Hormone replacement therapy is back in fashion. Celeste McGovern looks at the risks and alternatives
Aging is a rough ride for many women. Even those who have it all, like supermodel Brooke Shields—still beautiful at 59—admit to being surprised when the first signs of menopause hit them.
In her recently released memoir, Shields says she had her first perimenopausal hot flash while on a set filming in 2016. “The makeup artist couldn’t mop me down fast enough,” she said, and they had to pause the filming while she applied ice water and Sea Breeze astringent to her neck to cool down.
She was 50 then but was still shocked by the signature symptom of waning hormones signaling the end of her fertility. “It just wasn’t on my radar,” she wrote, “which is maybe strange but, I’ve also learned, entirely common.”
These days, however, it’s hard to avoid stories about menopause and the symptoms of declining hormones in midlife and beyond. Even celebrities openly share their struggles with hot flashes, brain fog, “crime scene” heavy periods, irregular periods, dry skin, flagging libidos and fatigue.
Platforms like X and Instagram are buzzing with hashtags like #MenopauseMatters and #MenopauseAwareness as women post about mood swings, forgetting people’s names, midlife acne, frozen shoulder, weight gain on the tummy and tinnitus.
There’s now an International Menopause Day (October 18), and organizations like the North American Menopause Society and the British Menopause Society are demanding greater public attention to the phase that defines 40 percent of a woman’s lifespan on average. Popular books on the subject say women should demand HRT to avoid the frail aging their mothers suffered.
A star in this menopause movement is ob-gyn Mary Clare Haver, author of The New Menopause (Rodale Books, 2024). She’s a proponent of increased access to hormone replacement therapy (HRT) the use of synthetic and “bioidentical” versions of the hormones that regulate menstrual cycles, fertility and pregnancy, which naturally wane as a woman ages.
The idea behind HRT is that replacing dwindling hormones staves off the symptoms of menopause and possibly the long-term consequences of loss of hormones, including cardiovascular disease and dementia, if started early enough.
The science is not as conclusive as it’s often made to sound. HRT has had its ups and crashing downs. While it’s currently riding a new high, emerging research continues to suggest there are hidden risks; it’s complicated to tease out which women might benefit, when and on which of the dozens of different formulations, and who is most at risk of serious side effects including stroke, dementia and heart disease.
HRT had its first boom in the 1940s, when US drug regulators approved Premarin, an estrogen formulation made from pregnant horses’ urine. With the release of a book about estrogen by gynecologist Robert A Wilson, Feminine Forever (M Evans and Company, 1966), Premarin use soared to 30 million prescriptions dispensed in the US in 1975 alone.
The same year, however, a major study published in the New England Journal of Medicine found that women on the drugs were 4.5 times as likely as non-users to develop endometrial cancer.1 The cancer was occurring in one to three of every 100 women taking the therapy.2 This brought the Premarin boom to a screeching halt.
Soon researchers figured out that adding progesterone to equine estrogens would mitigate the cancer risk. Some observational studies also showed the new formula could prevent bone loss and might decrease cardiovascular risks.
Soon, the American College of Physicians was on board with the new oral estrogen-progesterone combo, and the prescription bonanza began again. By the 1990s, about 40 percent of postmenopausal women were being treated with HRT.
Then came the next party crash. The landmark Women’s Health Initiative (WHI) study, the largest randomized, placebo-controlled study of its kind, was published in 2002, revealing that combined hormone therapy was linked to a higher risk of breast cancer, heart disease, stroke and blood clots.3
HRT prescriptions dropped a whopping 80 percent in the next few years, and training in menopause treatment fell out of fashion.4
In the current resurrection of HRT, you’ll hear increasingly that the WHI was flawed and is irrelevant today. According to Haver, the synthetic progesterone used in the study, medroxyprogesterone acetate, is hardly ever used anymore. Conjugated equine estrogens are but one of many choices, including bioidentical estrogens created to exactly mimic human ones.
Breast cancer is a rare occurrence with one extra case per 1,000 women per year of HRT use, according to the North American Menopause Society. The organization also says smaller observational studies show HRT might lower the risk of colon cancer.
There’s also growing acceptance of the “timing hypothesis”: WHI data shows women who started HRT earlier didn’t face the risks of the drugs and even enjoyed cardioprotective benefits compared to women who started after menopause. This is shifting the age of HRT prescription to younger and younger women. Now they’re getting it when hormones first start dwindling, up to 10 years before full cessation of menstrual cycles.
