A major study published in Mayo Clinic Proceedings found that systemic menopause hormone therapy use in the United States dropped from 4.4% in 2007 to just 1.7% in 2023.

The decline is striking because hormone therapy remains the most effective treatment for hot flashes and night sweats. Yet even among women ages 50 to 59, the group often considered most likely to have a favorable benefit-to-risk profile, only about 3.5% used systemic hormone therapy in 2023.

This does not mean every woman going through perimenopause or menopause should start hormones. It does suggest that many may be making decisions based on outdated fears, incomplete information, poor access to trained clinicians, or the belief that suffering is simply part of aging.

The message is not “everyone needs hormones.”

It is that every woman deserves an accurate, individualized conversation about her symptoms, health history, treatment options, and goals.

What the New Mayo Clinic Study Found

The observational study, “United States Menopausal Hormone Therapy Usage Trends,” examined women age 40 and older from 2007 through 2023 using a large U.S. database of commercially insured and Medicare Advantage populations.

Researchers defined hormone therapy use as at least 180 days of filled prescriptions for systemic estrogen-containing therapy during a calendar year.

The findings included:

• Overall use fell from 4.4% in 2007 to 1.7% in 2023.
• Among women ages 45 to 49, use fell from 2.9% to 1.5%.
• Among women ages 50 to 54, use fell from 5.8% to 3.4%.
• Among women ages 55 to 59, use fell from 7.1% to 3.5%.
• Oral hormone therapy remained the most common route.
• Use was consistently higher among white women than among Black, Hispanic, and Asian American women.[1]

The study did not prove why use declined. Prescription data can reveal patterns, but it cannot capture every medical contraindication, personal preference, clinical conversation, or prescription that was never filled.

Its definition may also miss short-term users, cash-paid prescriptions outside the database, some compounded products, and women without continuous commercial or Medicare Advantage coverage.

Even with those limitations, the decline is substantial, long-lasting, and clinically important.

How Did Menopause Hormone Therapy Become So Controversial?

The current fear surrounding hormone therapy can largely be traced to 2002, when early results from the Women’s Health Initiative, or WHI, raised concerns about breast cancer, blood clots, stroke, and cardiovascular disease in women taking a specific oral hormone regimen.

The findings were widely reported without enough context about the participants, formulations, treatment goals, timing, or absolute risks.

The average WHI participant was approximately 63 years old, and many were more than a decade past menopause. The trial primarily studied oral conjugated equine estrogen, with or without medroxyprogesterone acetate, for chronic disease prevention.

That is not the same clinical situation as a healthy 49-year-old seeking treatment for severe hot flashes, sleep disruption, vaginal discomfort, or painful sex during the menopause transition.

Still, the public message became simple: hormone therapy is dangerous.

Prescriptions fell. Clinicians became hesitant. Many women were told to wait it out or accept symptoms that were disrupting sleep, work, relationships, sexual health, and quality of life.

Later analyses produced a more nuanced picture.

Age at initiation matters. Time since menopause matters. Estrogen alone is not the same as estrogen combined with a progestogen. Oral therapy is not identical to transdermal therapy. Low-dose vaginal estrogen is not the same as systemic estrogen.

Medicine eventually rediscovered complexity, which had apparently gone missing while headlines were doing what headlines do.

What Changed With the FDA Hormone Therapy Warnings?

In November 2025, the U.S. Food and Drug Administration requested major labeling changes for menopausal hormone therapy products. In February 2026, it approved updated labeling for an initial group of six products.

The updated boxed warnings removed statements about cardiovascular disease, breast cancer, and probable dementia. The FDA also requested similar revisions across systemic and local vaginal products.

This did not make hormone therapy risk-free.

Cardiovascular and breast cancer information remains in the warnings and precautions sections of systemic product labels. The boxed warning for endometrial cancer remains on systemic estrogen-only products because unopposed systemic estrogen can stimulate the uterine lining in women who still have a uterus.

The FDA also added language encouraging clinicians to consider systemic hormone therapy for moderate to severe hot flashes and night sweats in women younger than 60 or within 10 years of menopause.

For a deeper explanation, read What the FDA Hormone Therapy Warning Changes Mean for Women’s Health.

The updated labeling gives clinicians and patients a more accurate framework for shared decision-making. It does not replace individualized risk assessment.

Is Hormone Therapy Safe for Menopause?

For many healthy, symptomatic women who begin treatment before age 60 or within 10 years of menopause, major menopause organizations conclude that the benefits generally outweigh the risks.

