‘Can I Take Hormone Therapy?’ Is the Wrong Question
This week, The New York Times told the story of women who feel shut out of menopause’s big moment. One of them was at a family party, half-laughing about her hot flashes with a stranger when the stranger turned serious: She’d wasted two years suffering before hormone therapy fixed everything. And the first woman went quiet—because she can’t take it.
Estrogen is everywhere now. On her friends, in her feeds, in the influencers promising this phase of life can feel different. And she’s been told the door to hormone therapy is closed to her. She said she felt isolated. Cut off. Another woman in the piece described the sense of having missed some golden ticket.
In 20-plus years of primary care, I’ve sat across from many women like this. And I want to say something I hope lands as relief rather than contradiction: In a lot of these cases, the door they think is closed isn’t.
The trouble starts with the question.
We’ve trained women—and, frankly, a lot of doctors—to ask “Can I take HRT?” as if hormone therapy were a single locked room you’re either let into or kept out of. That’s not how this works. The real question is narrower and, unlike the first one, answerable: “What are the specific risks and benefits of hormone therapy for me?” Not for women in general. Not for the woman at the party. For you—with your history, your body, your fears, the life you actually live.
Because risk sits on both sides of this decision. There are risks to taking hormones. There are also risks to not taking them: bone loss, cardiovascular disease, the toll on sleep and cognition and sexual function that estrogen’s absence can bring. “No” is not necessarily the safer answer; “no” just offers a different set of risks.
Let me give you a real example with the identifying details changed. One of my patients carries a genetic clotting disorder and has had both a deep vein thrombosis and a pulmonary embolism. On a quick read, she is exactly the woman who gets a fast, firm “absolutely not” to menopause hormone therapy. Her hot flashes, night sweats, and brain fog were miserable. So, here is what we did. This patient is already taking a daily blood thinner. And while oral estrogen does raise the risk of clots—it passes through the liver, which ramps up clotting factors—estrogen absorbed through the skin, in the form of a patch or a gel, doesn’t appear to carry that same risk. The evidence on this has been consistent for years, including in women with clotting mutations and even a prior clot. So, I started her on a transdermal patch.
I didn’t do that because I decided her risk was acceptable. I did it because her risk was never mine to accept or refuse. It was hers to weigh. My job was to hand her the real numbers and the real trade-offs—and then to honor what she chose to do with the body she has to live in.
This is where “not allowed” does quiet damage.
Sometimes a patient will have a strong or absolute reason to avoid hormones—like my patients with active hormone-sensitive breast cancer. But far more often what gets called a contraindication is something else entirely: a rushed clinician defaulting to “no” because “no” is faster, and safer—for the clinician.
One woman in the Times piece described raising the subject with her doctors and hitting a wall. “It just feels like you hit a dead end,” she said. I believe her. But a dead end in a hurried medical appointment is not the same as a dead end in medicine. We mistake the absence of a conversation for the presence of a contraindication.
Nowhere is this clearer than with breast cancer. It is the most recognized reason women are told they can’t take hormones, and the logic sounds airtight until you look closely. I have a patient who is BRCA positive—she carries a gene that puts her at higher risk for breast and ovarian cancer—and she chose to have her breasts and ovaries surgically removed. Her risk of breast cancer is now near zero. Her risks for bone loss, heart disease, and sexual dysfunction, given her family history, are high. They are also high on her list of concerns. She takes hormone therapy, and she is glad she does.
I have another patient five years out from estrogen-receptor-positive breast cancer and a mastectomy. Her recurrence risk was low, and she sat with the trade-offs of going on hormone therapy and decided—together with her oncologist—that her quality of life was worth taking them on. “I am more than a breast cancer patient,” she told me. She’s right.
And here I have to be precise about the science, because imprecision is exactly how good information curdles into blanket prohibition. Estrogen and progesterone do not cause breast cancer. What they can do is accelerate the growth of a tumor that already carries receptors for them on its cells. That distinction is real and it matters—it’s why we suppress estrogen in many women with hormone-sensitive cancers. But “can feed certain existing tumors” is not the same sentence as “causes cancer.” Treating the two as identical has cost a great many women a great deal of unnecessary suffering.
Now let me be just as clear about the other side, because the Times article is right that something has gone wrong with the messaging, and I don’t want to make it worse. Hormone therapy is being over-evangelized in the public square. It is not a cure-all. It will not protect every brain or every heart or reverse aging, regardless of what your social media feed implies. Plenty of women are better off without it. And there are genuinely helpful non-hormonal options to treat menopausal symptoms and to prevent the downstream effects of hormone depletion—from prescription medications and cognitive behavioral therapy to dietary changes and lifestyle interventions—that too few women are being offered.
This isn’t an argument to start every menopausal woman on hormones.
It’s an argument about who gets to ask the question, and who gets to weigh the answer.
Not every woman will benefit from hormone therapy. But every woman is owed the truth and the right to decide what to do with it. What’s been withheld from women isn’t the drug but the conversation. Health has always been a matter of trade-offs, and the person who has to live inside those trade-offs is the patient, not the doctor across the desk. The tragedy isn’t that some women can’t safely take hormones. It’s that so many of them were handed a “no” where a conversation should have been.
The fix isn’t a new drug. It’s a better question—asked by the patient and answered by someone who understands the data—and you.
Dr. Lucy McBride is a board-certified internal medicine physician who completed her residency at Johns Hopkins Hospital. She is the author of the newsletter Are You Okay? on Substack and you can pre-order her first book, Beyond the Prescription: A Doctor’s Guide to Taking Charge of Your Health, now.
Editor's Note: Every week, The Sunday Paper's team of journalists sift through the news to find what Rises Above the Noise, makes sense of what's happening in the world, and provides hope for your week to come. While we do our best to provide our own informative summary of each piece, some publications require their own subscriptions beyond our control.
Please note that we may receive affiliate commissions from the sales of linked products.