Proponents of HRT say there’s also evidence that estrogen replacement (with progesterone to offset cancer) can improve cognition. They point to a 2023 study showing that after taking HRT, women who carry the APOE4 gene linked to a higher risk of Alzheimer’s disease had improved memory recall and larger brain volume in areas key to information processing.5
More recent studies raise more questions, however, and point to serious risks, even for younger women and those taking the hormones longer.
Heart disease, stroke and blood clots. A Swedish study published in The BMJ in 2024 looked at how different types of menopausal hormone therapy affect the risk of cardiovascular diseases in women aged 50–58. It included data from 919,614 women in Sweden between 2007 and 2020.
Oral combined hormone therapy (both estrogen and progesterone by mouth) is the most popular form in Sweden. The study found women using this form had a higher risk of ischemic heart disease (caused by narrowed arteries).
Tibolone, a synthetic hormone that the body uses to make substances similar to estrogen, progesterone and testosterone, greatly increased the risk of ischemic heart disease, stroke and heart attack but not blood clots. Taking oral continuous estrogen-progestin therapy, sequential oral therapy or estrogen-only therapy increased the risk of blood clots by about 60 percent.
However, transdermal hormone therapy delivered via patches or gels, and growing in popularity in Sweden, didn’t appear to increase any of these risks.6
A Danish study of 980,000 women aged 51–70 years again found an increased risk of ischemic stroke with oral hormone therapies. But it found no risk of stroke with transdermal application and a reduced risk with vaginal estrogen.7
Alzheimer’s and dementia. Another Danish study in 2024 looked at about 61,000 Danish women with no history of dementia or contraindications for HRT from 2000 to 2018. About 1 percent developed dementia during that time.
Comparing those who did and didn’t use HRT, the researchers concluded that HRT increased dementia and Alzheimer’s disease risk, even in women who used it at age 55 or younger. The longer women were on the hormones, the higher the risk: 21 percent higher among those who took the drugs for a year or less and 74 percent higher among those who took them for more than 12 years.8
A 2024 study contradicted the mainstream dogma that estrogen protects the brain. It showed that using pure estrogen receptor antagonists or aromatase inhibitors, which block estrogen, was associated with a lower risk of developing dementia across the entire expected female lifespan.9
“This suggests that estrogen might actually be harmful to brain health, rather than protective,” health advocate and osteopath Dr Joseph Mercola wrote about the study. “If this is the case, it would explain why rates of dementia increase after menopause—not because of estrogen deficiency but because of the cumulative effects of lifelong estrogen exposure.”10 It flips the script on HRT and raises questions about its real safety for long-term brain health.
Autoimmune disease. A 2025 study reported that women using HRT are more likely to develop systemic lupus erythematosus (SLE) and systemic sclerosis (SSc), also known as scleroderma, a condition that hardens and tightens skin but may also affect blood vessels and organs.
The study looked at women aged 40 years and older in Sweden and found that relative to never-users of HRT, those taking hormones had a 30 percent higher risk of SLE and a 40 percent higher risk of SSc.
The risk was highest for women taking estrogen plus progesterone compared to either alone. Those who took both oral and transdermal medications had the greatest risk, a 90 percent higher chance of developing one of the autoimmune conditions. And women who started the therapy younger (aged 46–50) faced more than twice the risk of SLE and 50 percent higher odds of SSc.11
Breast cancer. The elevated risk of hormonal breast cancer usually means women who’ve had cancer are denied HRT prescriptions. But new cases of HRT-related cancer can’t be predicted.
The good news is that the body may begin to heal as soon as HRT stops, as in the 2022 case of a 61-year-old woman who had been on HRT for years and developed invasive ductal breast cancer. As soon as her hormone therapy halted, the growth rate of the tumor cells dropped by 20 percent.12
Other side effects. While many women describe how hormone replacement relieved their symptoms, on social media, you also find scores of women complaining about symptoms that arrived after they started HRT.
Since HRT consists of lower doses of the same hormones used in birth control pills, it’s not surprising that it comes with similar side effects. Irregular bleeding, skin breakouts, mood changes, headaches, dizziness, diarrhea and bloating are common.
“I started HRT and my hair started falling out within two weeks. Doctor said it was not due to HRT,” one woman commented online. “A few weeks later I stopped the HRT and my hair stopped falling out.”
Swelling of the eyes, lips and labia, changes in the shape of the cornea, fluid retention and even pancreatitis and gallstones requiring gallbladder removal are listed as HRT side effects. There’s also a catalogue of contraindications (see below).
Then there’s the vast and confusing array of HRT formulations. Conventional synthetic hormones are made from chemicals that are not the same as the ones your body makes. Bioidentical hormones are also made in a lab, but they’re usually derived from plant ingredients and are an exact match for the estradiol, progesterone and testosterone your body makes.
