9 myths about HRT doctors say are harming women’s health

What you’ve heard about hormone replacement therapy (HRT) is probably wrong — and it may be costing you.

If you’re a woman in perimenopause or menopause considering HRT, there’s a good chance you heard or read something about it that isn’t true. In a recent survey of more than 200 Hone Health physicians, the majority said up to 75% of women come to their appointment with at least one major misconception about HRT.

Much of the confusion around HRT, also called menopause hormone therapy (MHT), can be traced to a single study from 2002 that was widely misinterpreted as linking HRT to increases in breast cancer, heart attack, and stroke. “Many women are making life-altering decisions about their health based on information that the medical community moved past years ago,” says Jim Staheli, D.O., Medical Director at Hone Health. “These misconceptions are likely lowering their quality of life and possibly even shortening their lifespan.”

Nearly 1.3 million American women enter menopause each year, and the majority will experience symptoms — from hot flashes and sleep disruption to mood changes, brain fog, and sexual dysfunction — that can persist for years. Longer term, midlife estrogen decline may increase a woman’s risk of osteoporosis, metabolic syndrome, and cardiovascular disease.

Here are the top nine misconceptions about HRT that Hone physicians say they encounter most often, ranked from most to least common — and what they wish you knew instead.

Myth #1: HRT Dramatically Increases Breast Cancer Risk

Fear of breast cancer is the No. 1 driver of HRT avoidance, and it can be traced back to the 2002 Women’s Health Initiative (WHI) study, which was misinterpreted and highly publicized.

Headlines about the study claiming HRT increased breast cancer risk by 26% triggered widespread panic and large-scale abandonment of HRT by both women and their doctors. But subsequent analysis of the same data showed that the absolute increase in breast cancer risk for women using combination HRT (estrogen + progesterone) was only 8–9 extra cases per 10,000 women per year. And breast cancer rates were actually lowered by 23% in women taking estrogen-only HRT, compared to placebo.

Even in high-risk populations, including women who carry BRCA gene mutations, no research has shown HRT to significantly increase breast cancer risk. Doctors are even starting to consider HRT for survivors of certain types of breast cancer.

Myth #2: HRT Causes Weight Gain

Weight gain during menopause is common, but HRT isn’t the cause. As estrogen declines, so does muscle mass and resting metabolic rate, and this metabolic slowdown drives the changes most women notice on the scale. A meta-analysis of over a million women found that metabolism changes in menopause were linked to a nearly 3% increase in body fat, plus increases in waist circumference and visceral fat, the deep fat around your internal organs — all independent of whether they used HRT.

In fact, HRT has been shown to lower visceral fat and BMI compared to non-users, and to preserve lean muscle mass, which is important because muscle burns more calories at rest than fat does. One study found that women on estrogen-plus-progestin therapy lost significantly less lean mass over three years than women on a placebo. HRT also improves insulin sensitivity, which matters because insulin resistance accelerates during and after menopause and is one of the primary drivers of both weight gain and metabolic syndrome.

Myth #3: Bioidentical Hormones are Safer than Conventional HRT

There’s no scientific evidence that bioidentical hormones are safer than conventional HRT or that they do a better job of managing menopause symptoms.

“Bioidentical” refers to hormones that are structurally identical to those our bodies produce. They’re also sometimes called “natural hormones,” since they’re derived from plant sources rather than synthesized in a lab. But many commercially manufactured hormone treatments — including certain estradiol patches and progesterone tablets — already use bioidentical, plant-derived hormones, so in that respect, they’re not meaningfully different.

Myth #4: HRT Increases Heart Disease Risk

Declining estrogen levels during perimenopause can directly impact your heart health, and for decades, HRT has also been linked to heart risks. However, for most women, the opposite is true — HRT is cardioprotective if started before age 60 or within 10 years of menopause.

Women starting HRT after 10 years post-menopause may face different cardiovascular risks. The DOPS trial (Danish Osteoporosis Prevention Study), one of the few randomized controlled trials to examine HRT initiated early in menopause, found that women who began HRT shortly after menopause had significantly lower rates of heart failure, heart attack, and cardiovascular-related death after 10 years — with no increase in cancer or stroke risk. A large meta-analysis published in the British Medical Journal similarly found that women who started HRT under age 60 had reduced risk of coronary heart disease and all-cause mortality compared to non-users.

HRT improves cholesterol levels in postmenopausal women and reduces oxidative stress and inflammation, both of which contribute to arterial damage and plaque buildup. It also reduces insulin resistance and lowers type 2 diabetes risk, addressing two of the most powerful drivers of cardiovascular disease after menopause.

