Beyond the Headlines: Understanding Hormone Replacement Therapy Risks and Benefits

Dr. Brandi Sinkfield: So in your experience, what do you think is the biggest misconception about hormone replacement therapy?

Dr. Leah Millheiser: That hormones will kill you. I mean, this is honestly the word out on the street about hormones.

Continuing our multi-episode series on perimenopause, menopause care, and sexual wellness, this episode features a discussion about Hormone Replacement Therapy (HRT), addressing common misconceptions and exploring the evolving understanding of its benefits and risks. 

Dr. Brandi Sinkfield shares her personal journey from skepticism to a more informed perspective, highlighting the importance of understanding hormone therapy in the context of women's health, particularly during perimenopause and menopause. Dr. Brandi illustrates this by sharing further highlights from her conversation with menopause specialist Dr. Leah Millheiser. 

This episode also features excerpts from Golda Arthur's deeply personal story of navigating genetic cancer risk, surgical menopause, and the emotional fallout that followed.

This episode continues and the evolving role of digital health technologies in women’s health.

Topics Discussed

• We address the common misconceptions about Hormone Replacement Therapy (HRT)
• Why medical experts and patients are coming to a more nuanced understanding of the risks and potential benefits of HRT, including its cardioprotective effects when started in women under 60.
• The different options that are available to women concerning Hormone Therapy
• Common myths about HRT
• The importance of paying attention to our bodies and health changes

This episode will help you gain a deeper understanding of hormone replacement therapy and encourage you to consider your own health journey. 

For more from Dr. Brandi's conversation with Golda Arthur, listen to Episode 24: Early Signs of Perimenopause: Why Your Body May Feel Different Even When Your Labs Are Normal

Disclaimer
The information in this podcast is for informational purposes only and is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare providers with any questions you may have regarding a medical condition or treatment.

The personal views expressed by guests on Women's Digital Health are their own. Their inclusion here does not constitute an endorsement from Dr. Brandi, Women's Digital Health, or associated organizations.

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Edited by Steve Woodward at podcastingeditor.com/

Transcript

Dr. Brandi Sinkfield: So in your experience, what do you think is the biggest misconception about hormone replacement therapy?

Dr. Leah Millheiser: That hormones will kill you. I mean, this is honestly the word out on the street about hormones.

Dr. Brandi Sinkfield (intro): Welcome to the Women's Digital Health Podcast, a podcast dedicated to learning more about new digital technologies in women's health. We discuss convenient and accessible solutions that support women with common health conditions. Join us as we explore innovations like mobile health applications, sensors, telehealth, and artificial intelligence, plus more. Learn from a board-certified anesthesiologist the best tips to filling some of your health experience gaps throughout life's journey. 

Dr. Brandi Sinkfield: I'll be straight with you. I did not come into this conversation as someone who understood hormone therapy. I came into this very skeptical and honestly, a little afraid of it. During the pandemic, I met Joanna Strober. She's the founder of MidiHealth. And she asked me this question, which was, would I be interested in getting licensed to prescribe hormone therapy? 

And I was like, uh, no, isn't that for the gynecologist, you know, the specialist in women's health. I'm an anesthesiologist. I have a background in digital health. If anything, let's build something around women's health. Let's not prescribe something. And I'm definitely not going to prescribe something I don't fully understand. 

And that's because what I thought I knew about hormone therapy was completely shaped by the Women's Health Initiative. And like a lot of doctors and a lot of patients, I was like, this is very risky. It wasn't just a professional decision. It was also personal because I come from a family of women and, you know, our mantra is like, we just power through. You know, we don't complain. We don't slow down. We just deal with it. And underneath that is fear. Fear of hormone therapy, fear of doing something that could actually cause harm. 

But over time, my thinking is starting to change. And it's not been all at once. It's like in pieces. I start coming across more research that's reframing estrogen, not just something tied to symptoms, but connected to long-term quality of life things like brain health and heart health and bone health. And so that revelation hit differently for me. Because now I'm thinking, we've talked so much about the risks of hormone therapy, but I really have not talked a lot about the risks of losing estrogen.

So then I started hearing more physicians go back to the data behind the Women's Health Initiative, challenging what we all had been taught. And then I had to pause again. And I had to think like, wait a minute, hold on. Have we been getting this all wrong? So I went back to the data and what I found was a lot more nuanced than what I was ever taught, what any of us were taught. 

The more I looked into it, the more I realized this wasn't just about me or my family. This is about how an entire generation of doctors, nurses, anyone in the healthcare industry, including patients, how we were all taught to think about perimenopause, menopause, and hormone therapy. So in this episode, we're gonna unpack all of that. What we thought we knew, what the data shows, how it's changing, how we think about risk, not just for symptoms, but for long-term health. Because to understand where that fears come from, you have to go back to one study.