Within the bioidentical category are two choices: regulator-approved pharmaceutical versions in standardized doses and compounded bioidentical hormones made to order at compounding pharmacies. Compounded hormones are tailored to the patient by their practitioner and are more favored by functional and naturopathic practitioners.
These are often prescribed as creams dispensed in a device that increases the dose with each click. There are vaginal rings, troches (lozenges dissolved and absorbed in the mouth) and oral doses, which are less favored by alternative practitioners because of the risks above, which may be related to their passage through the liver for breakdown.
There are also injections and pellets—implants about the size of a grain of rice that leak out a steady stream of hormones for a couple of months.
On social media, Dr Taz Bhatia, an integrative doctor in Atlanta, Georgia, describes oral dosing as a “sledgehammer approach,” and she’s no fan of pellets or injections. “They’re off running the races in your bloodstream and there’s no way to pull them back.
“Megadoses are out. They’re hard on the liver, they’re hard on the gut, and they’re hard on you,” she adds.
There’s also a new drug that works on receptors in the brain to deter hot flashes. Fezolinetant (Veozah or Veoza) was approved in the US in 2023 and within a year had a black box warning slapped on it due to its risk of severe liver toxicity.13 In the UK, it was approved the same year and is available with a prescription but not through the National Health Service.
Given hazards like these, it’s not surprising that many women are looking for safer alternatives. Mindy Pelz is a go-to source for this information. Author of The Menopause Reset (Hay House, 2023) and Fast Like a Girl (Hay House, 2022), she lays out a lifestyle and nutrition-based plan to rebalance hormones, put hormonal symptoms in check and sail through menopause.
Practice intermittent fasting. One of the first things Pelz, a chiropractor, tells women in perimenopause and menopause is to start delaying their breakfast by an hour. Next, she encourages them to stop eating at a set time in the evening, and then to gradually narrow that window of eating to eight hours or less each day, say 11:00 a.m.–7:00 p.m., and then narrow it further to 12:00–7:00 p.m.
This is called intermittent fasting, or time-restricted eating, and is a “godsend for menopausal women,” Pelz says. To begin, it targets one of the most-cited complaints of perimenopausal and menopausal women: stubborn belly fat.
A 2024 study split a group of 62 menopausal women (average age 51) into two groups. One completed a 55-minute moderate-intensity resistance/endurance circuit twice per week, and the other did the same exercise routine but also limited their eating to an eight-hour window daily (fasting for 16 hours, including sleep time).
After 12 weeks, the exercise-plus-intermittent-fasting group had greater fat loss and body mass reduction than the exercise-alone group, which hadn’t changed much.14 The fat that exercise wouldn’t budge finally shifted when the time for eating was narrowed and fasting occurred.
Another three-month study in 40 people (including 31 women, average age 49) showed that restricting the time they ate to eight or nine hours in a day reduced belly fat and cut waist size by an average of 2.1 inches (5.3 cm).15
While intermittent fasting hasn’t been shown to alter sex hormones directly, it does amp up the body’s production of growth hormone,16 which begins to slow around age 30. Growth hormone burns fat, builds muscle and slows the aging process. It enhances mood and libido in both men and women, regulates testosterone and increases energy.17
Besides targeting belly fat, there’s heaping evidence that intermittent fasting works against a broad range of conditions that affect aging women. A 2019 review found that studies “consistently show the robust disease-modifying efficacy of intermittent fasting in animal models on a wide range of chronic disorders, including obesity, diabetes, cardiovascular disease, cancers and neurodegenerative brain diseases.”18
Periodic fasting also flips the body’s metabolic switch into ketone-burning rather than glucose-burning mode. According to the authors of the review, ketones elicit “highly orchestrated systemic and cellular responses that carry over into the fed state to bolster mental and physical performance as well as disease resistance.”
And when our bodies go without food, autophagy (“self-eating”) kicks in. The cells break down and recycle their damaged parts. “Think of autophagy as your cells’ way of self-detoxing,” says Pelz. “Your cells go into a massive repair phase, fixing dysfunctional components inside the cell.”
Two conditions generally have to be met to kick the body into true autophagy: fasting for 17 hours (at least) and limiting protein intake to under 20 g a day. “When you combine these two principles, you stimulate autophagy and your body will repair itself,” according to Pelz.
Eat smart. Pelz suggests what she calls a “ketobiotic diet,” in which the body produces ketones periodically and the food is “biotic”—rich in polyphenols and prebiotic, feeding the microbiome.
Unlike a strict ketogenic diet that limits carbs to 20–30 g per day, Pelz says the ketobiotic diet is about 50 g of net carbs per day, 50 g of net protein and greater than 60 percent of the total in healthy fats.
