Approaches to menopausal hormone therapy (HT) have swung back and forth — in the late 1960s the book Feminine Forever touted HT as a fountain of youth, then the Women’s Health Initiative studies in the 1990s linked HT with increased risks for heart disease and breast cancer. After a black box warning was put into effect in 2003, HT use in postmenopausal women declined precipitously.

HT is on the upswing again now that the black box has been removed, but guidelines still recommend its use only for treating moderate or severe menopausal symptoms such as hot flashes. But with social media messaging testifying to how HT can optimize the health of perimenopausal and menopausal women, patients are increasingly asking their doctors for prescriptions.

The Case for Preventive HT

Making a case for preventive HT — therapy given to prevent many menopause-related health issues — Anna Cabeca, DO, said, “Estrogen deficiency is not a benign state.” Cabeca, a Dallas-based ob/gyn, noted that estrogen deficiency is associated with accelerated bone resorption, visceral adiposity, insulin resistance, neurocognitive changes, and urogenital atrophy.

Similarly, David Ghozland, MD, a board-certified ob/gyn at Intimate Health Center in Orange County, California, said he has built much of his current practice around helping women navigate perimenopause and menopause with protocols that go beyond standard symptom management into actual long-term optimization.

“I started prescribing HT preventatively because several studies prove that earlier intervention can lessen severe symptoms,” he explained. For him, beginning HT during perimenopause can help preserve bone density, cognitive sharpness, and cardiovascular markers.

Another advocate of preventive HT, Bruce Dorr, MD, URPS, IFM-CP, senior medical advisor at Biote and a board-certified ob/gyn, said studies are clear that when women begin HT within 10 years of menopause or before age 60, the risk for cardiovascular events can be reduced. “This is significant because cardiovascular disease is the number one killer of women in menopause, and their risk shifts dramatically during this transition.”

Lipid profiles, he said, begin to worsen within 6 months of menopause, as do inflammatory factors, and metabolic changes drive weight gain that can compound vascular damage over time. Research also shows vascular compromise can begin when average estradiol levels fall below 38 pg/mL during the perimenopausal window.

Most Proven Potential Benefits

While the conclusions of recent research studies do not justify HT for preventing cardiovascular disease, dementia, or other chronic diseases, they dosuggest some potential health benefits.

Bones

“We know there are benefits for bone health,” said JoAnn E. Manson, MD, DrPH, professor of medicine and epidemiology, Harvard Medical School and chief, Division of Preventive Medicine, Brigham and Women's Hospital. Several studies have documented that HT helps preserve bone mineral density and prevent factures, she said.

Dorr said he has helped reverse osteoporosis in over 40 patients with a combination of both estrogen and testosterone.

Early Menopause or Ovarian Insufficiency

Women who have had a hysterectomy, who had a bilateral oophorectomy, or who are experiencing premature or early menopause could see the benefits from HT for prevention of cardiovascular disease, dementia, and other chronic diseases. In a randomized trial published in Annals of Internal Medicine, Manson and her co-authors reported estrogen-only HT was associated with a reduction in all-cause mortality for women younger than 60 years who had had both ovaries removed. Replacing estrogen at least until the average age of menopause could lower the risks for cardiovascular disease, osteoporosis, and cognitive decline, Manson said.

Sexual Health

Greg J. Marchand, MD, a board certified ob/gyn and a surgeon at the Marchand Institute for Minimally Invasive Surgery in Mesa, Arizona, said he frequently prescribes low-dose vaginal estradiol preventively in perimenopausal or early postmenopausal women. His goal, he said, is to preserve vaginal tissue health, prevent recurrent urinary tract infections, and stop atrophy from progressing.

With this HT formulation, Marchand said, there is minimal systemic absorption with no meaningful risks for breast cancer or endometrial issues. A systematic review of 46 randomized controlled trials published in Annals of Internal Medicine in 2024 supported low-dose vaginal estradiol to improve vulvovaginal dryness and dyspareunia in postmenopausal women.

Some studies have also suggested intravaginal testosterone might help with sexual function in perimenopausal and postmenopausal women. Cabeca said she has found testosterone therapy “transformative, particularly in women with persistent fatigue, low libido, and loss of motivation.” 

To Test or Not to Test

Though many perimenopausal women are now asking for hormone tests with an eye toward starting HT, follicle-stimulating hormone and estradiol levels fluctuate so wildly during perimenopause that many clinicians do not find blood tests for perimenopause helpful. “The blood test will add very little except cost,” said Manson. “If a clinic is routinely recommending this and women are paying out of pocket, that is not evidence-based.” Most clinicians, she said, can go by a woman’s medical history, her reports on her menstrual cycle, and her symptoms to know which stage she is in.

That said, Stephanie S. Faubion, MD, MBA, MSCP, medical director, The Menopause Society, and director, Mayo Clinic Center for Women’s Health, Rochester, Minnesota, said she might order a blood test for hormone levels if a patient is using a progestin-containing intrauterine device, has had a hysterectomy, or is experiencing early menopause. “It points you in the right direction” when you don’t have data about their natural bleeding pattern, she said.

Ghozland said he tests hormone levels to rule out undiagnosed thyroid dysfunction or adrenal fatigue, which he has found can be responsible for symptoms patients mistakenly credit entirely to menopause.

On the Horizon

Researchers are now testing new HT therapies like estrogen receptor-beta selective agonists, estetrol, and combination estrogen and selective estrogen receptor modulator therapy. 

In the meantime, many doctors are pursuing a personalized approach to HT, tailoring doses, routes, and timing to each patient based on their age, menopausal stage, symptoms, and risk factors (which are greater for patients who have contraindications such as cancer, older age, and when HT is in pill form).

Ghozland said he customizes treatments and retests patients regularly, adjusting formulations as symptoms evolve. “A woman might need more progesterone initially for sleep and mood stabilization, then require testosterone added later when libido and lean muscle become the primary concerns,” he said.

To Cabeca, HT care should be personalized and take into account a patient’s entire “endocrine ecosystem,” including their levels of follicle-stimulating hormone, progesterone, dehydroepiandrosterone, and testosterone. HT is about restoring a physiologic network, she said, one that includes ovarian, adrenal, and neuroendocrine signaling. “By expanding our lens to include…the full spectrum of hormones, we move closer to a precision-based model of menopausal care.”

“This is where I believe the future lies,” she said. “Not in rigid guidelines alone, but in thoughtful, individualized, and evidence-informed restoration of hormonal balance.”

Dorr reported serving as the senior medical advisor for Biote. Ghozland, Manson, and Faubion reported having no conflicts of interest. Cabeca reported selling supplements from her website.