Just over 20 years ago, menopause hormone therapy, or HRT, went from hero to villain overnight. Doctors took millions of women off the treatment after data from a high-profile study suggested it might increase the risk of breast cancer and stroke. Women relying on HRT to ease menopause symptoms (hot flashes, brain fog, and joint pain; we trust you’re familiar) were left with few options—and a lot of confusion.
That story is (finally) starting to change. Menopause hormone therapy is making a comeback, thanks to new research showing many of the risks linked to HRT were overblown. What’s more, leading menopause experts, including Mary Claire Haver, M.D. and Rachel Rubin, M.D., aren’t just putting women on HRT again—they’re keeping them on it. Why? New studies suggest HRT may improve bone health, boost sexual function, and even lower your risk for certain diseases as you age (1, 2).
Sherrie Palm, 70, is among the growing number of women choosing long-term menopause hormone therapy. “I have every intention of taking my hormones in my coffin with me so I can boogie on the other side of the dirt,” jokes Palm, who started HRT at 42.
Palm’s doctor is on board. In fact, they were the one to suggest she make HRT more of a long-term relationship than a fling. Other doctors are less gung-ho. While the latest studies about the benefits of extended HRT are promising, long-term data on its safety—like so much of women’s health—is frustratingly far behind. Weighing the potential benefits and risks can complicate doctors’ decision to prescribe HRT for longer, says obstetrician-gynecologist Kristin Friel, M.D., a menopause specialist in Pennsylvania.
Which leaves women—yet again—with a lot of confusion.
About the Experts
Kristin Friel, M.D., is a board-certified OB-GYN, fellow of the International Society for the Study of Women’s Sexual Health, and a NAMS-Certified Menopause Provider in the Lehigh Valley Health Network in Pennsylvania.
Greg Brannon, M.D., FACOG, ABAARM, is a board-certified OB-GYN and anti-aging medicine physician at Optimal Bio, a Bioidentical Hormone Replacement Therapy (BHRT) practice based in North Carolina.
Why Doctors Are Divided on Taking HRT Forever
Menopause hormone therapy wasn’t always controversial. In the late 1990s, around 15 million women started HRT every year (3). That changed with the 2002 Women’s Health Initiative (W.H.I.) study (4).
Early data from the landmark trial involving about 16,000 women suggested combined HRT increased the risk of breast cancer, heart disease, stroke, and blood clots in women who had been on combined HRT for five years or more (4). While the findings also suggested estrogen-only therapy might reduce breast cancer risk, concerns about stroke and blood clots remained. The early data risks were so concerning that the study was stopped early.
Unsurprisingly, doctors’—and women’s—perceptions of hormone therapy shifted fast. “Hormone therapy prescriptions just totally plummeted,” Friel says. Within a year of the W.H.I. study results coming out, menopause hormone therapy prescriptions were slashed in half (5).
The problem: The findings from the W.H.I. study were widely misinterpreted. Many participants had preexisting conditions, which skewed the data. Older women were enrolled in the study, and many had been in menopause for as long as 30 years (6, 7). We now know that starting estrogen-only HRT—and possibly combined therapy—earlier actually decreases the risk of heart disease (8).
In the years since the initial W.H.I. findings were released, researchers have taken a second look at the data. A 2024 review published in JAMA on long-term hormone use revealed that, for many younger menopausal women (typically those under 60), the benefits of hormone therapy likely outweigh the risks (6).
More recent research from the Women’s Health Initiative notes that the health risks of HRT are low (9). In 2017, the Menopause Society (formerly known as the North American Menopause Society or NAMS) released new guidelines on menopause therapy, noting that for most symptomatic women, the benefits outweigh the risks (10).
Guidance on how long women can stay on HRT is changing, too. Following the W.H.I. study, the prevailing advice from the American College of Obstetricians and Gynecologists was to take the lowest dose of hormones for the shortest time possible. NAMS’ latest guidelines empower doctors to prescribe the best dose and duration for each woman (10).
The types of hormone therapy predominantly prescribed today are also different from what was used in older studies, including the W.H.I. “They weren’t using estrogen or progesterone in their research,” explains menopause specialist Greg Brannon, M.D. “They were using equine estrogen and synthetic progestin, which caused relief of symptoms, but increased risk for blood clots and breast cancer.”
The way you take HRT also determines your risk. Research shows oral estrogen is linked to blood clot risk, but transdermal estrogen (via patch or gel) has minimal risk (11).
Today, most physicians prescribe a combination of estrogen and micronized progesterone, a pairing linked to lower breast cancer and heart disease risk (8).
So, can you stay on HRT forever? It depends on your and your doctor’s comfort. “We’re in an in-between zone right now,” Friel says, while we wait for new, better studies on the benefits and risks of current hormone therapies. “You have to be comfortable in that gray area and know that the current information will change.”
Benefits of Long-Term HRT
Recent studies suggest extended HRT may deliver several benefits.
Bone health
One out of every two women develops osteoporosis after menopause due to depleted estrogen levels (12). Research suggests that bone loss starts right before menopause: Many women lose 10-20 percent of their bone density during the first five years of perimenopause (13). Bone density continues to decline after menopause, albeit at a slower pace (14, 15).
Timing is everything for staving off bone loss, Friel says. Talking to your doctor about starting HRT as soon as you notice perimenopause symptoms may be your best bet at keeping bones fracture-free. “Estrogen doesn’t treat osteoporosis, but it does prevent it.” A 2023 study in the Journal of the Menopause Society found postmenopausal women who continued hormone therapy had higher hip bone density than women who had either never taken HRT or stopped HRT after menopause (16).