Every part of that statement matters.

“Many” does not mean all. “Healthy” requires a medical review. “Symptomatic” means there is a clear treatment goal. Timing influences risk.

Hormone therapy is also not one medication. It includes different hormones, doses, delivery methods, and combinations.

A personalized assessment may consider:

• Age and time since menopause
• Whether the uterus is present
• Symptom type and severity
• Breast and endometrial cancer history
• Blood clot, stroke, heart attack, and cardiovascular history
• Unexplained vaginal bleeding
• Liver health
• Blood pressure and cholesterol
• Blood sugar and insulin resistance
• Smoking history
• Bone health
• Migraine history
• Current medications
• Personal treatment preferences

Some women will be strong candidates for systemic hormone therapy.

Others may need a different delivery route, lower dose, local vaginal treatment, or nonhormonal therapy. For some women, systemic treatment may be inappropriate.

The goal is not one protocol for everyone. It is to stop treating no discussion and no treatment as the safest automatic default.

What Symptoms Can Menopause Hormone Therapy Treat?

Systemic hormone therapy is approved and widely used for moderate to severe vasomotor symptoms, including:

• Hot flashes
• Night sweats
• Temperature instability
• Sleep disruption related to night sweats

It can also help prevent bone loss and reduce fracture risk while treatment continues.

Low-dose vaginal estrogen can treat genitourinary syndrome of menopause, or GSM. Symptoms may include:

• Vaginal dryness
• Burning or irritation
• Pain during sex
• Reduced vaginal elasticity
• Urinary urgency
• Painful urination
• Recurrent urinary tract infections in some women

Because low-dose vaginal estrogen produces minimal systemic absorption, its risk profile differs from systemic hormone therapy.

Women also ask whether hormone therapy will fix fatigue, brain fog, anxiety, low libido, or weight gain.

The honest answer is that it depends on what is driving those symptoms.

Treatment may improve sleep, mood, concentration, sexual comfort, or energy when those problems are connected to vasomotor symptoms or estrogen loss. It is not a guaranteed solution for every midlife complaint.

Hormone therapy is also not a weight-loss drug. It may support sleep, insulin sensitivity, or body composition in some women, but it does not replace nutrition, resistance training, adequate protein, stress management, or appropriate obesity treatment.

Systemic Hormone Therapy vs. Vaginal Estrogen

People often use “hormone replacement therapy” or “HRT” to describe treatments that act very differently.

Systemic hormone therapy

Systemic therapy circulates throughout the body. It may be delivered through:

• Oral tablets
• Skin patches
• Gels
• Sprays
• Certain vaginal rings

Systemic therapy is used when symptoms affect the whole body, especially hot flashes and night sweats.

Women with a uterus usually need a progestogen alongside systemic estrogen to protect the uterine lining. Women who have had a hysterectomy may be able to use estrogen alone.

Low-dose vaginal estrogen

Low-dose vaginal estrogen primarily treats local vaginal, vulvar, sexual, and urinary symptoms. It may be provided as a:

• Cream
• Vaginal tablet
• Insert
• Low-dose local ring

Very little estrogen reaches the bloodstream compared with systemic tablets, patches, gels, sprays, or systemic rings.

Treating every estrogen product as though it creates the same exposure makes little clinical sense.[4]

Oral Estrogen vs. Transdermal Estrogen

The Mayo Clinic study found that oral therapy remained the most common route, although the use of both oral and transdermal treatment declined.

Oral estrogen passes through the liver before entering general circulation. This can affect clotting proteins, triglycerides, and other liver-mediated pathways.

Transdermal estrogen, delivered through a patch, gel, or spray, bypasses first-pass liver metabolism.

Evidence suggests blood clot risk may be lower with transdermal estrogen than with oral estrogen, although personal risk still matters.[4]

Patches are not automatically best for everyone. Cost, insurance coverage, skin sensitivity, convenience, dosing, symptom response, and medical history all influence the decision.

A better question than “Is HRT safe?” is:

Is this hormone, at this dose, through this delivery method, appropriate for this woman at this stage of menopause?

What About Bioidentical Hormones?

“Bioidentical” means a hormone has the same molecular structure as a hormone produced by the human body. Estradiol and micronized progesterone are common examples.

Bioidentical does not automatically mean:

• Compounded
• Natural
• Risk-free
• Safer
• More effective

FDA-approved bioidentical products have standardized manufacturing, dosing, quality testing, and safety labeling.

