Should I Consider HRT? What the Evidence Actually Says

by Kristyn Zalota | Menopauser | Perimenopause Coaching, Munich, Germany

So you are in your late 30s to 50s and you're not feeing at all like yourself. One minute you were cruising along, balancing home, career, health habits and a great social life. And then, out of nowhere, you feel like crap all the time. Welcome to perimenopause.

This symptom list for perimenopause is staggeringly long. Because oestrogen and progesterone receptors exist throughout your entire body — in your brain, your heart, your bones, your skin, your bladder, your joints, when the levels fluctuate and decline your body reacts.

Practically every system can be affected:

• Psychological: mood swings, anxiety, panic attacks, depression, brain fog, memory problems, loss of confidence

• Physical: hot flushes, night sweats, fatigue, joint pain, heart palpitations, weight gain (especially around the abdomen), skin and hair changes, frozen shoulder

• Genitourinary: vaginal dryness, painful intercourse, urinary urgency or frequency

• Cognitive: difficulty concentrating, reduced ability to multitask, struggling to find words

If you've been experiencing several of these at once and your doctor has run tests that are "normal" you are not alone. The frustrating reality is that no blood test will reliably diagnose it, because hormone levels fluctuate so much day to day. (This is something I spend a lot of time explaining in my perimenopause coaching sessions in - the absence of a clear diagnosis does not mean the absence of a real problem.)

What is HRT, exactly?

Hormone replacement therapy replaces the oestrogen, progesterone and testosterone that your body is no longer producing consistently. It doesn't push your levels back to those of your 20s. Think of it more as stabilising a system that has become unpredictable.

There are several types:

Combined HRT is oestrogen and a progestogen together. If you have a uterus, you need the progestogen component to protect your endometrium (womb lining) — oestrogen alone would overstimulate it. The type of progestogen matters more than most people realise, which I'll get to below.

Oestrogen-only HRT is typically prescribed after a hysterectomy. Interestingly, the data suggests oestrogen-only actually lowers absolute breast cancer risk compared to no HRT -something that rarely gets talked about.

Vaginal oestrogen is a low-dose, locally applied oestrogen for genitourinary symptoms like dryness, irritation, painful intercourse, urinary urgency. It works by directly rebuilding tissue, not just moisturising. No progesterone is needed alongside it because systemic absorption is negligible. It's also considered safe for breast cancer survivors in many cases, though individual clinical decisions depend on the specifics.

Body-identical vs synthetic — why it matters

Not all HRT is the same, and the distinction matters for safety.

Body-identical (also called bioidentical) HRT uses hormones with exactly the same molecular structure as those your body produces. The oestrogen is estradiol. The progesterone is micronised progesterone (brand names include Prometrium and Utrogestan). These are pharmaceutical-grade, regulated, and widely available in Germany and across Europe — they are not the same as compounded "bioidentical" preparations sold outside the pharmaceutical system, which I would not recommend due to lack of regulation.

Transdermal oestrogen (gel or patch) is generally preferred over oral for most women because it bypasses the liver, requires a lower dose to be effective, and carries a significantly lower risk of VTE (blood clots) than oral oestrogen.

Micronised progesterone has a more favourable safety profile than synthetic progestins. The data from the E3N-EPIC cohort study and other sources suggests it does not carry the same breast cancer risk signal as synthetic progestins such as medroxyprogesterone acetate. It's also better tolerated by many women — progesterone has a natural calming effect and can improve sleep quality.

The combination most commonly associated with the best safety profile for eligible women is transdermal oestradiol + micronised progesterone. This is what NICE NG23, the British Menopause Society, and EMAS all describe as the preferred formulation.

The study that scared a generation of women (and doctors)

In 2002, the Women's Health Initiative (WHI) published findings that sent HRT prescriptions plummeting worldwide. The headlines were alarming: increased breast cancer, heart disease, stroke.

What the headlines didn't explain:

• The average age of participants in the WHI was 63, which is well past the typical perimenopause window. Many already had subclinical cardiovascular disease.

  
  

• They took a specific synthetic formulation (conjugated equine oestrogen and medroxyprogesterone acetate) that is no longer standard practice in Europe.

  
  

• The risks reported were relative and the absolute numbers were small, while the benefits received little coverage.

Subsequent re-analysis has been unambiguous. EMAS, the British Menopause Society, NICE, and the International Menopause Society have all concluded that for healthy women under 60, or within ten years of menopause, the benefits of appropriately selected HRT generally outweigh the risks.