Dr. Leah Millheiser: You know, we didn't have this kind of access to care in the past. And so, unfortunately, there was a study that came out. A lot of people know about this study, the Women's Health Initiative. It came out in 2002. That study was stopped early. 

One arm, the estrogen-only arm, went out for three years only. The estrogen plus progesterone was stopped after five years. So they were both stopped early because the researchers found that the rate of heart disease and breast cancer or the incidence of heart disease and breast cancer and blood clotting and stroke was above what they deemed acceptable. 

And, you know, because of that study and it was an NIH funded study, it got tons of press. The messaging was hormones are not safe. Try non-hormonal alternatives. If you have to put somebody on hormones, lowest dose for the shortest amount of time. And so what happened?

People who were not super familiar with menopausal hormone therapy and menopausal healthcare who were seeing women, it was safer just to say hormones aren't safe.

Dr. Brandi Sinkfield: And that message stuck for decades.

Dr. Leah Millheiser: Well, thankfully, a group of researchers have gone through and combed that data, and it is the largest study of hormone therapy in the United States ever done in women. And they have gone through the data subsequently and found, wait a minute, You know, that study was designed in a way to almost find flaw because your average age of the woman was 63. 

The average age of a woman who goes through menopause is 45 to 55. So when you see three, you already have risk factors for cardiac disease. And then on top of that, you're putting women on an oral form of synthetic estrogen, which is still around, but most of us are not prescribing that anymore.

Dr. Brandi Sinkfield: Okay, and this is like where things really started to click for me because what she's saying is we're not even talking about the same patients or even the same way hormones are being used. You know, back in 2002, most of the women in that study, they were taking oral estrogen. And today, a lot of women are using transdermal forms like patches. And we're not waiting until years after menopause to even have the conversation.

We're talking about it a lot earlier during perimenopause. So when you take findings from that study and then apply it to the general population of women today, that's where the story starts to shift.

Dr. Leah Millheiser: The breast cancer one is the one that really freaked everyone out because when we announced the findings of the study, it was like, oh yeah, breast cancer will be increased in the estrogen and progesterone group, be increased by 20, I think it was like 27% or something in the 20th percentile. And it's not. So again, on re-analysis of the data, in that estrogen and progesterone group, it was one extra case of breast cancer per 1,000 women taking estrogen and progesterone. 

That was not statistically significant. So you couldn't say the risk, it wasn't causal, right? So risk was not related to cause. And that messaging was not as loud as the, oh, it will cause breast cancer. When they looked at the estrogen only group, the estrogen only group did not have an elevated risk. In fact, they had a slightly decreased risk.

Dr. Brandi Sinkfield: Yeah, I remember those headlines were loud. Hormones cause breast cancer. And that message didn't just stay within the realms of researchers and in research journals. It made it all the way into people's homes. You know, I think about my mom. This had to have been the early 2000s because I think she was also on estrogen and progesterone and then all of a sudden she was not. And I didn't fully even understand what was going on at the time. I just remember the shift. Suddenly, there were supplements like black cohosh, and soy milk, and tofu, and edamame. And I didn't realize at the time, but doctors were trying to replace with something without really understanding what needed to be changed. And, you know, looking back now, I don't think that was my mom's personal decision. I think that was a conversation she had with her doctor, which was the message was very clear that hormones cause breast cancer. And even if later on we will find out the data behind it wasn't clear, she made a dramatic shift based upon the doctor's recommendation at that time.

Dr. Leah Millheiser: But there's some newer data, new research that came out looking at 10 million Medicare charts. This was published last year. They actually saw in the estrogen-only group, there was, for women who continued estrogen therapy over the age of 65, there was not an elevated risk of breast cancer. So, you know, I think there was something to that. 

It made us look at the progesterone, but then progesterone we use now. So what we recommend now in 2025, compared to what we gave back then, we now recommend bio-identical, so structurally identical to what's in your body, circulating in your body, estrogen and progesterone. With the newer types of progesterone that we use, we do not see that elevated risk. It's more of a breast-neutral progesterone, which our older types of progesterone weren't necessarily. So it's a different world. 

We don't see that risk. At this point, I would not say 100% hormone therapy does not cause breast cancer, but the data does point towards that direction. Let's get some more good research on that first. I think people should be reassured. You know, there are even conversations happening right now as to whether or not women who have had breast cancer can go on hormone therapy. 

The good news is, is that those risks around heart disease. So what do we know about women who start hormone over younger than 60? Hormones give a cardio protective effect.