Compounded therapy may be considered when a needed dose or formulation is not commercially available. However, compounded products are not FDA-approved in the same manner and may vary in potency, absorption, and consistency.

A thoughtful treatment plan focuses on the clinical indication, hormone formulation, route, dose, monitoring, and patient goals.

Marketing labels should not replace clinical reasoning.

Why Are Women Still Not Receiving Treatment?

The Mayo Clinic study cannot assign a single cause, but several barriers likely contribute to declining menopause hormone therapy use.

Outdated fear

Many women still believe any estrogen use sharply increases breast cancer or heart attack risk. Some clinicians also remain uncomfortable prescribing because their education centered on the early WHI headlines rather than the evidence and guidance that followed.

Limited menopause training

Many medical training programs devote limited time to menopause care.

Women may see multiple specialists for sleep problems, anxiety, weight changes, sexual symptoms, urinary problems, or palpitations without anyone connecting the pattern to the menopause transition.

Dismissed or fragmented symptoms

Hot flashes are widely recognized. Other symptoms may be treated as unrelated problems.

These can include:

• Brain fog
• Anxiety
• Heart palpitations
• Sleep changes
• Painful sex
• Irregular menstrual cycles
• Urinary symptoms
• Reduced exercise recovery

Not every symptom is caused by menopause, but the pattern deserves a thoughtful evaluation.

Access and racial disparities

Hormone therapy use was lower among Black, Hispanic, and Asian American women than among white women.[1]

Access to trained clinicians, insurance coverage, cultural communication, trust, neighborhood resources, and unequal treatment recommendations may contribute to these differences.

Appropriate nonuse

Some women have medical contraindications, prefer nonhormonal treatment, experience unacceptable side effects, or do not need systemic therapy.

The goal is not to reach an arbitrary prescription rate. It is to make sure women who could benefit receive a balanced discussion.

What Are the Alternatives if Hormone Therapy Is Not a Fit?

Hormone therapy is the most effective treatment for hot flashes, but it is not the only option.

Nonhormonal prescription treatments may include:

• Certain selective serotonin reuptake inhibitors
• Certain serotonin-norepinephrine reuptake inhibitors
• Gabapentin
• Fezolinetant
• Other treatments selected according to symptoms and medical history

Vaginal moisturizers and lubricants may help mild vaginal dryness or sexual discomfort. Pelvic floor therapy may help pain, urinary symptoms, pelvic floor dysfunction, or sexual health concerns.

Lifestyle support still matters:

• Regular resistance training
• Aerobic exercise
• Adequate dietary protein
• Fiber-rich whole foods
• Consistent sleep routines
• Limiting alcohol when it triggers symptoms
• Smoking cessation
• Stress management
• Blood pressure management
• Metabolic health support

The best plan may combine medication, local treatment, nutrition, exercise, sleep support, and targeted care for thyroid, metabolic, sexual, or mental health concerns.

Hormone Testing: Useful Tool or Overhyped Shortcut?

Perimenopause is usually identified through age, symptoms, menstrual changes, and medical history.

A single estrogen or follicle-stimulating hormone result can be misleading because hormone levels may fluctuate significantly during the menopause transition.

Laboratory testing can still help identify conditions that mimic or worsen menopause symptoms, including:

• Thyroid dysfunction
• Iron deficiency
• Insulin resistance
• Diabetes
• Anemia
• Liver dysfunction
• Nutrient deficiencies
• Cardiovascular risk factors

Labs may also support safe prescribing and treatment monitoring.

The mistake is using one hormone number as the entire diagnosis. The other mistake is ignoring symptoms because a basic laboratory panel falls inside a broad reference range.

A more complete approach combines symptom patterns, medical history, appropriate testing, treatment goals, and follow-up.

Read Why Your Labs Say “Normal” but You Still Feel Terrible for more context.

Questions to Ask Before Starting Menopause Hormone Therapy

A useful consultation should answer more than a simple yes or no.

Consider asking:

1. Are my symptoms consistent with perimenopause or menopause?
2. Could another health condition be contributing to my symptoms?
3. Do I need systemic treatment, local treatment, or both?
4. What are my personal risks and contraindications?
5. Which delivery route and formulation fit my medical history?
6. If I have a uterus, how will the uterine lining be protected?
7. What benefits and side effects should I expect?
8. What symptoms require immediate medical attention?
9. How will my response to treatment be monitored?
10. When will we reassess the plan?

