The Hormone Therapy Conversation: Why "Approved for Prevention" Is More Complicated Than You Think

Hormone TherapyMenopausePreventionPerimenopause

Sep 29

Ever been told that hormone therapy is only for hot flashes? Or that it's too risky to even consider? As a nurse practitioner, I hear this all the time, and frankly, it's a myth that needs to be busted.

While it's true that menopause hormone therapy (MHT) isn't officially "approved" for preventing every chronic disease, that's not the full picture. Let's dive in and uncover the real story behind MHT and long-term health.

First, let's get the facts straight. MHT is approved for the prevention of osteoporosis, a condition that can have devastating consequences [1]. The risk of bone fractures is a serious threat to longevity, with about 28% of postmenopausal individuals who break a hip dying within a year. Among those who survive, about half never regain their independence [2]. As someone who has studied geriatric medicine, I know firsthand how much we underestimate the true danger of decreased bone density.

It's true that the U.S. Preventive Services Task Force (USPSTF) doesn't recommend MHT for the primary prevention of heart disease, dementia, or metabolic disease [3]. But it's also important to remember that most medical treatments aren't universally recommended—in fact, routine vaccinations and vitamin K shots for newborns are about the only ones that come to mind. The real story is far more nuanced, so let's get into the weeds.

The Secret Superpowers of MHT

While not officially approved for it, MHT has some pretty impressive "off-label" benefits.

MHT and Diabetes: MHT has strong evidence showing it reduces the risk of new-onset diabetes. Studies like the Women's Health Initiative (WHI) found that both estrogen-only and combined MHT significantly lowered the chance of developing diabetes compared to a placebo [1]. The American Heart Association even states that MHT started within 10 years of menopause (or before age 60) can offer metabolic perks like lower diabetes rates and improved insulin resistance [4].

MHT and Your Heart: MHT also helps your cardiovascular system in other ways. It can improve your cholesterol by lowering "bad" LDL cholesterol and total cholesterol [4-8]. It also helps reduce visceral fat (the metabolically active fat around your organs), which is a key marker of health [6-7]. For extra safety, we often prefer transdermal (through the skin) estradiol and micronized progesterone to minimize risks like blood clots [9].

Timing Is Everything: The "timing hypothesis" is a big deal in MHT. The Early versus Late Intervention Trial with Estradiol (ELITE) showed that starting estradiol soon after menopause (within six years) can slow the buildup of plaque in your arteries, a key sign of heart disease [10-11]. However, this benefit isn't seen when MHT is started later [10-11]. This suggests there's a critical window where MHT can provide a major benefit to your heart.

All major medical societies, including the American Heart Association, agree that MHT should be used until the average age of natural menopause in individuals with premature menopause (before age 40) to prevent serious risks like heart disease and dementia [4,12]. It just doesn't make sense that the heart and brain benefits of estrogen disappear if you enter menopause at age 45.

My Approach: Putting Patients First

Given this complex but encouraging data, I take a different approach in my practice. I never turn someone away who wants to explore MHT for prevention. Why?

First, I see firsthand how MHT dramatically improves quality of life. Patients often don't even realize their joint pain, low energy, or poor sleep are linked to menopause. A trial of MHT can be a powerful revelation, showing them just how much better they can feel.

Second, MHT is incredibly safe, especially with modern formulations. While the old WHI findings caused fear, newer research provides a clearer picture. The small increased risk of breast cancer with combination MHT (less than 1 in 1,000 extra cases per year) is similar to the risk from drinking two alcoholic beverages a day [1]. What's more, solo estrogen therapy actually reduces breast cancer risk [1]. The best part? MHT is associated with a lower overall risk of death when started within 10 years after menopause, and with transdermal estradiol and micronized progesterone, there's no increased risk of blood clots [1, 15].

I believe it's perfectly reasonable for a person to try MHT to see if it works for them. For too long, people have been left out of the decision-making process for their own bodies. In this confusing landscape, many turn to unproven treatments or social media gurus. By offering medically supervised, evidence-based MHT, I see my role as a form of harm reduction and an act of compassion. We can empower people to make an informed choice and improve their long-term health, keeping the end in mind.

Want to learn more? Book a Clarity Call with me.

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