For roughly twenty years, the standard answer to a woman asking about hormone therapy was some version of “we do not really do that any more.” A great many women accepted it, managed as best they could, and were never told what the reasoning rested on.
It rested largely on one trial, and on how its results were communicated.
What happened in 2002, and what was missed
The Women’s Health Initiative was halted early in 2002 and reported findings that were carried worldwide as a straightforward warning about hormone therapy. Prescriptions fell sharply and stayed low for two decades.
What travelled less well was the detail. The trial’s average participant was in her sixties, more than a decade past menopause, and it studied particular formulations at particular doses. Subsequent analysis found the risk picture looked materially different for women who began treatment near the onset of menopause rather than years afterwards. That distinction, now generally called the timing hypothesis, was not what the headlines said.
In late 2025 the FDA moved to remove the boxed warning from systemic menopausal hormone therapy products, reflecting how the evidence had shifted in the intervening years. Dr. Fandos has been practising and teaching bioidentical hormone therapy through that whole period, and we wrote about the change when it came.
None of this means hormone therapy is right for everyone. It means the conversation was closed prematurely, and it is now open again on better terms.
Perimenopause starts earlier than most women expect
Menopause is a single day: twelve months after a final period. Perimenopause is the transition leading to it, and it can begin in the early forties and run for several years.
It is also the phase most likely to be missed, because the presenting symptoms rarely arrive labelled. Cycles become irregular before they stop. Sleep fragments, often waking at the same time each night. Mood becomes less predictable in a way that feels unfamiliar rather than characteristic. Recall gets slightly slower. Body composition shifts toward the middle even when nothing about diet or activity has changed.
Any one of these has a dozen possible explanations. Arriving together in a woman in her forties, they have a fairly likely one.
What is happening underneath
Estrogen and progesterone do not decline in a smooth line. They fluctuate, sometimes considerably, before they settle low. That volatility is why symptoms can be inconsistent week to week, and why “your labs came back normal” is not the reassurance it sounds like when the sample caught a single point on a moving curve.
The changes are not only about how someone feels. Bone loss accelerates through the transition and in the years immediately after. Cardiovascular risk profiles change. Lean muscle becomes harder to hold and visceral fat easier to gain, which is a metabolic shift as much as a cosmetic one.
How the decision actually gets made
There is no single correct answer, and anyone offering one without looking at your specifics is guessing.
What a careful assessment involves: a full hormone panel rather than a single value, read against where you are in the transition. Thyroid, because it produces an overlapping symptom picture and is frequently the actual culprit. Metabolic and body composition markers, because those are the changes that compound quietly. Personal and family history, particularly cardiovascular and breast health, because those genuinely shape the risk calculation. And your own priorities, because a woman whose main problem is broken sleep and a woman whose main concern is long-term bone density may reasonably choose differently.
Bioidentical hormone therapy uses hormones structurally identical to the ones the body produces, and dosing is matched to your profile rather than issued as a standard prescription. For some women it is the right intervention. For others the answer is thyroid support, or a metabolic and strength-training plan, or targeted nutritional work, or some combination. The point of measuring first is to find out which.
What we would say to someone deciding
If you were told years ago that hormone therapy was not an option and you have not revisited it since, the ground has moved. That is worth a fresh conversation, particularly if you are in or near the transition rather than long past it.
If you are in your forties and something has changed that you cannot name, you are not imagining it and it is not simply stress. It is measurable, which means it is discussable.
And if you have already been handed a prescription without much of a workup, it is reasonable to ask what it was based on.
Book a consult and we will map what your hormones are actually doing, what else might be contributing, and what the options look like for you specifically.
