#042 - HRT and why it matters for midlife health

After two decades of unnecessary fear stemming from misinterpretation of the WHI (women’s health initiative) study, professional societies and healthcare providers worldwide are finally admitting: for the majority of healthy women, the benefits of HRT outweigh the risks. This is important, because menopause isn’t just about symptoms, it’s about long-term health. Declining estrogen, progesterone, and testosterone affect brain, bone, heart, muscle, metabolic health, and quality of life. HRT works at each of these levels. Below is a straightforward overview of what HRT actually is, why it matters, and what women should know.

Why HRT Matters for Long-Term Health

Menopause triggers a steep hormonal drop, primarily in estrogen, but also progesterone and testosterone. These hormones influence many systems that determine health:

• Bone density ↓ (osteopenia & osteoporosis risk increases sharply)

• Muscle mass & strength ↓ (accelerated sarcopenia)

• Cardiovascular risk ↑ (atherosclerosis progression increases post-menopause)

• Metabolic health worsens (insulin resistance, central adiposity)

• Cognition can be affected (especially in women with vasomotor symptoms)

• Sleep, mood, and sexual health often decline

HRT doesn’t just treat symptoms—it addresses the biological drivers of why midlife health changes so dramatically.

PART 1: Estrogen

What it does

Estradiol (aka estrogen replacement) is the foundation of HRT. In the UK, the safest, first-line option is systemic, transdermal estradiol (gel, patch, or spray). This route does not increase the risk of blood clots and carries lower risks and side effects compared to oral estrogen.

Benefits of estrogen replacement:

• Vasomotor symptoms: ~75–90% improvement

• Sleep + mood improvement

• Vaginal + urinary symptoms: dramatically better with local and/or systemic estrogen

• Bone health: prevents bone loss and reduces fracture risk

• Cardiovascular: when started <60 or within 10 years of menopause, there is evidence for cardiovascular protection

• Muscle + metabolic health: reduces central fat gain, improves insulin sensitivity, supports muscle maintenance

Breast Cancer Risk? The Reality:
Modern evidence is clear that the overall breast-cancer risk from HRT is very low for most women. UK bodies such as NICE, the MHRA, and the British Menopause Society now emphasise that the small risk signal seen in older studies—especially the WHI—was overstated and based on outdated formulations not commonly used today. Contemporary data, including long-term WHI follow-up and newer cohort studies, show that standard physiological HRT has little, if any, meaningful impact on breast-cancer risk, and that everyday factors like alcohol, inactivity, and higher body fat carry far greater risk than HRT does. Increasingly, biological models support what clinicians see in practice: there is no strong mechanism suggesting that routine menopause hormone therapy should fuel breast cancers. For most women, the benefits of HRT for symptoms, bone, metabolic health, and long-term wellbeing substantially outweigh the small and often overstated risks.

PART 2: Progesterone

If a woman has a uterus, progesterone is needed to protect the endometrium when using systemic estrogen. In the UK, the most common option is micronised progesterone (Utrogestan), however for those who need contraception too, hormonal IUDs (coils), or other hormonal birth control methods are also suitable.

What it does

• Protects the lining of the uterus

• Improves sleep for many women (due to GABA-modulating effects)

• Plays a role in bone health

• Mood balancing

PART 3: Testosterone

Testosterone is the least understood component of HRT, but sometimes the most transformative for midlife women.

Quick myth-buster: Women produce 3–4 times more testosterone than estrogen pre-menopause. Testosterone is not a “male hormone”—it’s fundamental to female physiology.

What testosterone helps with

Currently, the UK national guidance (NICE and the British Menopause Society) only recommends testosterone replacement for hypoactive sexual desire disorder (HSDD), aka. low sexual desire. However, many women who use it also see real improvements in:

• Energy + motivation

• Cognitive sharpness

• Muscle strength and training adaptation

• Recovery and exercise capacity

• Mood stability

• Confidence

These benefits can be clinically meaningful even if not yet included as licenced indications in the UK.

A quick note on testosterone availability in the UK

Until recently, the UK had no MHRA-licensed testosterone product specifically for women, which meant clinicians relied on off-label prescribing of male formulations in adjusted doses. In 2025, the MHRA approved AndroFeme® 1% testosterone cream for the treatment of HSDD—the first female-specific formulation licensed in the UK. It is not yet widely available, but this approval signals a major shift: testosterone is even more officially recognised as a legitimate component of menopause care when symptoms indicate a deficiency. This aligns with guidance from NICE and the British Menopause Society, which both support testosterone use for women when clinically appropriate.

