The Hormone Pendulum: Enthusiasm May Need A Reality Check

In the past few months, many women have been asking my opinion about starting hormone therapy. Most of them were over age sixty, some even over age seventy-five, and felt they may have “missed out.” I have had many years of experience in menopause care, especially with hormone management. Menopause and perimenopause are currently having a huge media moment. Online, on TV, and on social media, it seems that it has now (finally) been recognized that there are many women in perimenopause and menopause who need information, want their questions answered, and are looking to have their symptoms relieved. But how do they know which information is right, safe, evidence-based, and likely to help?

I think it’s great that women have the opportunity to move through these life stages with happy anticipation rather than fear and dread. But unfortunately, very often, either someone or some website has given them the wrong information about hormones—describing estrogen, especially, as something that all menopausal women must be on, no matter their age or health history. Otherwise, they are told, they will miss out on an opportunity to relieve all of their menopausal symptoms and have a better life.

The American College of Obstetricians and Gynecologists recommends starting menopausal hormone therapy (MHT) before age sixty or within ten years of natural menopause in women without contraindications (no reasons that they are unable to use hormones). This timing gives the most favorable balance of symptom relief versus risk. As a matter of fact, in its new clinical guidelines from November 1, 2026, MHT is recommended as the preferred pharmacologic treatment for vasomotor symptoms of menopause (hot flashes).*

It is recommended to use estrogen plus a progestogen if the uterus is present and estrogen alone if a hysterectomy (removal of the uterus) has been performed. These are also recommended to relieve sleep disturbances related to vasomotor symptoms (night sweats).

The “timing theory” has been known in the past as the “critical window theory” for the initiation of hormones in menopause. It states that there is an optimal time to start menopausal hormone therapy—a window when it is safest and offers the greatest benefits. Most menopausal hormone therapy had previously been recommended to start within the first ten years of menopause.

Starting later than that is now not considered “prohibited,” but it should require an individualized, shared decision that weighs symptoms, expectations, and goals against the risks of initiating hormones at a later age. Starting hormones more than ten years after menopause can raise the risk of a heart attack, stroke, and blood clots, depending on the type of hormone prescribed and your individual medical history. Risks should be assessed before starting any hormone therapy.

In spite of much questionable information presented in online forums, hormone therapy is not currently recommended as prevention for heart disease or dementia. However, benefits that may remain more than ten years after menopause include:

• Relief of persistent vasomotor symptoms
• Better sleep
• Better quality of life
• Fracture protection

Breast cancer risk with an estrogen-progestin combination is less than one extra case per one thousand women per year, and the risk is not increased with estrogen alone.

The distinction that matters most is that of starting MHT late versus continuing it at an older age. Women who started prior to or near menopause can generally continue after age sixty, with regular reassessment of risks. A healthy sixty-three-year-old who is more than ten years from menopause is NOT the same as a seventy-two-year-old who is more than twenty-two years out. Risk rises progressively with distance from menopause, and benefits dwindle for new starts at much later ages. A full assessment must be done before starting any menopausal hormone plan, and for some women, it may make sense to start hormones outside of the previously labeled “safe window.”

Menopausal hormone therapy can also have a protective effect on bones. A lack of estrogen is a risk factor for bone loss and osteoporosis. However, once again, timing is key: Women lose a large percentage of bone in the first five to six years after transitioning to menopause. A bone health program is most likely to be effective if it is started in midlife. This is when estrogen will offer the best protection.

It now seems that virtually everyone at every age believes that hormones will keep them young, help them lose weight, and return them to a healthy and happy sex life. The fear of missing out, or having “missed the window,” is real. But there are many other things that women over age sixty-five can do for their long-term health—like eating a higher-protein, healthy diet; doing regular weight-bearing and resistance exercises; getting good, deep, restful sleep; doing balance training; lowering the amount of alcohol they consume; maintaining a social support system; keeping the mind active with stimulating activities; and concentrating on self-care. Hormones cannot replace these well-regarded recommendations.

It’s never too late to start new things, but when initiating a menopausal hormone therapy plan, there should be more thoughtful consideration. A relationship with a perimenopausal and menopausal care team that will take a detailed history is key. The team needs to learn what your expectations and goals are, discuss the risks and benefits with you, and provide evidence-based guidance and information.

Good menopause care isn’t about getting every woman on hormones; it’s about knowing which women will benefit, which may be harmed, and when the risks may outweigh the benefits. FOMO may be real, but the perceived endless benefits of hormone therapy may not be there for everyone.

• Menopausal Hormone Therapy and Cardiovascular Risk in Midlife Women with Vasomotor Symptoms. JAMA Internal Medicine. 2026. Wang Z, et al.
• Management of Menopause-Related Vasomotor, Sleep, and Mood Symptoms. Obstetrics and Gynecology. 2026. Committee on Clinical Practice Guidelines.