapy has resurged. This revival stems partly from recognition that menopausal symptoms have been under-treated, leaving many women to suffer unnecessarily. However, it has also brought a concerning resurrection of old claims about hormone therapy for preventing chronic diseases including heart disease and dementia. (3)
These renewed claims often rest on weaker types of studies—observational research or studies that rely on measurements like cholesterol levels rather than actual heart attacks or strokes. Some advocates argue that the WHI findings don't apply to newer hormone therapy formulations or body-identical hormones, though the distinction between synthetic progestins and natural progesterone remains poorly understood by many practitioners and patients alike. (3)
The result? The debate has become polarised once again. Some reject all forms of hormone therapy for any purpose whatsoever, whilst others advocate its use broadly. This all-or-nothing thinking doesn't serve women well—particularly when it fails to account for the meaningful differences between hormone formulations.
What's often missing from this debate is clarity about which specific hormones are being discussed. When someone says "hormone therapy increases breast cancer risk," are they referring to synthetic progestins like MPA, or body-identical progesterone? The answer matters enormously for making informed decisions, yet this crucial distinction is frequently absent from public discussions and even conversations between doctors and patients.
Understanding the Details: Age, Timing, and Individual Risk
One of the key criticisms of the WHI trials focuses on the age of participants. The average age was 63 years—older than the typical age at which women start to use hormone therapy for managing hot flushes and other symptoms. This older age was necessary to study health problems that typically affect older women, but it raised important questions about whether the findings apply to younger, newly menopausal women. (2)
Recent analyses have provided some reassuring news for younger symptomatic women. A detailed look at the data examined how hormone therapy affected heart health specifically in women with moderate to severe hot flushes at different ages. The findings showed that hormone therapy was associated with the greatest heart disease risk in women with symptoms in their 70s, but did not detect increased risk for heart problems in younger women experiencing hot flushes. (4)
This suggests that younger postmenopausal women with symptoms are at lower risk of heart complications with hormone therapy—an important distinction that gets lost in the all-or-nothing debate. (4)
The Fundamental Misunderstanding: Menopause Is More Than Just Low Oestrogen
Perhaps the most important point to understand is this: menopause—and more importantly, midlife ageing in women—is not simply a matter of low oestrogen that needs to be replaced.
Menopause represents a complex biological and psychological transition driven by far more than changes in any single hormone. The symptoms and changes vary widely among women and can include: (5)
Hot flushes and night sweats
Sleep problems
Memory and concentration changes
Sexual concerns
Vaginal and urinary symptoms
Mood changes
Or minimal symptoms in some women
The body systems affected by menopause are numerous and complex. Consequently, no single medication or treatment—including hormone therapy—can address, eliminate, or prevent all menopausal changes or related health issues. (5)
This understanding fundamentally changes how we should approach menopause care. Rather than viewing hormone therapy as a universal solution, we need to recognise it as one tool amongst many in a comprehensive approach to supporting women through this transition.
Moving Towards Individualised Care
The path forward requires freeing menopausal hormone therapy from unrealistic expectations—and from the confusion created by decades of muddled terminology. Decisions about hormone therapy should be approached like any other medication, with clear understanding of which specific hormones are being considered and what the evidence shows about their individual safety profiles. (2)
For women considering hormone therapy, understanding the difference between synthetic progestins and body-identical progesterone is essential. Progestins and progesterone both protect the uterine lining from unopposed oestrogen stimulation (which is important for preventing uterine cancer), but their effects diverge significantly in other tissues including the breasts, brain, and cardiovascular system.
Body-identical hormones—specifically oestradiol and progesterone that are molecularly identical to what the body produces naturally—are increasingly recognised as having more favourable safety profiles than their synthetic counterparts. Oral micronised progesterone, available under brand names like Prometrium and Utrogestan, represents a meaningful alternative to synthetic progestins for women who need progestogen therapy alongside oestrogen.
