Editor’s note
Before I begin, I want to be honest about what this edition is and what it isn't.
This isn't a pro-HRT piece and it isn't anti-HRT either. HRT is a personal decision, one that looks different for every woman depending on her symptoms, her health history, her lifestyle and her own feelings about it. I'm not a medical professional, so please don’t take anything in this edition as medical advice.
What I am is a woman in midlife who spent months asking herself whether or not HRT was right for her.
Perimenopause is being talked about more than ever before, and much of what I came across was overwhelmingly positive, stories of improved sleep, fewer hot flushes, better moods and women describing HRT as “life-changing”. What I found less of were honest conversations about not taking it.
Some women are advised against HRT for medical reasons, others choose not to take it, some are still weighing up their options, yet there seemed to be very little discussion about what can happen if you don't. This made me curious.
So that's where this edition begins, not with an agenda, but with a question.
Before we dive in…
Before I get into what I found, it's worth clearing up something that kept coming up on Threads, because I think the way we talk about this matters.
Women were saying things like "I'm in full-blown menopause" or "my doctor confirmed I'm in menopause" and I understand why, it's how most of us talk about it, but technically, menopause isn't a phase, it's a single moment in time, the point when you haven't had a period for twelve consecutive months. That's it, one date you could almost circle on a calendar.
Everything leading up to that point is perimenopause, when hormones start to fluctuate and symptoms often appear, sometimes as early as your late thirties. Everything after is postmenopause.
The reason I want to clarify this is because I think a lot of women experiencing symptoms in their early forties assume they're too young for any of this to be relevant, when they might be in perimenopause and not realise it.
What I’ve learned
01.
If I don't take HRT, will my symptoms eventually go away on their own?
For many women, yes. A lot of the symptoms associated with perimenopause, hot flushes, disrupted sleep, mood changes, do tend to ease once you've moved through the transition and into postmenopause, though the timeline varies significantly from woman to woman.
Some women move through perimenopause with minimal symptoms, while others find it significantly disruptive. Both experiences are valid, and neither tells you anything about whether you should or shouldn't be taking HRT.
It's also worth noting that not everything we experience in midlife is purely hormonal.
Research suggests there's a real overlap between true perimenopause symptoms and other factors that tend to coincide with this stage of life, things like stress, changes in relationships, work pressures, shifts in identity and general life demands.
Unpicking what's hormonal and what's circumstantial isn't always straightforward, which is part of what makes this transition so difficult to navigate.
02.
What are the benefits of taking HRT?
If you've spent any time in the midlife or perimenopause space online, you'll already have a sense of this. The benefits of HRT are probably the most covered part of the whole conversation, and I don't want to repeat what you've likely already read elsewhere.
So just to summarise, because it's relevant to everything that follows. HRT isn't just about managing symptoms in the short term, it can also be preventative, supporting long term health in ways that go well beyond hot flushes and disrupted sleep.
The research points to a reduced risk of coronary heart disease, type 2 diabetes and osteoporosis, and some evidence around a reduced risk of Alzheimer's disease. These aren't small things, they're some of the most significant health risks women face as they age, which is part of why the conversation around HRT has shifted so dramatically in recent years. Different types of HRT carry different benefits, as does the age you start taking it and how long you take it for.
That's the part the internet has covered extensively. What I was more curious about was everything else.
03.
What are the risks, and are they as frightening as they seem?
This is where the conversation gets complicated, and where I want to tread carefully, because the risks of HRT are real, but they're also frequently misunderstood and fear of those risks has historically stopped women from accessing something that might genuinely help them.
The risk most women think of first is breast cancer and the evidence here is nuanced.
Some types of combined HRT are associated with a small increased risk, while oestrogen-only HRT appears to carry little to no increased risk for most women. The level of risk varies depending on the type of HRT, the dose, how long it's taken for and individual health factors.
Other reasons some women can't, or choose not to take HRT include certain hormone-sensitive cancers, a history of blood clots, some autoimmune conditions and other individual health considerations.
What I'd say here is if fear of the risks is the main thing stopping you from exploring HRT, the most useful thing you can do is speak to a doctor who can look at your specific health history and give you an informed picture of what the risks mean for you, rather than for women in general.
