By Dr. Karina Angiletta, PhD, FNP-C
For years, women were told that hormone therapy was dangerous, that estrogen increased the risk of serious disease, and that treatment should be discontinued as they aged.
But our understanding of estrogen has evolved considerably.
Today, we recognize that estrogen is far more than a hormone responsible for reproduction or controlling hot flashes. It plays important roles in maintaining bone strength, cardiovascular function, metabolism, and brain health.
So, if you are already 60, 65, or even older, have you missed your opportunity to benefit from hormone therapy?
The answer is not necessarily. But the timing, type of treatment, and your individual health history matter.
Estrogen Does Much More Than Relieve Menopause Symptoms
One of the most important developments in menopause medicine has been recognizing the broader physiological roles of estrogen.
Bone health: Estrogen helps regulate bone remodeling and reduces bone breakdown. When estrogen declines during menopause, bone loss accelerates, increasing the risk of osteoporosis and fractures.
Importantly, systemic hormone therapy has been demonstrated to preserve bone density and reduce fractures. This is an established benefit supported by randomized clinical trials, not merely a theoretical advantage.
Cardiovascular health: Estrogen influences blood vessel function, cholesterol metabolism, and several pathways involved in cardiovascular health.
Research suggests that the cardiovascular effects of hormone therapy may depend substantially on when treatment begins. Some studies suggest favorable outcomes when therapy starts closer to menopause, although randomized evidence has not conclusively established hormone therapy as a method of preventing heart attacks or strokes.
Brain health: Estrogen receptors are found throughout the brain, including regions involved in memory and cognition. Estrogen participates in neuronal signaling and other processes relevant to neurological health.
These biological effects have generated considerable interest in estrogen's potential neuroprotective properties. However, whether menopausal hormone therapy prevents Alzheimer's disease or dementia remains uncertain.
These potential long-term benefits deserve serious consideration—not dismissal simply because hormone therapy has historically been discussed primarily as a treatment for hot flashes.
Why Did Hormone Therapy Become So Controversial?
Much of the controversy began with the Women's Health Initiative (WHI), a major study whose early findings generated widespread concern about hormone therapy.
The study provided valuable safety information, but its findings were frequently generalized beyond the specific populations and treatments investigated.
The hormone regimens studied included oral conjugated equine estrogens, with or without medroxyprogesterone acetate. These are not identical to every formulation used today, including transdermal 17-beta estradiol.
The participants also included many women who were substantially beyond the menopausal transition.
Subsequent research has helped clarify that age, timing, formulation, route of administration, and individual risk factors can meaningfully influence treatment decisions.
In February 2026, the FDA approved important changes to menopausal hormone therapy labeling, removing several risk statements from boxed warnings while retaining relevant safety information elsewhere in product labeling.
This represents an important evolution toward more individualized discussions of hormone therapy's benefits and risks.
Does Starting After 60 Change the Decision?
Yes—and this distinction remains essential.
For healthy women who begin systemic hormone therapy before age 60 or within approximately 10 years of menopause, the benefit-risk balance is generally more favorable when treatment is clinically appropriate.
For women beginning systemic therapy later, the absolute risks of cardiovascular events, blood clots, stroke, and dementia require additional consideration.
However, age alone should not replace a thoughtful, individualized clinical evaluation.
A woman who began hormone therapy years earlier and continues to benefit is also in a different situation from someone considering systemic treatment for the first time at age 70.
The Menopause Society does not recommend automatically discontinuing hormone therapy at 65. Continuing treatment may be reasonable with appropriate indications, monitoring, and periodic reassessment.
Not All Estrogen Treatments Are the Same
An important distinction is the difference between systemic and local estrogen therapy.
Systemic estradiol, delivered orally or through the skin, affects tissues throughout the body. Transdermal therapy may offer advantages regarding blood clot risk compared with oral estrogen, although neither route eliminates the need for individualized assessment.
Low-dose vaginal estrogen primarily treats local vaginal and urinary symptoms, with generally minimal systemic absorption.
For women experiencing vaginal dryness, painful intercourse, or recurrent urinary infections associated with menopause, local therapy can be valuable even when systemic hormone therapy is not appropriate.
Women with a uterus generally require adequate endometrial protection when using systemic estrogen. Any postmenopausal bleeding warrants appropriate evaluation.
A More Complete Approach to Menopause Care
I believe menopause care should extend beyond simply asking whether a woman is experiencing hot flashes.
Bone health, cardiovascular risk, metabolic health, sleep, sexual health, cognitive concerns, and overall quality of life all deserve attention.
Hormone therapy has established benefits for menopausal symptoms and bone protection, while its potential cardiovascular and neurological benefits continue to be investigated.
It should not be prescribed solely with the promise of preventing heart disease or dementia. But neither should its broader physiological effects be ignored.
The goal is not to prescribe estrogen to every woman. It is to make sure women receive accurate information about its benefits, limitations, and risks—and have the opportunity to make informed decisions.
At Full Spectrum Health & Wellness, I provide individualized, evidence-informed hormone and menopause care through telemedicine throughout Idaho and Washington.
Learn more about personalized hormone care
Book a complimentary introductory call
Coming Next: A Book Worth Reading — Estrogen Matters
One of the most thought-provoking books about menopause medicine is Estrogen Matters by medical oncologist Avrum Bluming, MD, and psychologist Carol Tavris, PhD.
The authors revisit decades of research, challenge influential interpretations of the Women's Health Initiative, and explore estrogen's possible contributions to cardiovascular, bone, and brain health.
I particularly appreciate the book's invitation to question longstanding assumptions about women's health.
In my next article, I'll review Estrogen Matters, explain why I recommend reading it, and examine which of its arguments are strongly supported by research—and where important scientific questions remain.
Because women deserve more than fear-based messaging. They deserve the complete scientific conversation.
Scientific references
The Menopause Society: 2022 Hormone Therapy Position Statement
Women's Health Initiative Randomized Trials and Clinical Practice: A Review (2024)
This article is for educational purposes and does not replace individualized medical advice.