Ideal menopause management uses a comprehensive care approach tailored to each woman's specific symptoms and health concerns. This means:
Comprehensive Assessment: Understanding the full range of symptoms and their impact on quality of life, not just focusing on hot flushes.
Individualised Risk-Benefit Analysis: Considering factors such as age, time since menopause, personal and family medical history, symptom severity, and importantly, which specific hormone formulations are being discussed.
Informed Decision-Making: Discussing evidence-based options—including the distinctions between synthetic and body-identical hormones—so women can make choices aligned with their values and priorities.
Ongoing Monitoring: Reassessing symptoms, treatment effectiveness, and any side effects regularly.
Beyond Hormone Therapy: The Full Toolkit
Hormone therapy is only one tool in the toolbox of menopause care. Other evidence-based options include approved medications and behavioural strategies for managing menopausal symptoms. (6)
Non-Hormonal Medication Options: Several medications have been approved or show evidence for managing hot flushes, including certain antidepressants and other agents that work through different pathways than hormone therapy.
Behavioural Approaches: Evidence supports various strategies including cognitive behavioural therapy specifically designed for hot flushes, sleep hygiene practices, stress management techniques, and lifestyle modifications.
Complementary Therapies: Whilst the evidence varies (for a multitude of reasons, often nothing to do with the treatments themselves) some women find benefit from approaches such as mindfulness, acupuncture, and a variety of herbal preparations—though these should be approached with appropriate caution and awareness of potential interactions with other medications. Herbs and supplements, whilst 'natural' are not always appropriate and should not be self-prescribed, seeking the help of a knowledgable practitioner is as important as seeking the help of a doctor for medications.
The challenge? These approaches are not widely known partly because there aren't enough clinicians well-trained in menopause care.
The Training Crisis in Menopause Care
Here's a sobering statistic: fewer than 1 in 10 doctors in the US, completing their training in internal medicine, family medicine, and obstetrics and gynaecology report feeling confident in their ability to manage menopausal health. (7)
These sentiments are echoed in Australia, with a 2024 Senate Hearing revealing that the health sector was rife with misinformation, a lack of knowledge and outdated practices.
Read that again. The vast majority of doctors finishing their training in the specialties most likely to care for menopausal women don't feel confident doing so. This represents a massive gap in medical education and women's healthcare.
Without adequately trained clinicians, women are left to navigate the complex landscape of menopause alone. Many turn to the growing marketplace of over-the-counter supplements, 'Dr Google' and AI, all of which can lead to inappropriate, inadequate and in some cases dangerous results.
Moreover, women and even clinicians are increasingly guided by online voices—podcasters, influencers, wellness entrepreneurs—many whose advice rests on minimal scientific evidence. Without proper training and access to evidence-based information, how can women or their healthcare providers separate legitimate guidance from marketing hype?
The solution requires substantial investment in menopause education across medical training programmes, continuing education for practising clinicians, and better distribution of evidence-based menopause information. Women may seek care for their diverse menopausal symptoms from multiple medical specialties, allied health professionals, and mental health professionals—all of whom need relevant menopause knowledge.
The Innovation Imperative: Advancing Menopause Science
Too often, menopause care is equated with hormone therapy, full stop. This narrow focus limits our ability to help women effectively. The field must continue active investigation and innovation in menopause care.
Research Priorities Include:
Testing newer hormone therapy formulations with proper clinical trials
Development and testing of new non-hormonal therapies
Rigorous study of behavioural options for menopause management
Attention to specific groups, such as women over 60 with ongoing symptoms
Basic science investigating why menopausal symptoms occur and why they often persist for years
Expanded focus to include less well-recognised but highly troublesome symptoms such as cognitive changes
Care models that enable widespread reach, given the limited number of menopause specialists
The evidence base supporting menopause care remains too limited. Investment in menopause science, its symptoms, and its implications for ageing women's health is urgently needed.