What’s out on the diet are refined carbohydrates and sugars. What’s in are clean animal protein and healthy fats like coconut oil, olive oil and grassfed butter.
Feed your microbiome. The gut is ground zero for hormone health. That’s because some of the principal hormone regulators are bacteria belonging to the microbiome—a group of at least 60 different bacteria known collectively as the estrobolome. Two critical estrobolome bugs are Lactobacillus reuteri and Lactobacillus rhamnosus, which you can find in probiotics, alone or in combination with other favorable bugs.
The estrobolome produces specific enzymes that influence estrogen in circulation, breaking down so-called bad estrogens and building up the good ones.19
When the estrobolome is impacted by things damaging to the microbiome, it can affect everything that estrogen affects—just about every tissue in the body. That’s why Dr Pelz thinks it’s so important for women to protect their microbiomes by avoiding unnecessary antibiotics, including prescriptions, those in hand sanitizers and those used in meat.
“The easiest way to stop toxifying your gut is to stop eating fake foods,” says Pelz. Feed it with a lot of whole foods and try daily to get food rich in polyphenols, probiotics and prebiotics (see below).
If you think you might be or get pregnant, stay away from HRT to avoid harming the baby’s development. If you’ve had cancer, you’re generally advised against HRT. Women who’ve had strokes, heart attacks, blood clots, deep vein thrombosis or pulmonary embolism are advised against HRT.
New policies by groups like the North American Menopause Society also caution against starting HRT more than 10 years after the onset of menopause or after age 60, stating that women who do so face “greater absolute risks of coronary heart disease, stroke, veinous thromboembolism and dementia.”
A healthy microbiome is vital to a healthy menopause. Here are some ways to look after yours.
Foods to include in your diet
Chemicals to cut from your diet
Some chemicals added to foods destroy the good bacteria:
Herbal remedies can be a powerful treatment for menopausal symptoms. Here are some proven to work.
Black cohosh
Black cohosh (Cimicifuga racemosa or Actaea racemosa) has been used for centuries in traditional Native American medicine and folk medicine. Studies have found it may help with conception in women who have polycystic ovary syndrome (PCOS)1 and is as useful as drugs against uterine fibroids.2 A 2023 review found it may reduce menopausal symptoms overall and hot flashes specifically.3
Dosage: 20–40 mg twice daily
Cautions: Avoid when pregnant or breastfeeding. Buy from a reputable source and don’t confuse it with white or blue cohosh. If you develop symptoms of liver toxicity (dark urine, yellow skin or abdominal pain), discontinue immediately and contact a doctor.4
Red clover
Red clover, a flowering legume rich in phytoestrogens called isoflavones, has also been used traditionally to reduce menopausal hot flashes and has been reported to help with hair thinning and skin aging.5
Dosage: Up to 80 mg daily, beginning with 20–40 mg once or twice daily
Cautions: Avoid if pregnant or breastfeeding.
Chasteberry
As far back as Ancient Greece, the fruit of the Mediterranean chaste tree, called chasteberry or Vitex agnus-castus, has been used to treat fertility and a wide range of women’s reproductive issues, including hot flashes and night sweats.6
Dosage: 160–240 mg daily
Cautions: Do not take if you are pregnant or breastfeeding or have a history of any mental illness. Chasteberry has been reported to induce psychosis when taken for premenstrual symptoms.7 Since chasteberry can disrupt the function of medicines including antipsychotics, birth control and other hormonal treatments, discuss it with your doctor.
Dong quai
This traditional Chinese medicine for hormonal balance has been used to increase libido and reduce premenstrual symptoms.
Dosage: 2–4 g powdered root daily, divided into two or three doses
Cautions: Do not take dong quai if you are pregnant or breastfeeding or if you are taking a blood-thinning drug. Dong quai contains coumarin, which is used in blood-thinning drugs like Warfarin and could raise your risk of bleeding. It may also react with other natural blood thinners, such as ginger, gingko and garlic, which could raise your risk of bleeding or bruising.
It should not be taken by those on birth control or any form of hormone replacement.
Allergic reactions are rare but known.
Licorice root extract
Derived from the roots of the licorice plant, licorice has a long history of use in traditional medicine for treating women’s reproductive complaints. Research has confirmed it’s as powerful as HRT for hot flashes and night sweats.8
Dosage: 6–18 mg daily (do not exceed)
Cautions: Do not take if pregnant or breastfeeding. Long-term licorice consumption can raise blood pressure and lower potassium levels.9 Do not consume licorice root within two weeks before surgery since it may disrupt blood pressure control during surgery.
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