Not All HRT Is the Same

One of the biggest mistakes in menopause medicine is talking about hormone therapy as though it is one thing.

It is not.

HRT is not a single treatment. The type of estrogen, whether progesterone or progestin is added, the dose, and the delivery method all change the conversation.

That is exactly what a 2024 study on hormone therapy beyond age 65 highlighted. In a large observational analysis of more than 10 million Medicare women, the authors found that outcomes varied by formulation, route, and strength.

One of the clearest signals from the study was that estradiol generally looked more favorable than conjugated estrogens, and that lower-dose vaginal and transdermal options tended to look more favorable than higher-dose oral therapy.

But this is also where nuance matters.

When estrogen was combined with progestin or progesterone, the picture became more mixed. The study found that both estrogen plus progestin and estrogen plus progesterone were associated with a 10 percent to 19 percent higher breast cancer risk in this older population.

At the same time, estrogen plus progestin was also associated with significant reductions in endometrial cancer, ovarian cancer, ischemic heart disease, congestive heart failure, and venous thromboembolism.

In other words, combination therapy cannot be reduced to a simple “good” or “bad” label.

This is why I am so careful with wording when I talk about menopause treatment.

The question is not simply whether hormone therapy is safe or unsafe.

The real questions are:

• Which hormone?
• What dose?
• Which route?
• Does she have a uterus?
• What is her personal and family risk profile?

That is what thoughtful menopause care looks like.

For women in perimenopause and menopause, this matters because better decisions come from better questions. And the better informed you are, the less likely you are to be guided by fear, headlines, or oversimplified rules.

This is why individualized care matters so much in midlife women's health.

PMID: 38595196