What Women Deserve
The polarised debate about menopausal hormone therapy—miracle cure versus dangerous drug—doesn't serve women well. Neither does the rush to embrace the next supposed magic bullet, whether that's a pharmaceutical product, supplement, or wellness trend.
Women deserve more than this. They deserve:
Evidence-Based Information: Access to clear, accurate information about menopause and treatment options based on rigorous research, not marketing claims or individual stories.
Trained Healthcare Providers: Clinicians who feel confident and competent in menopause care, who can discuss the full range of options and help women make informed decisions.
Individualised Care: Treatment approaches tailored to their specific symptom profile, health history, and personal priorities—not one-size-fits-all recommendations.
A Comprehensive Toolkit: Access to the full range of evidence-based options, including hormonal therapies when appropriate, non-hormonal medications, behavioural strategies, and lifestyle approaches.
Ongoing Support: Recognition that menopause is a transition that may require different approaches at different times, with healthcare that adapts to changing needs.
The Path Forward
Moving beyond the pendulum swing requires several shifts in how we approach menopause and its management:
Reject All-or-Nothing Thinking: Hormone therapy is neither a miracle cure nor a poison. It's a medical treatment with specific benefits, risks, and appropriate use cases that should be evaluated individually for each woman.
Embrace Complexity: Menopause is a complex, multisystem transition that requires comprehensive care, not a single pharmaceutical solution.
Prioritise Education: Substantial investment in menopause education for healthcare providers at all levels is essential.
Demand Evidence: Whether discussing hormone therapy, supplements, or lifestyle interventions, we need to insist on evidence from well-designed studies, not just theoretical benefits or individual success stories.
Centre Women's Experience: Care should be driven by women's actual symptoms and priorities, not by what we think menopause "should" look like or what's easiest to prescribe.
Invest in Research: The limited evidence base for menopause care represents a failure to prioritise women's health. This must change. Research with the intent of seeking answers, rather than financial outcomes will allow a broader range of strategies to be investigated, particularly plant-based, traditional and natural lifestyle treatments, which traditionally do not offer a patentable product for financial gain.
Menopause requires a holistic, person-centred approach…because
‘it’s a complex multisystem transition affecting sleep, cognition, mood, and sexual health—not simply an oestrogen deficiency requiring hormone replacement’
Conclusion: A Call for Comprehensive Care
The menopause transition affects virtually every woman (or those assigned female at birth) who lives beyond midlife. With women comprising over half the world's population and spending almost half their lives in their peri- or postmenopausal years, getting menopause care right matters enormously—not just for individual women, but for the people who care about them and for public health.
Most women will experience menopausal symptoms with varying degrees of impact on quality of life. Many could benefit from appropriate, evidence-based menopause care. Yet our current system often fails them, caught between polarised positions about hormone therapy and lacking the trained workforce to provide comprehensive care.
The field must evolve beyond its fixation on whether hormone therapy is good or bad. Women don't need miracle cures or dangerous drugs, lotions or potions. They need—and deserve—a comprehensive suite of tools to navigate this critical phase of life, delivered by knowledgeable healthcare providers who can support individualised decision-making.
That's the standard we should be working towards. Not perfect, not simple, but thoughtful, evidence-based, and centred on women's actual needs and experiences. It's time to move beyond the pendulum swing and build something better.
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References:
Watkins ES. The Estrogen Elixir: A History of Hormone Replacement Therapy in America. Johns Hopkins University Press; 2010.