How HRT fits into longevity + women’s health

HRT works best as part of an integrated health strategy as it is synergistic with the following:

• Strength training → counters sarcopenia (muscle wasting)

• Cardiovascular exercise → offers cardiovascular + metabolic protection

• Protein intake → supports muscle + recovery

• Sleep interventions → improves sleep, which improves everything else

• Stress management → HRT balances mood

For active women, HRT often restores the physiological foundation that makes training, muscle building, and recovery actually effective again.

Why men should also care
Menopause doesn’t just affect women; it affects relationships, families, training partners, and performance. Men already understand the principle through testosterone replacement therapy (TRT): when hormones decline, energy, strength, recovery, mood, and quality of life suffer and treating that decline can be transformative. Menopause hormone therapy applies the same logic to female physiology. For men with partners, mothers, or colleagues in midlife, understanding HRT means supporting evidence-based care, rather than dismissing real changes as “just ageing.”

Closing: A modern, evidence-based approach

We are finally moving beyond HRT fear based on misinformation. The UK now has clear, updated, sensible guidance that supports the use of HRT for most symptomatic women and for preventative health benefits when started early. For many women, HRT is not about “treating menopause”—it’s about preserving strength, cognition, cardiovascular health, confidence, and vitality in midlife and beyond.

Dr Kate Whitehouse

Bibliography

Guidelines & Regulatory Bodies

• National Institute for Health and Care Excellence (NICE). Menopause: Diagnosis and Management (NG23). Updated 2019.

• British Menopause Society. Tools for Clinicians: HRT and Breast Cancer Risk. Updated 2023.

• Medicines and Healthcare products Regulatory Agency (MHRA). Marketing Authorisation: AndroFeme 1% Testosterone Cream. 2023.

• International Menopause Society (IMS). Global Consensus Statement on Menopause Hormone Therapy. Baber RJ et al., Climacteric. 2016.

Breast Cancer Risk & WHI Follow-Up

• Chlebowski RT et al. Breast Cancer After Use of Estrogen-Alone in Postmenopausal Women. Lancet. 2020.

• Manson JE et al. Menopausal Hormone Therapy and Long-Term All-Cause and Cause-Specific Mortality. JAMA. 2017.

• Fournier A et al. Postmenopausal Hormone Therapy and Breast Cancer Risk: E3N Cohort Studies. Cancer Research, 2007; Breast Cancer Research and Treatment, 2014.

• Stute P et al. Micronised Progesterone and Breast Cancer Risk. Climacteric. 2018.

• Bluming A & Tavris C. Estrogen Matters. Little, Brown; 2018.

• Prior JC. Revisiting Estrogen Risks: Biological Mechanisms. Climacteric. 2017.

Benefits of Menopause Hormone Therapy

• Boardman HM et al. Hormone Therapy for Preventing Cardiovascular Disease in Postmenopausal Women. Cochrane Database of Systematic Reviews. 2015.

• Shifren JL & Gass MLS. Menopause Hormone Therapy and Symptom Management. Menopause. 2014.

• Greendale GA et al. Menopause Hormone Therapy and Bone Health. J Clin Endocrinol Metab. 2012.

• Stuenkel CA et al. NAMS Position Statement on MHT and Midlife Health. Menopause. 2015.

Testosterone in Women

• Davis SR & Wahlin-Jacobsen S. Testosterone in Women: Physiology and Clinical Significance. Lancet Diabetes Endocrinol. 2015.

• Burger HG. Androgen Production in Women. Fertil Steril. 2002.

• Miller KK. Androgen Deficiency in Women. J Clin Endocrinol Metab. 2005.

• Reed MJ et al. Androgens in Female Physiology. Clin Endocrinol (Oxf). 1987.

• Islam RM et al. Meta-analysis: Testosterone for Hypoactive Sexual Desire Disorder in Postmenopausal Women. Lancet Diabetes Endocrinol. 2019.

• British Menopause Society. Talking Testosterone. 2022.

Exercise, Menopause & Longevity

• Elavsky S & McAuley E. Physical Activity and Menopause Symptom Reduction. Menopause. 2009.

• Sternfeld B et al. Exercise and Vasomotor Symptoms. Menopause. 2014.

• Exercise and Menopause Symptoms: A Narrative Review. Maturitas. 2019.