Dr. Brandi Sinkfield: So about this cardioprotective effect of hormones, I'm starting to hear more cardiologists talk about this, and it's making me rethink about how hormone therapy was even presented. Most of us were taught to think about hormone replacement therapy as a risk. We weren't really taught to think about hormone replacement therapy as a potential benefit to women, and quite frankly, more women often feel like the benefit to hormone replacement therapy is not something that people really even care about.

Dr. Leah Millheiser: We were sort of devalued and run away. That has completely changed. And I think, you know, that came from this. This was not something that stemmed from the medical schools and the residency program saying we have to do more. from women saying, we are done being cast aside. We feel invisible. 

We shouldn't feel invisible. We are women who are at the top of our career in our 40s and 50s. We have a ton to contribute. We're in the C-suite. We're a clinical professor. We're CEO of a company, like whatever. at the top of our career, or you've been home with the kids, you're a stay-at-home mom, your kids are now launched, this is the second phase of your life, you wanna reinvent yourself. Women are amazing.

Dr. Brandi Sinkfield: Women wanting more, this is how we change the perspective and how we don't think just about symptoms, we think about how we value women in this stage of life. But here's something I want you to hear me on. This is something that, as an anesthesiologist, I sit and think about in the operating room. So if you guys want a sneak peek as to what stuff is going through my brain in the operating room, this is what I see over and over and over again. 

So young girls, middle school age, the emphasis is on sports education and physical movement. And I think every middle school girl remembers her sex ed education, OK? And then right around their 20s, they start to get a lot of signals from the beauty industry, positive things like eat healthy and work out. But the motivation is to stay young and look beautiful, right? And then after that, there's like this long period of time where there's really no signaling, no reinforcement until you have a child. And then that moves you into this prenatal care. 

And then after you have the baby, there's this long stretch of time where no one is really sending out a lot of messages about how important it is to invest long term in your health. And the reality is during that time, that's when the cardiovascular or the heart risk, that's when it's quietly building. And so we as physicians, we don't catch it early because we're trained to look for abnormal numbers, abnormal blood pressures, high hemoglobin A1Cs, high cholesterol levels. 

So by the time the numbers change, the process of that slowly building, it's been happening over years. The reality is that it's not just one thing, it's the accumulation of everything. It's the change in sleep, change in weight and where it's distributed, the change in how your body is handling glucose, even when your labs still look normal. And that's the part we don't talk enough about. You can push through the hot flashes, you can normalize the fatigue, you can explain away the weight gain, but you don't really feel your blood pressure slowly rising. You don't really feel when insulin resistance is happening in real time. So this isn't just about symptoms, it's about understanding that these hormonal changes affect multiple systems at once. 

And perimenopause isn't just like a steady decline, it's really this fluctuation and unpredictable changes in your hormones. So that by the time the numbers finally do change, a lot of women are thinking like, hey, I've been feeling like this for years. and they just didn't have the words or the numbers to back up how they've been feeling. To be fair to doctors, we're often only seeing patients like once or twice a year, and that's really not enough to catch this slow long-term change. It's not just a clinical gap. This is actually an ecosystem gap. 

Real prevention happens over time. It happens through your environment, your friends and family, your habits, how often you're checking in with your body. And so hormone therapy, it's one option among many, but if you've been noticing changes in your body and you're not sure what to do with that, or you've just been scared to even explore it, you're not alone. 

This is not about rushing into any decision. It's really about understanding what's happening instead of just pushing through. The goal is not to push any treatment. It's just to get you thinking about how do you check in with yourself and how do you build these habits and build that toolbox that can actually support you in your long-term health journey. 

Dr. Brandi Sinkfield (mid-roll): Hey listeners, it's Dr. Brandi. Thanks for listening to this episode of Women's Digital Health. subscribe to Women's Digital Health on your favorite podcast platform. If you want to know even more about how to use technology to improve your health, subscribe to our newsletter on womensdigitalhealth.com. Follow us on Instagram, Facebook, YouTube, and LinkedIn. Enjoy the rest of this episode. 

Dr. Brandi Sinkfield: Up until this point, we've been talking about hormone therapy as an option, and it is always an option. Every woman has to make that decision for herself. But for some women, the question isn't just, do I want relief from symptoms? It's, what happens to my body when estrogen disappears? And what risks am I willing to take either way? Golda Arthur was in that position. She was at high risk for ovarian cancer.

Golda Arthur: I think looking back on it now, I was in perimenopause for quite a few years and it was awful. It was just terrible. I would go into these rages, rages. And the thing about rages is like, they're not over nothing. You know, there's always something that's worth going into a rage about, frankly. But I didn't feel like I had control over my emotions, definitely. I had zero control over my weight.