Women should also keep up with appropriate breast, cervical, colorectal, cardiovascular, and bone health screening.

Hormone therapy is part of a health plan. It is not a substitute for one.

What This Study Means for Women Right Now

The Mayo Clinic findings expose a treatment gap, not a mandate.

Hormone therapy use has reached historic lows despite updated guidance, increased public awareness, and an FDA effort to correct overly broad boxed warnings.

Many women who could benefit may still avoid treatment because they are scared, uninformed, dismissed, or unable to find clinicians trained in menopause care.

Responsible menopause care also requires honesty.

Hormone therapy has real benefits, real risks, and important differences based on age, timing, formulation, delivery method, and medical history.

The pendulum should not swing from “hormones are dangerous” to “hormones are harmless.”

It should move toward accurate information and individualized medicine.

Women should not have to choose between suffering in silence and buying into aggressive promises. They deserve a careful review of their symptoms, health risks, treatment choices, and follow-up needs.

A More Personalized Approach to Menopause Care

At 1st Optimal, menopause care considers the full picture, including:

• Current symptoms
• Medical history
• Metabolic health
• Thyroid function
• Cardiovascular risk
• Sleep quality
• Nutrition
• Body composition
• Sexual health
• Personal goals

When hormone therapy is medically appropriate, treatment should be personalized and monitored.

When hormone therapy is not appropriate, women still deserve evidence-based alternatives and a plan that addresses the factors contributing to their symptoms.

Explore perimenopause treatment options, learn about personalized women’s hormone care, or book a free health consultation.

You do not need to accept “your labs are normal” or “this is just aging” as the end of the conversation.

Educational only, not medical advice. Hormone therapy is prescription treatment and should be considered with a qualified healthcare professional who can review symptoms, medical history, medications, screening needs, and individual risks.

Frequently Asked Questions

Why has menopause hormone therapy use declined?

Use dropped sharply after the 2002 Women’s Health Initiative findings raised concerns about breast cancer, stroke, blood clots, and cardiovascular disease.

Later research added important context about age, timing, formulation, and delivery method, but fear and prescribing hesitation have persisted.

What percentage of women use menopause hormone therapy?

The 2026 Mayo Clinic study found that 1.7% of women age 40 and older in its U.S. database met the definition of systemic hormone therapy use in 2023.

Among women ages 50 to 59, use was approximately 3.5%.

Is hormone therapy safe for women under 60?

For many healthy women with bothersome symptoms who begin treatment before age 60 or within 10 years of menopause, the benefit-to-risk profile is generally considered favorable.

Medical history, treatment route, dose, uterus status, and treatment goals still matter.

Does hormone therapy cause breast cancer?

Risk differs according to the type of treatment, length of use, and individual health history.

Estrogen combined with a progestogen has a different risk profile from estrogen alone. Personal risk factors and treatment duration require individual review.

Is vaginal estrogen the same as systemic HRT?

No.

Low-dose vaginal estrogen primarily treats vaginal and urinary symptoms and produces much lower systemic exposure than oral tablets, patches, gels, sprays, or systemic vaginal rings.

Can HRT help with menopause weight gain?

Hormone therapy is not a weight-loss medication.

It may improve sleep, symptom control, or body composition in some women, but weight management still requires attention to nutrition, muscle mass, physical activity, sleep, stress, and metabolic health.

How long can a woman stay on hormone therapy?

There is no universal stopping age that applies to every woman.

Treatment should be periodically reviewed based on symptoms, benefits, side effects, health changes, personal risks, and preferences. Some women may use treatment for a limited period, while others may continue longer with appropriate clinical monitoring.

Should hormone levels be tested before starting HRT?

Hormone testing is not always necessary to diagnose perimenopause or menopause, especially in women over 45 with a typical symptom and menstrual pattern.

Testing may still help rule out thyroid problems, anemia, insulin resistance, nutrient deficiencies, and other conditions that can cause similar symptoms.

References

1. Faubion SS, et al. United States Menopausal Hormone Therapy Usage Trends. Mayo Clinic Proceedings. 2026.
2. FDA Requests Labeling Changes for Menopausal Hormone Therapies.
3. FDA Approves Labeling Changes to Menopausal Hormone Therapy Products.
4. The Menopause Society: Hormone Therapy.
5. USPSTF: Hormone Therapy for the Primary Prevention of Chronic Conditions.