I've read about this several places, but I'm going to summarize this article for you quickly. There was a large, high-quality study of women's health generally and hormone therapy specifically that started in the 90s and was reported out in 2002. Researchers stopped the study because it showed a sharp increase in negative outcomes for women on HRT.

Doctors took the sensible step of not prescribing HRT. Classes in medical school stopped discussing HRT and in the one class that most medical students take on women's health, menopause became a one-paragraph end to the book on fertility. That said, the number of studies about women's cardiovascular health and breast cancer increased significantly (from practically nothing, but it was growth).

One: The Timing Hypothesis

The original researchers and many of others (this was a huge study, and several groups of scienties all over the world were using the data) went back over the numbers. The timing hypothesis explains one of the results that shook out over time: in short, when you take HRT matters a lot. Women who are younger than 60 and within 10 years of menopause show imrprovement of symptoms, improved cardiocascular profiles, and many other good things.

Two: New Estrogen Replacements

Basically, they used to use conjugated equine estrogens, and now we use estradiol. Estradiol "acts" like our own estrogen and if you want more detail about the pharmakokinetics and ways that it mimics our own body's prodcution of estrogen, check out 5.1 and 5.2 here

Notably, when researchers returned to the WHI study, even the conjugataed equine estrogens were found to have "a null effect on breast cancer risk" when used with progesterone in typical menopausal women.

Three: Study Design

Like many studies, there was a tradeoff with the large number of participants and the complicating factors. On the upside, that's allowed the study to continue to yield fruitful results (below) with further analsysis, but the complications made the results murky at the time. For example, many of the women who were on the placebo dropped out. Other women who aren't typically targets for HRT (women in their 80s, per se) were included. This is all typical but it took time to parse.

Four: Other Studies

There have been many studies since the WHI study that have used the data and found encouraging results for HRT's protective effect on heart health , etc.

Five: New Delivery Methods

Somewhere along the line, researchers realized that the increase in risk of adverse cardiovascular event (stroke or heart attack) was a pharmacokinetics problem: it's how the stuff gets into your system. Transdermal delivery of hormone therapy (and many other drugs) eliminates risk of adverse cardiovascular events (this study is one of many that point to this conclusion).

The initial study was huge and very publically stopped, right when the 24-hour news cycle had just been invented. Doctors had it drilled into their heads if they were already practicing, and if they were in medical school between 2002 and 2012ish, there was literally no education in most medical schools about perimenopause, with menopause garnering a quick note as the end of the section on fertility.

Studies started to appear around 2012 that indicated that estradiol was safer (you may remember Whoopie Goldberg talking about using yam cream on her cootchie on the View; she might've been using one of the yam-derived estradiols but I'm not taking the time to look that up). At the same time, breast cancer awareness was growing and many women, doctors, and scientists remembered the mention of increased breast cancer risk mentioned in 2002 when the WHI study was ended. Besides that, there's only so much research money to go around, and it was going to boobs in the early 2000s.

Interesting HRT research and re-assessments of the WHI study have been coming along steadily since 2012, but doctors would have to be reading the journals in their spare time to learn more. American doctors don't have spare time and conferences and other commuication methods are often driven by pharmaceutical company advances than patient needs.

That said, the Journal of the American Medical Association published a re-assessment of the original WHI studdy in 2023, along with the original authors . The American Heart Association began noting the importance in controlling vasomotor events in content of cardivascular health and noted that HRT might be the way to do it (although jury's out here and there's no recommendation to use HRT as a method of controlling cardiovascular outcomes). By 2023, Britain, Australia, Germany, France, and a bunch of European countries I'm too lazy to look up again all followed guidelines that are examplied by Britain's NICE ones ; they were developed as a result of reassessment of HRT studies. So many more doctors are getting up to date, even in the US.

We do know that estrogen replacements increase the risk of uterine cancer if they are not opposed by progesterone simultaneously. When you take both, there are some studies that show that it actually lowers your risk of some endometrial cancers.

People take estradiol night sweats and hot flashes, but low estrogen can be the cause of other symptoms, from itchy ears and thinning feet pads, lip skin, and hair, a new weird body smell, those chin hairs, digestive changes, and (really, read this list from the Cleveland Clinic) more.

Estradiol, the replacement method we use now, comes in creams, gels, and patches. If you're not at increased risk of stroke,and especially if you are having a ton of bleeding, a doctor may prescribe a regular birth control pill. Notably, the pill contains a stronger, different dose of estrogen which you can read more about the criteria and differences in prescibring in this Jen Gunter piece.

