Menopause: Yes, hormone therapy is safe

"I've seen my older sisters' menopause as suffering, with a lot of agony, almost as if they were going through an illness." With these words, Sonia, a 49-year-old lawyer and the youngest of five sisters, describes the stigma and fear inherited from a generation of women marked by the mistrust that arose in 2002. That year, the study was published. Women's Health Initiative (WHI) It sparked a global alarm by linking hormone therapy to an increased risk of breast cancer and heart attacks. The impact was immediate: prescriptions plummeted by up to 80% in many countries, leaving millions of women in a state of helplessness with symptoms that severely diminished their quality of life. "However, I was already aware of what could happen and knew that, when the time came, I would want treatment," explains Sonia.

Two decades later, the paradigm has shifted. Dr. Elisa Llurba, head of the gynecology and obstetrics department at Hospital Sant Pau, emphasizes that today science offers a much more precise interpretation: "Since the study was published in 2002, there has been a reanalysis of the data and new epidemiological studies and meta-analyses that have reassessed this risk." The most recent confirmation comes from Denmark: a large-scale study involving 800,000 women, published last February in the prestigious British Medical Journal (BMJ)The study concludes definitively that the therapy does not increase the risk of death, either from cardiovascular causes or cancer. The fundamental error of the WHI was ignoring the existence of a biological tipping point: if hormones are initiated within the "window of opportunity," the body recognizes and uses them to protect blood vessels and neurons; but if they are introduced late in an organism that has already learned to function without them, the response can cease to be defensive and become counterproductive.

The original trial from two decades ago suffered from a fatal design flaw: the average age was 63. Studying the therapy in women who had been off estrogen for ten years, whose arteries had already lost elasticity, skewed the results. Furthermore, 30 percent were obese and 10 percent were smokers, factors that overestimated cardiovascular risk compared to a healthy population. Finally, the study was limited to the standard of the time: synthetic hormones administered orally (conjugated equine estrogens) along with a synthetic progestin (medroxyprogesterone acetate), far removed from today's bioidentical and transdermal options. The landscape has changed so much in medical science that, by the end of 2025, a committee of experts has urged the FDA (the US drug agency) to update the warnings of danger—the so-called black box of hormones. They argue that current labels are outdated and that official regulation must finally recognize "that the risk depends on age and when it starts."

Time is everything

Why does the body react so differently at different times? The answer lies in tissue health. In the early stages of menopause, a woman's arteries typically retain their natural elasticity. In this scenario, estrogens are not an aggressive external agent, but rather a biological ally that promotes vasodilation through nitric oxide production and positively modulates blood lipid profiles. According to Llurba, starting treatment at this time—defined as the "most physiological and natural" approach—not only alleviates hot flashes but also acts as a preventative shield, reducing overall mortality and the risk of coronary heart disease by 30% to 48%. The impact is so significant that current studies associate this early initiation with a 3.3-year improvement in life expectancy. The reason a patient like Sonia has a radically different safety profile from the volunteers in the 2002 study lies in this "state of the vascular terrain." While the WHI participants received hormones in arteries that had already accumulated years of silent damage and estrogen deficiency, Sonia's intervention affected a still-receptive system. In her case, the therapy works by maintaining a flexibility that still exists; in the WHI, it reached tissue that had already forgotten how to process the hormone.

Llurba warns that risk factors are not static, but rather are activated as soon as estrogen deficiency appears and become entrenched over time. If too much time passes—generally more than ten years after menstruation ceases—a woman's biological makeup is no longer the same: the arteries may have already developed silent atherosclerotic plaques. In this scenario, administering estrogen for the first time can be counterproductive because, far from protecting, the hormone can destabilize these already formed plaques, promote their rupture, and cause thrombotic events, heart attacks, or strokes. Therefore, for Llurba, the key to safety is not to miss the window in which the system is still receptive. Beyond this limit, the treatment offers no clear benefit and may even increase cardiovascular risk.

From "mare's urine" to bioidentical precision

But the change isn't just a matter of when, but of what. Dr. Marimer Pérez, a gynecologist and science communicator, explains that current pharmacology has abandoned estrogens derived from mare's urine in favor of bioidentical ones (natural estradiol and progesterone). According to Pérez, this chemical precision allows progesterone to act on GABA receptors—the brakes of the nervous system—improving sleep and reducing anxiety without the oncological effects of synthetic hormones. This safety is further enhanced by transdermal administration (gels or sprays). Absorbed through the skin, the hormone goes directly into the bloodstream "bypassing the liver," thus avoiding the activation of clotting factors in the liver and drastically reducing the risk of blood clots compared to older oral pills.

As the doctor points out, this format allows for what she calls a "tailor-made" approach, faithfully mimicking the natural secretion of the ovary by progressively adjusting the minimum dose according to each woman's needs and tolerance. This strategy of starting with the minimum effective dose and progressing according to each woman's tolerance allows for optimal symptom suppression while minimizing side effects. However, Pérez clarifies that the therapy is not a primary treatment for psychological disorders, but rather a supportive measure that should always be accompanied by healthy lifestyle habits.

Beyond physical protection, Pérez emphasizes one of the most frequent complaints of menopausal women: mind fogAlthough science is still cautiously observing the direct impact of HRT (hormone replacement therapy) on memory, Pérez highlights a vital domino effect: "A woman who doesn't sleep well, with hot flashes and an interrupted sleep pattern, will have much more difficulty concentrating." However, her most powerful clinical observation goes beyond hot flashes. "Every week I see women in my practice who are being treated with antidepressants and anxiolytics and who, after starting hormone therapy, improve so much that they can even stop this medication," she says. For this gynecologist, restoring hormonal balance is, in many cases, the key for the brain to "switch on" again. Even in the realm of sexual desire, Pérez is emphatic: "How do you function sexually without hormones? I don't think you can at all." Estrogens are fundamental not only for preventing pain (dyspareunia), but also for maintaining self-esteem and the neural connections necessary for libido.

The path to autonomy

Sonia represents the search for autonomy in the face of the stigma that still persists in some medical practices. Her path was not straightforward: before finding a solution, another gynecologist flatly refused to treat her, leaving her symptoms unanswered under the argument that it was "the expected thing to do." For Sonia, this was not just a matter of health, but of maintaining her identity and security. The lawyer explains that the discomfort is not always a serious crisis, but a persistent unease that affects social life. In her own words: "I have friends who suffer from such severe hot flashes that they are so uncomfortable that they stop going out. There is no reason to have to go through this hardship that affects life on a professional, personal, family, and social level."

With her current gynecologist, she found an evidence-based approach that validated her need for treatment, as she was at the ideal biological stage. In addition to therapy, she adopted a holistic change in her habits: "She specifically recommended strength training, instead of so much cardio, which is what I used to do. We reviewed not only the symptoms but also my lifestyle." As Dr. Pérez emphasizes, this combination is key, since a metabolic change occurs at this stage, requiring specific nutrition and active muscle to maintain.

The paradigm shift is definitive. Science has moved from the "one size fits all" approach and the fear of 2002 toward precision medicine in which the timing of onset is everything. In this new scenario, menopause is no longer perceived as the end of health or a sentence to suffer in silence, but as a physiological stage that demands dialogue and evidence. Sonia, who has overcome the "neglect" her sisters experienced to regain her well-being, is the best example. In the 21st century, the secret is no longer just biology, but autonomy: that each woman, informed about her own "window of opportunity," is in control of her body and freely chooses how she wants to age.