To put breast cancer risk in context: the data used in the UK suggests that combined HRT is associated with roughly four additional cases per 1,000 women over ten years compared to those not using HRT. For comparison, obesity (BMI ≥ 30) is associated with an additional 24 cases per 1,000. Drinking two or more units of alcohol daily adds approximately five additional cases. This isn't to minimise the concern but the breast cancer risk deserves proportionate, comparative framing, not reflexive fear.

What the professional bodies actually say

The European Menopause and Andropause Society (EMAS), of which I am a member, states:

"For healthy women under 60 or within 10 years of menopause using appropriately selected systemic MHT, the benefits generally outweigh its risks. MHT is the most effective treatment for vasomotor symptoms, improves sleep and mood, and prevents osteoporosis and fractures. Benefits also extend to cardiometabolic health when therapy is tailored and appropriately timed."

The British Menopause Society is equally clear on duration: there should be no arbitrary time limits placed on HRT use. If symptoms persist and benefits outweigh risks for the individual woman, the treatment can continue.

NICE NG23, the clinical guideline that governs perimenopause and menopause care in England, recommends that HRT be offered to women with menopausal symptoms after an informed discussion of risks and benefits. It explicitly states that fears about breast cancer risk should not prevent women from accessing treatment that could significantly improve their quality of life.

These are the guidelines I use as anchors in my perimenopause coaching practice in Munich. They represent the current European and international clinical consensus not outdated fear.

The longer-term picture beyond symptom relief

Perimenopause isn't just about how you feel in the moment. The hormonal changes of this phase have long-term consequences for your health that are often undersold:

• Bone density declines rapidly in the years around menopause. Oestrogen is the primary regulator of bone maintenance, and HRT has strong evidence for preventing and treating osteoporosis.

• Cardiovascular health may be improved by oestrogen started early in the menopause transition. This is an area of active research, but the cardiometabolic benefits of well-timed HRT are increasingly recognised.

• Cognitive function - there is growing evidence, though not yet conclusive, that oestrogen in the perimenopausal window may support neurological function and reduce long-term dementia risk. Early withdrawal of oestrogen has been associated with accelerated cognitive ageing in some studies.

• Urogenital health - untreated genitourinary syndrome of menopause (GSM) is progressive and does not resolve on its own. Vaginal oestrogen is effective, evidence-based, and safe for most women.

  
  

Leaving perimenopause untreated isn't risk-free. It is a choice with its own set of long-term consequences.

Who should not take HRT — and why this conversation belongs with a doctor

HRT is not appropriate for every woman. The main contraindications include:

• Certain oestrogen-dependent cancers (though even here, the picture is more nuanced than many assume — a menopause-informed specialist can help you understand your individual situation)

• Unexplained vaginal bleeding

• Active or recent VTE (blood clots) — though transdermal oestrogen carries a much lower risk than oral

• Active liver disease

• Pregnancy

• 
  

This is exactly why HRT can only be prescribed by a medical professional. My role as a perimenopause coach, working with expat women in Munich and across Germany, is to help you understand the evidence, articulate your symptoms clearly, and walk into that clinical consultation informed and ready to have a real conversation. Not to prescribe or recommend specific treatment for you.

The question I'd encourage you to sit with

The question isn't: "Is HRT safe?"

It's: "Given my individual health history, symptom burden, and long-term health goals, do the benefits of HRT outweigh the risks for me?"

That's a question your doctor can help you answer. I would recommend that you go in equipped. Know your symptom pattern. Know what body-identical means. Know that you can ask about transdermal options. Know that "some women can't take it" is different from "it's dangerous for everyone." Know that you are entitled to an informed conversation, not a dismissal.

If you're an expat woman in Munich or elsewhere in Germany and you'd like guidance on how to plan your next visit to the gynecologist, reach out. That's why I am here.

Kristyn Zalota is a Certified Menopause Wellness Practitioner, Perimenopause Coach, and member of the European Menopause and Andropause Society (EMAS). She holds an MA from Yale University and has lived in Munich, Germany for over ten years, supporting English-speaking expat women navigating perimenopause. She does not prescribe or recommend specific medical treatments. All clinical decisions should be made with a qualified healthcare provider.

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Sources and further reading

• EMAS Position Statement on Menopausal Hormone Therapy (2023)

• NICE Guideline NG23: Menopause: diagnosis and management (2015, updated 2019)

• British Menopause Society Consensus Statement on HRT

• Fournier A et al., E3N-EPIC cohort study on breast cancer risk and HRT type

• Women's Health Initiative (WHI) study and subsequent re-analyses

• Lobo RA. Where are we 10 years after the Women's Health Initiative? J Clin Endocrinol Metab. 2013

• NICE NG23 evidence review on HRT and risk