Manson JE, Crandall CJ, Rossouw JE, et al. The Women's Health Initiative randomized trials and clinical practice: a review. JAMA. 2024;331(20):1748-1760. doi:10.1001/jama.2024.6542
Huang AJ, Grady D. Menopausal hormone therapy for prevention of chronic conditions: when is enough, enough? JAMA. 2022;328(17):1712-1713. doi:10.1001/jama.2022.19098
Rossouw JE, Aragaki AK, Manson JE, et al. Menopausal hormone therapy and cardiovascular diseases in women with vasomotor symptoms: a secondary analysis of the Women's Health Initiative randomized clinical trials. JAMA Internal Medicine. Published online September 15, 2025. doi:10.1001/jamainternmed.2025.4510
Thurston RC, Thomas HN, Castle AJ, Gibson CJ. Menopause as a biological and psychological transition. Nature Reviews Psychology. 2025;4:530-543. doi:10.1038/s44159-025-00463-9
The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause. 2023;30(6):573-590. doi:10.1097/GME.0000000000002200
Kling JM, MacLaughlin KL, Schnatz PF, et al. Menopause management knowledge in postgraduate family medicine, internal medicine, and obstetrics and gynecology residents: a cross-sectional survey. Mayo Clinic Proceedings. 2019;94(2):242-253. doi:10.1016/j.mayocp.2018.08.033
Briden L. The crucial difference between progesterone and progestins. Lara Briden - The Period Revolutionary. Published October 5, 2024.
Asi N, Mohammed K, Haydour Q, et al. Progesterone vs. synthetic progestins and the risk of breast cancer: a systematic review and meta-analysis. Systematic Reviews. 2016;5:121. doi:10.1186/s13643-016-0294-5
Fournier A, Berrino F, Clavel-Chapelon F. Unequal risks for breast cancer associated with different hormone replacement therapies: results from the E3N cohort study. Breast Cancer Research and Treatment. 2008;107(1):103-111.
Mirkin S, Amadio JM, Bernick BA, et al. Cardiovascular effects of medroxyprogesterone acetate and progesterone: a case of mistaken identity?. Menopause. 2008;15(4 Pt 1):806-809. doi:10.1097/gme.0b013e31815eb314
Frequently Asked Questions:
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For most women under 60 or within 10 years of menopause, hormone therapy is relatively safe when used appropriately. The key is understanding that synthetic progestins (like those tested in the Women's Health Initiative) carry different risks than body-identical progesterone. Safety depends on your age, health history, which hormones you use, and how long you take them.
Always discuss your individual risk factors with a qualified healthcare provider. -
Progesterone is the natural hormone your body makes. Progestins are synthetic laboratory-created compounds designed to mimic progesterone but with different chemical structures. Think butter versus margarine—similar purpose, different substances. Research shows progesterone has a 33% lower breast cancer risk than synthetic progestins and appears safer for heart health. This distinction matters enormously for your decision-making.
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You will need to speak to your doctor to answer this. Most women use hormone therapy for 3-5 years, but this isn't a hard rule. Duration depends on your symptoms, health history, and risk factors. Women starting before age 60 with severe symptoms may safely continue longer if benefits outweigh risks. The "lowest dose for the shortest time" approach has evolved to "the appropriate dose for as long as needed." Regular reviews with your healthcare provider are essential.
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If you have any concerns about any medications, speak to your doctor. However, the short answer is - No, hormone therapy should not be used solely to prevent chronic diseases. The Women's Health Initiative showed synthetic hormones increased heart disease and dementia risk in older women. However, emerging evidence suggests body-identical hormones started early in menopause (before age 60) may offer some protection. Hormone therapy's primary purpose is managing menopausal symptoms, not disease prevention.
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There are many lifestyle, nutrition, diet and herbal strategies which provide women great benefit. Often they can negate the need for MHT at all, but not all women are the same.
Natural treatments provide support for the body’s innate ability to regain balance - particularly, when there are deficiencies and imbalances in specific nutrients, or blocked due to lifestyle, diet or chemical exposure.
Even if you are able to take hormone therapy, investigating natural strategies with a qualified naturopath, is always a great first step.
Unfortunately, many people try self-prescribing herbs and supplements or follow advice of non-qualified people - which can have mixed, and potentially harmful results. Keep in mind that many herbs can interact with medications and your experience may be different to your friends - because your body is different.
There is NO one-size-fits-all answer to treating menopausal symptoms!
