The Debate Over Hormone Replacement Therapy in Menopause

Menopause can cause hot flashes, night sweats, sleep disturbances, mood changes, cognitive issues, low libido and joint pain—often disrupting daily life, relationships and overall well-being. Hormone replacement therapy (HRT) can mitigate some of these symptoms, but many women shy away from it, concerned that HRT may increase their risk of breast cancer. We asked Dr. Dolores Roman, a medical director at Independence Blue Cross, for insight into the risks, benefits and research related to HRT, which has been front-and-center in today’s health conversations.

What are the most common misconceptions about HRT?
Dr. Dolores Roman: One of the most common misconceptions about HRT is that all forms significantly increase the risk of breast cancer. In reality, the risk depends on factors such as the type of HRT, duration of use and personal health history.

How much of the fear around HRT stems from outdated studies?
DR: Many of the fears about HRT and breast cancer risks can be traced back to research published in the early 2000s, particularly the initial results of the Women’s Health Initiative (WHI) study. This large-scale trial reported an increased risk of breast cancer among women using combined estrogen-progestin therapy (EPT), which led to a sharp decline in all types of HRT and widespread concern among patients and providers.

What does the latest research tell us about the risk of breast cancer with HRT?
DR: Recent findings from a large-scale NIH study have helped clarify the relationship between modern HRT and breast cancer risk, especially in women under 55. The study found that the type of hormone therapy used plays a critical role in determining risk. Women who used estrogen-only hormone therapy had a 14% lower risk of developing breast cancer compared to those who never used hormone therapy. In contrast, women who used combined estrogen-progestin therapy (EP-HT) had a 10% higher risk of breast cancer, with the risk rising to 18% if used for two-plus years.
What other factors impact risk?  
DR: The timing of when HRT is initiated is also important. Women who begin HRT closer to the onset of menopause, typically within 10 years, usually have a lower overall risk profile compared to those who start it later. Starting HRT well after menopause can increase the risk of both breast cancer and other conditions like cardiovascular disease. Family history of breast cancer is another key factor. While HRT can still be an option for women with a family history, the decision needs to be made carefully. If there are inherited mutations like BRCA1 or BRCA2, the baseline risk of breast cancer is significantly higher.

What are the benefits of HRT?
DR: Women who begin HRT before age 60 or within 10 years of menopause onset and who are at a low-to-average risk for cardiovascular disease and breast cancer may experience more benefits than risks when using HRT to manage these symptoms. In addition to symptom relief, HRT has been shown to help preserve bone density and reduce risk of fractures, particularly in postmenopausal women who are at risk for osteoporosis. While HRT is no longer recommended for the prevention of chronic diseases like heart disease or dementia, it remains a clinically supported option for improving quality of life during the menopausal transition when used appropriately.

What should women ask their doctors when considering HRT? 
When thinking about starting hormone replacement therapy, women need to have a clear, informed conversation with their healthcare provider. Some good questions to ask might include:

• What are the benefits of HRT for my specific symptoms?
• What are potential risks, especially considering my personal and family medical history?
• Are there different types or forms of HRT, and which one is best for me?
• How long should I expect to be on HRT, and how will we decide when to stop?
• Will HRT affect my risk for conditions like breast cancer, heart disease or osteoporosis?

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