3 myths about perimenopause and hormone replacement therapy

While browsing Facebook a few weeks ago, a post about Menopausal Hormone Therapy (MHT) (which is the same thing as Hormone Replacement Therapy - HRT)

in a mom thread got my attention. A woman in her mid-30s who thought she was undergoing perimenopause because she had low libido, joint pain, brain fog, and migraines was crying out for help to find a doctor who would prescribe MHT. She lamented that her doctor wanted to work on lifestyle factors while prescribing a few natural supplements.

The comment feed was filled with support from other women, providing links to telehealth doctors who they were confident would prescribe the medication. I restrained myself from commenting - I would have offered a less popular take: that her doctor's approach was reasonable, and that a good provider looks at the whole picture before prescribing hormones. I knew this was a much larger conversation than could be addressed in a Facebook thread.

The thread was full of women claiming that MHT was perfectly safe and did not cause breast cancer. Considering the WHO is predicting a 77% rise in cancer diagnoses from 2022 to 2050, I think we need to approach general claims that MHT is safe for every woman with a critical eye, especially when there are individual genetic factors involved, and there are other treatment approaches for the symptoms of perimenopause besides hormone therapy.

I think the question of MHT and breast cancer risk deserves a more nuanced conversation than social media usually allows. I will address it, but first, let's break down common myths out there regarding perimenopause and hormones. 

Myth #1: Perimenopause = need for MHT.

The frustrated woman who posted on Facebook did not complain of the most common symptoms of perimenopause - which are hot flashes, insomnia, fatigue, mood swings/anxiety, and weight gain. She just assumed that her symptoms were related to perimenopause likely because this is the recurring message being perpetuated on social media. 

While low libido, joint pain, brain fog, and migraines are common in perimenopause, it doesn't mean that the hormone shift is necessarily to blame. Given the joint pain, brain fog, and migraines its fair to say she is struggling with inflammation in perimenopause.

Inflammation has many causes, including pathogens, toxins, and lifestyle factors.

Cortisol levels rise in perimenopause, and are known to cause low libido and brain fog; however, my approach to treatment in this case would have likely been to look further into her stress, relationships, whether she was having pain or vaginal dryness with intercourse affecting her libido, and reassure her that her brain fog would likely settle out after the menopausal transition.

MHT could absolutely be discussed, but use of it for her conditions (unless there were menopause-related vaginal symptoms) would be off-label, and that there are risks involved.

For her symptoms, addressing inflammation would be a sensible place to start, alongside an honest conversation about whether MHT fits. This approach recognizes that each woman's body is unique and may require a different treatment plan, emphasizing the importance of personalized care in addressing health concerns.

Myth #2: MHT fixes everything.

The primary indications of MHT in perimenopause are hot flashes, vaginal atrophy, prevention of bone loss, and buildup of LDL cholesterol.

NOT: brain fog, fatigue, low libido (unless related to vaginal dryness/atrophy), or migraines.

Brain fog: No large RCTs are showing an increase in cognitive function with MHT in menopause. There may be a modest benefit in early menopause, but more research is needed. At any rate, addressing neuroinflammation and stress is more likely to improve mental clarity.

Joint pain: The positive effects of MHT on joint pain are very modest, although real - after one year of ERT compared to placebo, there were 6% fewer women reporting pain. We can often do better by addressing inflammation, biomechanics, and pain directly.

Migraines: Oral, high-dose ERT may increase the frequency of migraines. Some small trials have suggested that transdermal estrogen may help reduce perimenopausal migraines, but the research is not settled. There are MANY causes of migraines, and while they can be hormonal, we can use lifestyle factors and key natural supplements to affect hormones. Hormones are not always needed but may help her get relief.

Low libido: Low libido may be improved by Testosterone Replacement Therapy (TRT) in menopausal women, however, there are potential side effects of acne, hair loss, increased facial hair, and deepening voice. Long-term safety studies have not been completed. Testosterone does convert into estrogen in the body in a process called aromatization, which is concerning (more on this later). Additionally, there are several other causes of low libido including stress, depression, and medication, yet, many women are turning to testosterone first. 