These benefits are closely tied to what clinicians call the “window of opportunity” — the period within 10 years of menopause onset, or before age 60, when estrogen’s cardioprotective effects are most pronounced. Women who initiate HRT more than 10 years post-menopause, or who have significant pre-existing cardiovascular disease, should undergo individualized assessment before starting therapy.

Myth #5: You Can’t Start HRT After 60

There is no strict age cutoff for starting HRT. Whether it’s right for you depends on your health history, symptoms, and lifestyle. That said, women who start after 60 or more than 10 years past menopause may have a different benefit-risk profile than those who start earlier.

The myth about age limits was driven largely by the 2002 WHI study, which showed that estrogen plus progestin didn’t prevent heart attacks in women over 60, and that risks appeared to increase with age and long-term use. Those findings were applied to all women regardless of age or timing, leading many doctors to stop prescribing HRT to older patients altogether. Later reanalysis showed that the elevated risks in the original trial were concentrated in a much older, less healthy population than most menopausal women seeking treatment.

Today, most evidence supports an individualized approach. If you’re over 60 and considering HRT for the first time, work with your physician to find the right type, dose, and delivery method for your specific health profile.

Myth #6: You Must Stop HRT at 65

For healthy women who still have symptoms, continuing HRT beyond 65 is a reasonable option — ideally with low-dose or non-oral formulations, and with regular physician monitoring. The Menopause Society states explicitly that there is no general rule for discontinuing HRT based on age, and the latest research backs that up.

A large 2024 study published in Menopause, based on the records of 10 million senior Medicare women, found that continuing HRT beyond 65 was associated with reduced risk for a striking range of serious health outcomes. For women on estrogen alone, continuing beyond 65 was associated with reduced risk of mortality, breast cancer, heart attack, congestive heart failure, and dementia. For women on combination therapy, breast cancer risk was modestly elevated but can be mitigated by choosing low-dose transdermal or vaginal formulations over oral.

Women may want to stay on HRT longer if they’re still experiencing menopause symptoms. Research shows that symptoms like hot flashes can persist for seven to 12 years, and 42% of women between the ages of 60 and 65 still report experiencing them.

Myth #7: HRT Causes Blood Clots

HRT delivered transdermally (via patch) does not increase the risk of blood clots in most healthy women. In fact, both transdermal and lower-dose HRT may decrease the risk of stroke and blood clots when started before age 60.

That said, oral estrogen may carry a slight increase in blood clot risk because the hormone passes through the liver first, increasing production of clotting factors, the body’s defense against blood vessel injury.

Myth #8: Blood Tests are Required to Diagnose Perimenopause

Perimenopause is a clinical diagnosis, meaning it’s based on what you’re experiencing, not what your labs show. Hormones are so unpredictable during this transition that a single blood test can’t tell the whole story. And what looks normal on paper is just normal for your age group, so a woman in her 40s or 50s, when hormone levels are naturally lower, can have perfectly unremarkable results and still be in perimenopause. That said, if doctors see two follicle-stimulating hormone (FSH) readings above 25 IU/L taken about a month apart, that does support the diagnosis. “It’s a useful data point, just not the whole picture.” says Staheli.

That said, perimenopause testing still has real value. Blood work can rule out conditions that mimic perimenopause, such as thyroid dysfunction or low iron; establish baseline hormone levels that help guide treatment decisions; and flag menopause-related shifts in cholesterol, insulin, and inflammation that often creep up before symptoms appear. Catching these changes early means they can be managed before they become serious.

Myth #9: HRT is Only for Hot Flashes

HRT is considered the most effective treatment for hot flashes, but it also addresses changes in mood, sleep, energy, cognitive function, and sexual function. HRT has been shown to improve sleep by reducing night sweats and sleep disturbances and also improve mood and cognition.

HRT also treats a cluster of symptoms clinicians call genitourinary syndrome of menopause (GSM), including vaginal dryness and irritation, painful intercourse, urinary urgency, increased frequency, and recurrent urinary tract infections. Many women suffer through these symptoms for years without connecting them to menopause or knowing that treatment exists. For GSM specifically, low-dose vaginal estrogen is highly effective, and the effects stay local in the body, making it an option even for some women who aren’t candidates for systemic therapy.

Beyond symptom relief, HRT confers meaningful long-term health benefits, including shoring up bone density and reducing the risk of fractures, including hip fractures, which carry a higher mortality risk than most people realize, and significantly reducing the risk of heart disease and cardiovascular-related death.

This story was produced by Hone Health and reviewed and distributed by Stacker.