All of the transdermal methods -- creams, gels, and patches, avoid the increased risk of stroke and have a very small dose.

People take progestin to oppose estrogen since estrogen-only HRT increases risk of uterine cancer, and to imrpove mood. It comes in pill form, as part of the Mirena IUD, or as a patch. There's also apparently a progesterone pill?

Testosterone Replacement This is prescribed much less often, and isn't FDA-approved for HRT in the US. Most of the symptoms that drive women to take HRT are resolved by estrogen-progestin, but the women who take a very tiny compounded dose often do so for mental acuity, libido, and energy when other factors (thyroid dysfunction, vitamin or mineral deficiency, etc) have been eliminated as contributors.

Testosterone is complicated, but Britain's NICE guidelines do have standards for treatment of women with low libido. Some of the online companies offer supplements of the precursors for testosterone production ( this reasonably reputable company has a discussion of it ). There's no FDA oversight of this use, and now the MAHA people are cranking up testosterone use for women's workout outcomes and that just sounds like it's about to be a very grifty space. Buyer beware, again.

Look up the list of symptoms and see if you fit in the most common ones. Doctors aren't going to prescribe you something because your ears itch. And sometimes, we're too literal about the key words that docotrs are looking for. Like, are you having trouble sleeping because you're unusually warm on a regular, new basis? Say night sweats even if you are not actually sweating. Are you not even bothering to find that saucy book on your Kindle, but you don't care because men are trash? Say "low libido."

My gyno had never heard of HRT patches, so when I asked for an estrodial patch, she was thinking the birth control patch. Having what you're considering pulled up so you can point to it can go a long way to not flailing around.

I'm not trying to be cheesy, but I made this so you could have the big picture in your head. But your body is weirder than this, and even solutions that work for others may not work for you.

Certainly tests can reveal deficiencies, thyroid levels, and get a read on your hormone levels for that moment in time. If you, for instance, return a 0-level for estrogen, that's good information. But it doesn't mean you won't swing up later that day. It's important to talk with your doctor about treating the symptoms you're experiencing. The entire greater British Isles treats women with little tiny doses of HRT first; it's not crazy to ask more questions about what the doctor is looking for. Sometimes you'll find out they've never prescribed HRT and you may want to find someone more informed (even if you still do the tests with that doctor).

I continue to recomend Midi because they are covered by insurance, real nurse practitioners, and a LOT of people I know who've used them were recommended sensible, basic, low-cost solutions. Some of the other services push their supplements, which seems sneaky to me.

So, probably not? It's related to these problems. The American Heart Association (AHA), for example, is trying to bring more attention to the ways that mid-life hormone changes increases the risk of adverse cardiovascular events. The AHA doesn't directly recommend HRT for high cholesterol (even though estrogen increases "good" cholesterol in women and generally more hot flashes seems to be related to a higher risk for heart atttaack and stroke) because of studies showing that presecribing say, the Pill, to women in their 50s for hot flashes can increase stroke risk, as I discuss under "Estrogen Replacement".

Weight gain during mid life is very depressingly not conclusively related to changes in hormone levels ( except that we change where we store it, with more settling around our bellies). HRT can address problems underlying weight gain, like the hot flashes that cause poor sleep that cause overeating, or low energy. HRT like testosterone might improve your body's ability to make lean muscle mass when you work out. But there's not a "low androgen equals plumpness" smoking gun that I've seen.

So HRT is not approved for use to solve any of these problems. Low estrogen can exacerbate or even cause some of these things, but people age? It's complicated and that's why I like for people to know how things work when they talk with their doctors! None of the countries that approve HRT approve it for solving these problems.

Sigh. Perimenopause was super under-studied and now it's grifter central. There aren't that many studies about putting estrogen on your face, and the ones that exist are almost all funded by and produced for a small number of pharmaceutical companies (such as Ferndale Pharma).

The studies (like this one are small, have questionable signficance scores, and are often based on vibes ("perception of improved appearance"). It's also worth noting that estrogen thickens skin, so covering your face in estrogen cream might deepen wrinkles. There are some studies that show systemic estradiol (like a patch or gel) on your abdomen increases collagen in neck tissue? So we have that.TBH, the studies I could find made me more hopeful about glycolic acid (not an androgen) than I was before.