What We Know (and Don’t Yet Know) About The Benefits of Hormone Therapy (HRT)
- Dr Natalie Hutchins
- Dec 8, 2025
- 6 min read
By Dr Natalie Hutchins
Hormone Replacement Therapy (HRT), more accurately called Menopause Hormone Therapy (MHT) has become one of the most discussed topics in women’s midlife health. Few areas of women’s health have seen such dramatic swings in public perception as hormone therapy. For years, women were told that HRT might have a serious negative impact on their health. Now, some headlines suggest women must be on it, even without symptoms.
The truth, as always, lies somewhere in between.
For many women, it can be transformative; others find that they don’t need it and some are unsuitable for it. And because the public conversation has become so polarised, it can be hard to separate hope, fear, and hype from what the evidence actually says.
A comprehensive 2025 review published in Clinical Endocrinology offers one of the clearest summaries to date of what HRT is proven to do, where benefits are likely but not yet certain, and where the science is incomplete. Below, you’ll find a summary of what we do know and the claims we don’t yet have the evidence for.
HRT for Menopause Symptoms
The strongest and most consistent evidence for HRT lies in treating menopausal symptoms. Hot flushes, night sweats, disrupted sleep, vaginal dryness, joint discomfort, changes in mood, and brain fog are all intimately tied to fluctuating and falling oestrogen levels during the menopause transition. These symptoms affect most women to some degree, and for about a quarter, they become clinically severe and prolonged.
Across decades of high-quality trials, HRT is unequivocally the most effective treatment for vasomotor symptoms and the many secondary effects on sleep, mood, cognition, and libido they create. Improvement is often rapid and substantial. This remains an area of overwhelming international consensus and the clearest indication for hormone therapy.
HRT and Bone Health
Oestrogen plays a central role in maintaining bone density. After menopause, when oestrogen levels drop, bone loss accelerates. Without intervention, this can lead to osteopenia, osteoporosis, and increased fracture risk.
Large, well-designed trials and meta-analyses consistently show that HRT reduces the risk of hip, vertebral, and other fractures by approximately 20–37%, with the strongest effect in women who begin therapy before age 60. It also improves bone mineral density across the spine and hips.
Reassuringly, women do not experience a “rebound” increase in fractures when they stop HRT. For these reasons, HRT is recognised in many international guidelines as a valid option for bone protection in early or natural menopause, particularly in women who also have bothersome menopausal symptoms.
HRT and Genitourinary Symptoms
Genitourinary symptoms, including vaginal dryness, painful sex, urinary urgency, and recurrent urinary tract infections, become increasingly common after menopause and unlike symptoms like hot flushes which getter better the further from the menopause you are, these symptoms often worsen over time without treatment.
Local vaginal oestrogen or vaginal DHEA provides highly effective relief, restores vaginal tissue health, and improves sexual comfort and urinary symptoms. Unlike systemic HRT, low-dose vaginal oestrogen does not require added progesterone and has extremely low systemic absorption. It can be used alone or alongside systemic HRT.
Most women can use it safely long-term, including many with a history of breast cancer (though caution is required and this should still be after discussion with your oncologist).
HRT and Sexual Wellbeing
Some women experience a distressing loss of sexual desire in midlife. After other causes have been explored, including relationship dynamics, psychological factors, and medication side effects, testosterone therapy may help. However, a trial of standard hormone therapy (with just oestrogen +/- progesterone) is often tried as first line initially as it is common to see women’s sexual desire improve with this alone without the addition of testosterone. Having said that, for some women, standard hormone therapy is not enough and they benefit from the addition of testosterone. It can also be used alone if oestrogen is not needed. An important point to note is that not all women will be distressed by their lack of sexual desire and if they are not, it does not need to be treated.
HRT and Cardiovascular Health
The relationship between HRT and heart health is one of the most complex areas of menopause medicine. Early observational studies suggested cardiovascular protection, but large randomised trials later failed to confirm these findings. Today, major guidelines agree: HRT should not be prescribed to prevent heart disease in women with a natural, age-appropriate menopause.
However, several modern trials are frequently cited as evidence of potential benefit, so it is important to understand what they truly showed. The Danish Osteoporosis Prevention Study (DOPS) used contemporary oestradiol-based HRT rather than the older formulations studied in the Women’s Health Initiative. DOPS reported a relative reduction in a combined cardiovascular outcome (which included death, heart failure and heart attacks) when women started HRT soon after menopause that was quite impressive. But, the absolute benefit was small (less than 1% risk reduction), meaning the actual number of prevented events was low. In addition, the study had important limitations: it lacked placebo control, included few cardiovascular events overall, and had substantial dropout and crossover. These issues weaken the reliability of its findings. DOPS therefore suggests a possible benefit but is not strong enough to guide clinical decision-making that are usually made from a body of evidence, all showing the same thing.