Painless sex
While hot flashes, mood swings, and night sweats often stop once you’re officially in menopause (that’s a full year after periods have stopped), sexual symptoms like low libido and vaginal atrophy can linger.
As many as 57 percent of postmenopausal women deal with vaginal atrophy, the thinning and drying of the vagina’s walls caused by plummeting estrogen (17). Estrogen is essential for maintaining vaginal tissues’ thickness, elasticity, and lubrication (18). Dramatic drops in the hormone reduce blood flow and collagen production in vaginal tissues, causing discomfort, irritation, and less lubrication.
Estrogen isn’t the only hormone that starts to dip during perimenopause. Testosterone also independently drops around perimenopause, and even after menopause, which can mess with your libido (18).
Fortunately, this doesn’t mean you have to accept a life of celibacy. Staying on hormone therapy may help restore your sex drive and keep your vagina happy. Data from the widely-cited Kronos Early Estrogen Prevention Study (KEEPS) shows that topical estrogen is especially powerful at improving desire, arousal, lubrication, orgasm, satisfaction, and lowering pain during sex (19).
Palm can attest. She says a combination of HRT, estradiol vaginal cream, and testosterone have kept her libido humming and her vagina atrophy-free.
Research suggests that starting menopause replacement therapy before you hit 60 (or within 10 years of your last period) can decrease your overall risk of death by nine percent (2). Continuing treatment may boost your lifespan even more.
A 2020 study in the journal Menopause followed more than 8,000 women for 22 years (20). It found the longer women took estrogen therapy, the longer they lived—many well into their 80s and 90s. Scientists suspect this boost in lifespan is partly because estrogen helps ward off chronic diseases like osteoporosis and type 2 diabetes, which speed the aging process (2, 21).
Estrogen may also keep heart disease at bay. Women’s risk of cardiovascular disease skyrockets when estrogen takes a nosedive (22, 23). Compared to their premenopause counterparts, women in menopause are twice as likely to experience heart-related medical events like heart attacks (24). And women who stop HRT before age 60 may have an elevated risk of dying from a cardiac event (25). A groundbreaking study in the Journal of the Menopause Society found women who continued estrogen-only therapy after age 65 had reduced risk of several severe health conditions, including cancer, heart failure, and dementia (26). Estrogen therapy combined with progestin or progesterone therapy by itself appears to lower the risk of endometrial and ovarian cancers and heart disease (26).
Brain health
Women are about twice as likely to develop Alzheimer’s disease than men (27). And low estrogen levels in menopause may be linked to faster cognitive decline (28). A 2023 study in the journal Alzheimer’s Research and Therapy found that women with the APOE4 gene (a major genetic risk factor for Alzheimer’s) who took HRT had improved memory and greater brain volume than APOE4-positive women who didn’t receive hormone treatment (28).
Is Long-Term HRT Safe?
While long-term HRT offers benefits, Friel notes that it isn’t a “one-size-fits-all.”
Women over 60 may not be good candidates for long-term, systemic HRT
The Menopause Society recognizes two main types of menopause hormone therapy: estrogen-only (ET) and estrogen with progesterone (EPT). These treatments can be taken systemically, meaning they circulate through your bloodstream via an oral tablet, patch, gel, emulsion, spray, or injection. Or, you can apply estrogen, prasterone locally to the vagina, for instance, to help with symptoms in that specific area.
Systemic, oral hormone therapy is linked to a higher risk of breast cancer, stroke, and blood clots, particularly for women over 60, Friel says. While the W.H.I. is still the largest study that shows this risk, newer research also suggests breast cancer risk may go up after five or more years on HRT—especially with systemic EPT (29). However, transdermal estrogen-only treatment may not carry the same risk (30).
“I see patients every year, and we make sure nothing has changed medically for them that would tell me they shouldn’t continue on hormones,” Friel explains. After five to eight years, she discusses potential long-term risks and ultimately collaborates on the decision with her patients. Many stop hormone therapy or switch to a local, estrogen-only treatment.
Women with ongoing symptoms may benefit
Some women have menopause symptoms well into their 60s and 70s. “That’s the group that really should stay on treatment because those are the symptoms that we know estrogen helps with,” says Friel. Vaginal estrogen cream can be used indefinitely to offset vaginal dryness and atrophy with no risk.
If I Stop HRT, Will My Symptoms Come Back?
Once you stop hormone therapy, your levels will return to your new, lower baseline and remain consistent (31). Your symptoms may come roaring back—or not.
“It’s sort of a trial and error,” Friel explains. “If you don’t do okay stopping HRT, then we will revisit restarting it, but maybe at a lower dose.”
The Bottom Line
For years, women were told to stop HRT as soon as they entered postmenopause to avoid increased risk of breast cancer, blood clots, and stroke. Recent research indicates the risk is low. Studies also suggest long-term HRT may deliver benefits like better bone and brain health, painless sex, and increased lifespan. However, extended HRT is a decision that should be shared between you and your doctor with appropriate counseling. Ultimately, you and your doctor should decide how long you should stay on menopause hormone therapy.
Rebekah Harding is a Health Writer at The Edge. She is an experienced health and lifestyle writer with both digital and print bylines in Men’s Health, Cosmopolitan, Yoga Journal, Giddy, and more.
