Should I take menopausal HRT?

Our read is that HRT, when initiated around the time of menopause, can offer significant benefits for cardiovascular health, bone density, brain health, and overall healthspan.

Experts suggest that the widespread avoidance of HRT, largely due to misunderstandings of past studies, has contributed to an epidemic of osteopenia and osteoporosis.

While there are considerations regarding timing and specific protocols, the consensus leans towards judicious use of HRT to improve health outcomes.

HRT should ideally be initiated around menopause, within the first ten years of cessation of periods, and before atherosclerosis is established. It should be started before a woman reaches a menopausal state with flat-lined estradiol and progesterone and very high FSH/LH. Dennis Erdman MD suggests HRT should be administered for both men and women. Options include vaginal rings for local and systemic treatment, IUDs for progesterone, and topical testosterone. Labs should be checked, not just symptoms. Women with pre-existing cardiovascular disease are generally not recommended to start hormone therapy.

• 01Dennis Erdman MD suggests that Hormone Replacement Therapy (HRT) should be administered for both men and women (Peter Attia, 1x).
• 02Vaginal rings for HRT provide local and systemic treatment but are often prohibitively expensive and not covered by insurance (Andrew Huberman, 1x).
• 03Initiating HRT at the time of menopause is doubly beneficial for individuals with the E4 genotype due to Alzheimer's risk considerations (Rhonda Patrick, 2x).
• 04Women may experience significant bone loss by the time they reach full menopause, even without HRT (Peter Attia, 1x).
• 05There have been zero additional deaths due to HRT from breast cancer over the past 20 years (Peter Attia, 4x).
• 06Judicious use of interventions like HRT, proper exercise, and reasonable nutrition can improve healthspan by five years (Peter Attia, 1x).
• 07Women experiencing hormonal shifts during perimenopause and menopause may benefit from more frequent dental visits and potentially hormone replacement therapy (HRT) to support oral health (Andrew Huberman, 1x).
• 08Starting HRT early in life, especially before atherosclerosis is established, may be beneficial for cardiovascular health (Peter Attia, 1x).
• 09Widespread avoidance of HRT following the Women's Health Initiative study has contributed to an epidemic of osteopenia and osteoporosis in postmenopausal women (Peter Attia, Rhonda Patrick, 6x).
• 10Initiating HRT at menopause is not associated with increased risk of heart disease, breast cancer, or other adverse outcomes, and may reduce risks of heart disease, dementia, and bone density loss (Rhonda Patrick, 1x).
• 11Women with pre-existing cardiovascular disease are recommended not to start hormone therapy, and the ideal time to start is around menopause (within the first ten years of cessation of periods) (Peter Attia, 1x).
• 12Hormone replacement therapy (HRT) using a vaginal ring, an IUD for progesterone, and topical testosterone can be a low-maintenance and relatively inexpensive solution for perimenopausal women (Peter Attia, 1x).
• 13Hormone replacement therapy (HRT) is a treatment for cardiovascular disease risk reduction, benefiting brain health, bone health, vasomotor symptoms, and vaginal atrophy (Peter Attia, 1x).
• 14Hormone replacement therapy (HRT) should be initiated before a woman reaches a menopausal state with flat-lined estradiol and progesterone and very high FSH/LH (Peter Attia, 3x).

Starting testosterone replacement therapy can increase the risk of sleep apnea and cause sleep disturbances (Andrew Huberman, 1x). Long-term combination hormone replacement therapy increases breast cancer risk, and bone loss accelerates after stopping HRT (Peter Attia, 1x). The headline that HRT increases breast cancer risk by 27% is based on an inappropriate context, as the absolute risk increase was only 0.1% (Andrew Huberman, 1x). Menopausal hormone therapy is generally not recommended if a woman is more than 10 years past menopause or over age 65 (Peter Attia, 1x). Not taking hormone therapy in postmenopausal women carries risks including genitourinary changes, increased UTIs, pelvic pain, osteoporosis, hip fractures, dementia, Alzheimer's, and cardiovascular disease (Peter Attia, 1x). The pellet industry for hormone replacement therapy has issues regarding women's health due to lack of FDA-approved pellets and insufficient safety/efficacy studies (Peter Attia, 1x). HRT is not ideal for bone health in women in their 40s and 50s due to their low risk of osteoporotic hip fracture (Peter Attia, 1x). Hormone replacement therapy is a serious medical intervention that is often administered incorrectly (Peter Attia, 2x). The idea that labs should never be checked and only symptoms matter in hormone therapy is incorrect (Peter Attia, 1x). The belief that HRT increases the risk of dying from breast cancer is a misconception (Peter Attia, Rhonda Patrick, 2x). Estrogen therapy lowers Lipoprotein(a) levels but is not recommended solely for this purpose due to potential increased cardiovascular risk (Peter Attia, 1x). The Women's Health Initiative study results were misunderstood and misinterpreted, leading to a decline in HRT prescription (Peter Attia, 6x). For women with established cardiovascular disease, HRT may increase risk due to inflammatory markers and a pro-thrombotic effect (Peter Attia, 1x).

The evidence for hormone replacement therapy's application in perimenopausal women is not robust (Peter Attia, 1x). Menopause hormone therapy's impact on metabolic flexibility requires further research and should be combined with lifestyle interventions (Peter Attia, 1x). More robust evidence for perimenopausal application and metabolic flexibility impact would change the verdict.