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Should you start hormone therapy in perimenopause to protect your brain, bones and heart, or only to treat symptoms?

What the experts say

Sara Szal GottfriedMD · board-certified OB/GYN by her own account · precision medicine

Start inside the window, and evaluate it as a geroprotective intervention rather than a symptom remedy. Waiting turns prevention into management.

What it rests onShe argues the ten-year window from roughly 35 to 45 is when ovarian hormone decline reorganises brain, bone, vascular, immune and metabolic systems at once, so 'Starting hormone therapy in perimenopause or early menopause is biologically different from starting it ten years later.' Her evidence is three recent papers she summarises: hormone therapy as potential geroprotection rather than symptom relief; an association between hormone therapy use and a smaller gap between epigenetic and chronological age in postmenopausal women, which she labels 'association, not proof of causality'; and menopause-linked pro-inflammatory IgG glycosylation that estradiol replacement moved back. She credits the North American Menopause Society for legitimising hormone therapy and argues its framework is symptom-centred and needs to evolve for the longevity era.

Source: saraszalmd.substack.com ↗
Jennifer GunterMD · OB/GYN and pain medicine physician

Hormone therapy is for symptoms. No professional society recommends it for preventing heart disease or dementia or for increasing longevity, and telling women otherwise creates estrogen FOMO.

What it rests onShe writes, before setting out her own low, medium and high-risk framework for who should be offered hormone therapy: 'no professional society recommends menopausal hormone therapy (MHT) for the prevention of cardiovascular disease or dementia, or for increasing longevity', quoting the 2022 Menopause Society Guidelines that 'Long-duration hormone therapy use and use in older women is not appropriate for reduction in the risk of coronary heart disease or dementia.' She names the behaviour she is arguing against: 'there are people, some who are even doctors, making claims that incorrectly suggest otherwise', and reports women being encouraged to overstate hot flashes in order to obtain oestrogen for protection. Her closing formulation: 'if the data showed that every single woman should start hormone therapy, those would be the recommendations from all the medical professional societies. And it's not.'

Source: vajenda.substack.com ↗

Overview

Both women are talking about the same person and disagreeing about what she needs. Gunter's post is about who can safely be offered hormone therapy and her answer is broad: the same post divides patients into low, medium and high risk in order to say who should have it, so reading her as anti-hormone reproduces the exact misreading she spends her career correcting. Gottfried is not arguing that symptomatic women should be denied treatment either.

The divide is the INDICATION, and therefore the candidate: Gunter's candidate is a woman with hot flashes or night sweats or a listed 'yellow light' reason, and Gottfried's candidate is any woman in the transition, symptomatic or not, on the grounds that the transition itself is the risk. Mind the date gap too: Gunter's post is from Aug 2023 and Gottfried cites papers from the three years after it, so this is one to revisit.

Where they agree

Both hold that hormone therapy is safe and appropriate for symptomatic women in or near the transition, both prefer transdermal oestrogen for its lower thrombotic risk, both hold that low-dose vaginal oestrogen is under-prescribed and under-used, and both hold that most women in perimenopause are being under-served by conventional care. Neither disputes the timing principle that starting near the transition is safer than starting a decade later.

What would settle it

A randomised trial of hormone therapy initiated in perimenopause with hard outcomes (incident dementia, fracture, cardiovascular events) rather than biomarkers or epigenetic age, in women who are not selected for severe vasomotor symptoms.

Nothing of that shape exists, which is why one side argues from mechanism, cohort and epigenetic association and the other argues from the absence of a guideline recommendation. A published change of position by any major menopause society would move this immediately.

Practice does not pick a winner here

You do, and your call is dated, kept, and yours to change. Follow the people you already trust and what they publish turns into a short daily practice.

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