Dr. Brandi Sinkfield: Golda was already navigating the instability of perimenopause, but then she had her ovaries removed and everything changed.

Golda Arthur: That year after surgical menopause was very flat. It was like almost a deadening of everything. And the physical symptoms were actually probably worse. I was sleeping four hours a night. I had debilitating joint pain. I couldn't, you know, I walk an hour a day. I could not walk 15 minutes without being in pain. And I stopped. I stopped walking. I stopped a lot of my exercise, the stretching that I would do. I used to do yoga every night before I went to bed. The pain of stretching was too much for me. Like my joints were deteriorating. I didn't gain any weight during that year, but neither did I lose any. And it was just every day, it was kind of like coming up from underwater and trying to swim to the shore. So it was a different experience than perimenopause for sure.

Dr. Brandi Sinkfield: So Golda Arthur, she had the RAD5-1C gene mutation, and that mutation is like one of the highest risks for ovarian cancer. And even in that context, she still chose to pursue hormone therapy, not because it was easy or risk-free, but because she had experienced, you know, what it felt like to go without hormones. If you want to hear the full story and what that decision looked like and how she's doing now, check out episode 24 with Golda Arthur in Surgical Menopause. 

You know, she highlights something really important. When we talk about hormone therapy, we're not just like talking about one thing. There are so many different types of hormone therapy. for people with different health experiences. And there's often different delivery methods. There's even different hormones altogether like testosterone. There's also local therapies like vaginal estrogen. So those are gonna be separate conversations. We're gonna break down those hormones in our upcoming episode on sexual health.

But before we close out, I do wanna address a few myths that I keep hearing because I'm getting a lot more questions about hormone therapy after my last episode. So myth number one, hormone replacement therapy is forever.

Okay, so the reality is hormone replacement therapy is optional. It's a choice, it's not something every woman needs, and it's not something you're committing to for the rest of your life. You can start it, you can stop it, you can reassess it, adjust it based upon how your body responds. 

Myth two, hormone replacement therapy can cause weight loss. So for this one, I can see how you may be led to this idea that hormone replacement therapy can cause weight loss, but the reality is that it doesn't directly cause weight loss. For some women, though, when they take hormone replacement therapy, when they improve their sleep and then they reduce symptoms like joint pain and stiffness, they start to stabilize how they feel. And then that starts to create these positive conditions where they have momentum. The strategies that they were using to want to work out or change their diet, they start to work again. 

Myth number three, the access is easy. So the reality of this myth is that there are real access and cost barriers to hormone replacement therapy. It's not always covered. And for many women, there are still out-of-pocket expenses to using hormone replacement therapy. And that's why part of the conversations you're seeing more about is menopausal benefits in the workplace at a policy level. Oh, and by the way, if you're trying to access care right now and you're running into delays and other barriers, don't take it personal. The demand has significantly increased for hormone replacement therapy as more people talk about it. So you might be experiencing back orders and delays on shipments. 

Myth number four, if you don't take hormone replacement therapy, just deal with it. Stepping back from all of this, regardless of what you decide about hormone therapy, your body still deserves your attention. Even if hormone therapy isn't for you, that doesn't mean you ignore what your body is telling you. 

Joint pain shouldn't be dismissed. Sleep disruption shouldn't be dismissed. Cardiovascular or heart health should not be dismissed. Understanding how estrogen and progesterone shift over time, meaning from adolescence to being a mature adult, that's a part of your overall understanding and investment in your health. 

For a long time, women's health conversations have focused on having a baby. And once that phase ends, the conversation disappears. Your health isn't defined by whether or not you have children. It just matters, period. 

So today we've covered a lot. We've talked about where the fear around hormone therapy came from and how the Women's Health Initiative shaped an entire generation of thinking.

We've unpacked what the data actually shows, including what was misinterpreted, and we shifted the conversation from just symptom relief to understanding what's happening in the body during this transition. 

In the next episode, we're gonna expand this conversation and talk more about sexual health during perimenopause and how these hormonal shifts show up and what options women actually have.

If this episode resonated with you, there are a few ways to stay connected and support this work. Number one, join the Women's Digital Health community on WhatsApp. We're having conversations in real time. Number two, subscribe to the podcast and please leave us a review so more women can find us because this conversation, honestly, we should have had a long time ago. 

And remember, You are more than enough, even more than that. Bye for now. 

Dr. Brandi Sinkfield (outro): Although I'm a board-certified physician, I am not your physician. All content and information on this podcast is for informational and educational purposes only. It does not constitute medical advice and it does not establish a doctor-patient relationship by listening to this podcast. Never disregard professional medical advice or delay in seeking it because of something you heard on this podcast. The personal views of our podcast guests on women's digital health are their own and do not replace medical professional advice.