Two further trials, ELITE and KEEPS, add more nuance and also tested modern preparations of HRT. The ELITE trial found that women who started HRT within six years of menopause had slower progression of carotid artery thickening, a marker of early atherosclerosis (‘clogging’ of arteries), which is very promising but this biological effect did not translate into fewer heart attacks or strokes. However, the KEEPS trial, which studied low-dose oral and transdermal oestradiol with micronised progesterone in healthy, recently menopausal women, showed no improvement in cardiovascular markers such as coronary artery calcification or carotid intima-media thickness, nor any difference in cardiovascular events.
Taken together, these trials show that while early HRT may influence some vascular biomarkers, there is no convincing evidence that modern HRT prevents cardiovascular disease in real-world terms and it’s important to be honest with women about this.
The key exception is women with premature ovarian insufficiency (POI) or early menopause, for whom HRT genuinely replaces missing hormones and is linked to better cardiovascular outcomes.
HRT, Dementia, and Cognitive Health
Despite popular claims that HRT protects long-term brain health, current evidence does not support using HRT to prevent dementia. Studies differ widely in participant age, hormone type, dose, duration, and health profile, making results inconsistent and difficult to generalise. At present, pooled data show no overall effect, positive or negative, on dementia risk. This remains an important area of ongoing research, but not an indication for prescribing HRT.
What HRT Cannot Do
We have a current epidemic of mistrust between the medical profession and women, most of it entirely warranted. As such, it is incredibly important that we are honest about the limits of what we know about HRT. It does not prevent ageing, reverse metabolic disease, guarantee protection against cardiovascular disease, prevent dementia, or cause weight loss. It is not suitable for every woman and cannot replace the foundational lifestyle factors of sleep, exercise, nutrition, and alcohol moderation that remain central to long-term health.
A Balanced Way Forward
HRT is a highly effective treatment for menopausal symptoms, offers meaningful protection for bone and urogenital health, and can greatly improve quality of life. But it is not yet proven to be a universal solution, nor a preventive therapy for chronic disease. HRT can be a powerful tool but not because it promises everything, but because it is exceptionally good at what it is truly designed to do.
References
Original review paper:
Schierbeck LL., Rejnmark L., Tofteng CL., et al. Effect of hormone replacement therapy on cardiovascular events in recently postmenopausal women: randomised trial. BMJ. 2012;345:e6409. (DOPS Trial)
Hodis HN., Mack WJ., Henderson VW., et al. Vascular Effects of Early versus Late Postmenopausal Treatment with Estradiol. New England Journal of Medicine. 2016;374:1221–1231. (ELITE Trial)
Harman SM., Brinton EA., Cedars MI., et al. Kronos Early Estrogen Prevention Study (KEEPS): design, baseline characteristics, and potential implications. Climacteric. 2014;17(2):155–166.
Harman SM., Black DM., Naftolin F., et al. Arterial imaging outcomes and cardiovascular risk factors in recently menopausal women: the KEEPS trial. Annals of Internal Medicine. 2014;161(4):249–260. (KEEPS cardiovascular endpoints)
Rossouw JE., Anderson GL., Prentice RL., et al. Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women: Principal Results From the Women’s Health Initiative Randomized Controlled Trial. JAMA. 2002;288:321–333. (WHI)
Manson JE., Aragaki AK., Rossouw JE., et al. Menopausal Hormone Therapy and Long-term All-cause and Cause-specific Mortality: The Women’s Health Initiative Randomized Trials. JAMA. 2017;318(10):927–938.
Boardman HM., Hartley L., Eisinga A., et al. Hormone therapy for preventing cardiovascular disease in post-menopausal women. Cochrane Database Syst Rev. 2015;3:CD002229.
Zhu L., Jiang X., Sun Y., Shu W. Effect of hormone therapy on the risk of bone fractures: A systematic review and meta-analysis of RCTs. Menopause. 2016;23:461–470.
Watts NB., Cauley JA., Jackson RD., et al. No increase in fractures after stopping hormone therapy: WHI. J Clin Endocrinol Metab. 2017;102:302–308.
North American Menopause Society (NAMS). 2020 Genitourinary Syndrome of Menopause Position Statement. Menopause. 2020;27:976–992.
Biehl C., Plotsker O., Mirkin S. Efficacy and safety of vaginal estrogen products for GSM. Menopause. 2019;26:431–453.
McVicker L., Labeit AM., Coupland CAC., et al. Vaginal estrogen therapy use and survival in females with breast cancer. JAMA Oncology. 2024;10:103–108.
Cold S., Cold F., Jensen MB., et al. Systemic or vaginal hormone therapy after early breast cancer: Danish cohort. J Natl Cancer Inst. 2022;114:1347–1354.
Davis SR., Baber R., Panay N., et al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. J Clin Endocrinol Metab. 2019;104:4660–4666.