04.
Why do some women choose not to take HRT?
Some women can't take HRT for medical reasons, certain cancers, clotting conditions or other health factors make it unsuitable. Some women try it and find the adjustment phase, which can include breast tenderness, irregular bleeding and other temporary side effects, isn't something they want to continue with. Some women find that lifestyle changes, good nutrition, sleep, movement, manage their symptoms well enough and some women simply decide it isn't right for them, for reasons that are entirely their own.
Something else I came across in my research that I think deserves to be mentioned, for some women, the decision not to take HRT isn't purely practical, it's psychological.
Taking HRT can feel like crossing a threshold, a marker of a life stage some women aren't ready to name yet, the end of fertility and ageing becoming visible. This can be genuinely difficult to sit with, in a way that has nothing to do with the science and everything to do with how we feel about getting older.
04.
Can I have a healthy perimenopause and postmenopause without HRT?
This was the question I found hardest to research, because the answer is so specific to individual circumstances and lifestyle.
What I can share is my own perspective and I believe the foundations of health matter here: regular movement, resistance training, good nutrition with adequate protein, good sleep and stress management. These aren't just general wellness advice, they're the things research consistently points to as genuinely protective during this transition, with or without HRT.
The long term benefits of HRT on bone density and heart health are real and worth factoring into any decision, which is exactly why this has to be a personal one, made with proper medical support rather than based on what worked for someone else.
It's also worth revisiting something from earlier in this edition. Not everything we experience in this phase of our lives is purely hormonal. Fatigue, mood changes, disrupted sleep and weight shifts can all be influenced by lifestyle factors too, and sometimes addressing those makes a more noticeable difference than expected.
That said, I don’t want to suggest that lifestyle alone is a good substitute for HRT, because for some women it isn't. The long-term benefits of HRT on bone density, heart health and other factors are real and worth understanding, which is why this has to be a personal decision made with proper medical support rather than based on what worked for someone else, or what I'm sharing here.
What it means
What I noticed while researching this edition is that the loudest voices in the HRT conversation, on both sides, tend to drown out the women who are simply trying to figure out what's right for them.
The wellness industry profits from our uncertainty, the pharmaceutical industry profits from our symptoms and somewhere in the middle of all of that noise is a woman in her forties trying to work out what her body is doing and what, if anything, she should do about it.
HRT is not a miracle cure, and it isn't something to be afraid of either. It's a medical intervention with real benefits and risks that works differently for different women, and that some women can't, or choose not to use.
What I keep coming back to, and what runs through everything at MIDLIFE, is this: the most important thing isn't which decision you make, it's that you make and informed one, based on your own curiosity, your own health history and what you feel is right for you, rather than following advice blindly or being pressured in either direction.
This is your body, your health, your decision.
Something to try
If HRT is something you're considering or confused about, the most useful first step isn't another article or another Instagram account. It's a conversation with your doctor, and if you don't feel heard there, seek out a medical professional who specialises in women's health or menopause specifically.
Go with questions written down - your symptoms, how long you've had them and how they're affecting your life.
Something worth listening to
Dr Mary Claire Haver: The Menopause Masterclass
Dr Mary Claire Haver is one of the most respected voices in women's health and menopause research. This masterclass covers HRT, the research behind it, the risks, the benefits and what women need to know before making any decisions.
It's long, but worth it.
Final thoughts
This was one of the harder editions to research, not because the information isn't out there, but because there's so much of it, so much contradiction, so many strong opinions and so many studies that are genuinely difficult to interpret without a medical background.
What I came away with is this: a well-informed doctor, ideally one who specialises in women's health or menopause, is the most valuable resource any of us has in navigating this transition. Not social media, not this edition, not the most vocal voice in a Threads comment section.
Every woman's experience of perimenopause is different, every woman's risk profile is different and every woman's relationship with her own body and ageing is different. That's not a reason to feel overwhelmed, it's a reason to be curious, to ask questions and to trust yourself enough to keep looking until you find the answers that are right for you specifically.
Until the next edition,
Jamine
Editor, MIDLIFE
midlifeedition.co
Coming in Edition 07:
Why am I craving a quieter life?
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