For years, hormone therapy (HT) has been treated like the hormonal bogeyman—whispered about cautiously, offered reluctantly, and often dismissed altogether. But a groundbreaking body of evidence is turning that narrative on its head.
Let’s talk about timing. And why it matters more than you think.
The Timing Hypothesis—Why When You Start HT Changes Everything
The central idea behind this comprehensive review by Hodis and Mack is the “timing hypothesis.” It’s simple but revolutionary: HT reduces heart disease and mortality if started in women under 60 years old or within 10 years of menopause. Wait too long, and the benefits fade—or even backfire.
In other words, estrogen protects healthy vessels but doesn’t fix damaged ones. Start early, and HT keeps arteries youthful and supple. Start late, and those arteries may already be beyond rescue.
Real Data, Real Impact
🔹 Meta-analyses of 30+ randomized trials show that HT started before age 60 reduces:
- All-cause mortality by up to 39%
- Heart disease by 30–50%
🔹 The Danish Osteoporosis Prevention Study (DOPS) confirmed this, showing:
- A 52% reduction in cardiovascular disease after 10 years of HT
- A 43% reduction in all-cause mortality
That’s not a rounding error. That’s a medical breakthrough we’ve been ignoring for too long.
Better Than Statins?
Here’s the kicker: HT outperforms statins, aspirin, and ACE inhibitors for primary prevention in women. None of those drugs consistently reduce all-cause mortality or heart disease in women. Yet HT does—when started at the right time.
But What About the Risks?
Let’s clear the air: risks exist—but they’re rare and often exaggerated. In women under 60 or within 10 years of menopause, risks like blood clots occur in fewer than 10 per 10,000 women per year, and only if you are taking oral estrogen and progestin, if you use estrogen through the skin and oral natural micronized progesterone, there is no increased risk of clot.
Bonus: HT actually lowers diabetes risk by 20–30%. Statins? They increase it.
Why Are We Still So Cautious?
Because the WHI study from the early 2000s scared everyone. But the WHI included women who were, on average, 63 years old—many 10+ years past menopause. Not the women who typically seek HT for symptoms in their 40s and 50s.
It’s time to stop letting outdated data dictate modern care.
The Bottom Line
Hormone therapy, when started at the right time, saves lives. It reduces heart disease. It lowers all-cause mortality. It protects against osteoporosis and diabetes. And it can do all that with fewer side effects than many drugs routinely prescribed without a second thought.
Dr. Aoife O’Sullivan is a family physician, board certified by the American Board of Family Physicians and a menopause specialist, certified by the North American Menopause Society, dedicated to empowering women through their midlife health journeys. She is the founder of Portland Menopause Doc, co-founder of the Portland Menopause Collective, podcaster on The Dusty Muffins, and an expert speaker, frequent podcast guest and active contributor to midlife women’s health research.
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