There are many other symptoms of perimenopause that I haven’t touched on yet (fatigue, weight gain, insomnia to list a few), but the point is that MHT is only shown to be helpful for a handful of perimenopause symptoms; yet, so many women are looking to MHT to resolve all of their symptoms.

Naturopathic medicine has a multitude of strategies for addressing perimenopausal symptoms and concerns without always requiring the addition of hormones.

Myth #3: MHT carries the same breast cancer risk for every woman.

If there are no concerns that MHT could lead to breast cancer, why does ACOG recommend against MHT in women who have had breast or endometrial cancer? This tells us that hormone therapy isn't the right fit for every woman, and that individual risk matters.

We know that about 80% of breast cancers are estrogen positive (ER+). This means that the tumor cells have receptors that bind estrogen and can use it to grow. We also know that some women genetically metabolize their estrogens to a form that is much more potent, meaning it can more directly damage DNA, and is more likely to bind to estrogen receptors.

Women with ER+ breast cancer tend to have higher levels of this more potent estrogen to bind to receptors on tumor cells.

Many doctors and influencers who recommend MHT reference the 2019 Lancet meta-analysis, which found that the risk for breast cancer was duration-dependent, higher for estrogen-progestin than estrogen-only, and not associated with low-dose vaginal estrogen.

Why the confusion around MHT then? The 2019 Lancet meta-analysis on MHT did not take into account individual genetics. So, you have a pool of women, some of whom have a decreased genetic risk of breast cancer, some of whom have an increased genetic risk of breast cancer, and when combined, the risk appears to be neutral.

The 2022 NAMS Position Statement on MHT generally regards the benefit-risk ratio as favorable in women who begin MHT under the age of 60 years old, or within 10 years of onset of menopause. However, it is stated that “Risks of hormone therapy differ for women, depending on type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is needed. Treatment should be individualized using the best available evidence to maximize benefits and minimize risks, with periodic reevaluation.”

Considering the rate at which cancer is rising, wouldn't you want to know whether you are a woman whose body pushes estrogens into the more potent, and more proliferative form of estrogen before starting MHT? Or, wouldn’t you want to have the peace of mind of starting MHT knowing that your body pushes your estrogen to the more protective form of estrogen? 

The bottom line is that MHT may be wonderful for some women, but may cause harm in others and part of individualized treatment is understanding estrogen metabolism, alongside family history and personal medical history. 

The good news is that you can learn about your estrogen metabolism by having your genetic data evaluated (please note this is an emerging area in medicine and that the reearch is not settled). In the interest of “doing no harm”, I offer to evaluate genetics for women who want more information before deciding on hormones. It's optional, but for some women it adds useful detail. 

We are leaving an era of generalized recommendations - based on research in populations without genetic data - and entering an era of personalized medicine. You don't have to wait for the rest of medicine to catch up to get personalized information. 

We'll break down estrogen genetics further in my next blog post.

Ready to talk it through? Book your first visit, in person in Longmont, CO, or virtually in Colorado, Arizona and Washington. We'll look at the root causes of your symptoms and help you decide whether HRT is right for you.

About the Author: Dr. April Graham is a Naturopathic Doctor and Exercise Physiologist, Owner of Avra Health. She is passionate about helping women transition through menopause healthfully and gracefully.

Acknowledgments: 

I credit Dr. Penny Kendall-Reid for enlightening me in these matters through her GeneRx.ca platform and her mentorship. 

Resources: 

Many resources are linked directly in the article.

Kendall-Reid, P. (2025, July 11). Moving Through Perimenopause/Menopause: Why we need to rethink treatment![Conference presentation]. AANP 2025 Convention, Palm Springs, CA, United States.

Disclaimer: 

This isn’t medical advice — just information. Please talk with your healthcare provider before making changes to your health plan.