There’s a lot in the news these days about menopausal symptoms and HRT. Concerns about it increasing risk of certain cancers now appear minimal and there is increasing evidence of long term benefits which are not limited to troublesome symptoms. In addition to typical menopausal and peri-menopausal symptoms such as hot flushes, brain fog, joint pains, mood swings and vaginal dryness, there is also evidence of HRT increasing longevity and reducing age-related loss of bone density and cardiovascular changes.
Considering the underlying mechanisms for how oestrogen is protective, it appears that the beneficial effects of oestrogen are mediated through its ability to reduce inflammatory species. Evidence suggests that menopause is closely associated with an increased release of pro-inflammatory cytokines, such as interleukin (IL)-6, IL-1, and tumor necrosis factor-α (TNF-α) (Cioffi et al., 2002). Oestrogen has been shown to inhibit such chemicals (Lambert et al. 2004).
Some evidence suggests that HRT is protective against the development of cardiovascular disease and atherosclerosis and all cause mortality if started before the age of 60 or within 10 years of menopause (Hodis et al., 2022; Vigneswaran & Hamoda, 2022). However a 2024 study published in the BMJ on nearly a million women in Sweden showed increased use of oral oestrogen-progestin therapy was associated with an increased risk of heart disease and venous thromboembolism, whereas the use of tibolone was associated with an increased risk of ischaemic heart disease, cerebral infarction, and myocardial infarction (Johansson et al., 2024). Choo et al. (2025) found HRT use to be associated with increased risk of stroke in a study of nearly 20,000 Korean women with no underlying cardiovascular disease. Conversely another study of Korean women with diabetes/pre-diabetes showed a protective effect of HRT against stroke (Song et al., 2025) A most recent review of the literature concluded: ‘Though many interventions of MHT can alleviate the uncomfortable symptoms of menopause they may also augment cardiovascular risk’; they noted that there is a lack of high quality randomised control trial evidence for the more modern formulations of HRT that are widely considered safer (D’Costa et al,. 2025).
Following evidence of significant benefit, NICE guidelines recommend HRT to help preserve bone density and prevent osteoporosis and fractures in women under 60 (Vigneswaran & Hamoda, 2022; NIfHaC, 2015). Most recent evidence continues to support the protective effect of HRT on bone health (e.g. Holloway-Kew et al., 2025; Platt et al., 2025)
It has been suggested that HRT may help to reduce age-related muscle loss, specifically via antiinflammatory effects which may also support muscle satellite cell function involved in muscle repair (La Colla et al., 2015; Perandini et al., 2018). However evidence from reviews of many studies is conflicting (Burton & Sumukadas, 2010) and suggests it is either minimally protective (Taaffe et al., 2005; Greising et al. 2009), or not at all (Kenny et al., 2003; Javed et al., 2019).
Questions about HRT benefit in dementia remain as the evidence is not clear and likely is affected by multiple factors such as type of HRT, individual age, hormonal status and health (Sayfullaeva et al., 2024; Mosconi et al., 2025; Watermeyer et al., 2025; Gravelsins & Galea, 2025). Although some data suggests a that HRT is beneficial, a large observational study of about 60,000 women in Denmark found HRT associated with increased risk of dementia (Pourhadi et al., 2023). In addition,more robust experimental data also suggests the same; a study of over 100,000 women concluded that HRT may be associated with an increased risk (Sung et al., 2022) as did Cai et al. (2024) which investigated nearly 19,000 women on hormone-modulating therapy for breast cancer. Since it has been found that HRT increased risk of alzheimers in women with genetic biomarkers for the condition (Jauregi-Zinkunegi et al., 2025) it is particularly important to take an individual approach to prescription.
HRT may therefore be viewed as protective in many ways through its antiiinflammatory effects and it appears to be of benefit not only for relieving immediate menopausal symptoms but also for longer term protection from the effects of aging, although more recent findings concerning dementia and cardiovascular risk above, are concerning. The benefits of HRT also appear to be dose-dependent; it has been suggested that lower hormone doses are more protective than higher doses (Baik et al., 2024) although it is not clear why. There may be a balance to be struck between risk associated with higher doses and the benefits of the anitinflammatory effect of HRT. Hormonal changes at the menopause (and pre-menstrually) are an additional stress on the body, which increases inflammation further. However there are many other ways in which inflammation may be addressed to reduce unwelcome development of a wide range of inflammatory health problems, without using low dose HRT to address this inflammation. Using other methods of reducing inflammation could therefore allow the individual to avoid the risk of any negative effects of HRT.
The significant benefits of HRT in studies above may also be related to the populations to which they apply. Note the the Korean studies (Choo et al., 2025; Song et al., 2025) found HRT effective in prevention of stroke only in a population suffering from diabetes and not in those who were healthy, where stroke risk was actually increased. In the UK 34% of 46-48 year olds were found to have two or more chronic inflammatory health problems in The British Cohort Study (2015) indicating that a large proportion of the female population around menopause are significantly affected by inflammation. This suggests that anything (such as HRT) that reduces inflammatory load will be particularly beneficial in the general population. It also suggests that other ways of reducing inflammation will also be of benefit (see below), including for those who cannot take HRT or choose not to. For those women who cannot or prefer not to take HRT it is therefore of great importance that they focus on an anti-inflammatory lifestyle. ‘Healthy’ women with low levels inflammation may therefore not benefit from HRT and may even be at risk of damaging effects.
There is no consensus of opinion about which HRT formulations are best for individuals and research continues to address this; oestrogen only formulations may increase uterine cancer and stroke risk but progestogens also come with other cancer and cardiovascular risks (Ylikorkala et al., 2025; Bofill Rodriguez et al.,2025).
It is also worth noting that declining oestrogen from the ovaries may be compensated for by other tissues in the body such as the adrenals, fat, bones and brain. Crucially, oestrogens are produced to act locally – for example cardiovascular problems have been observed to increase post-menopause but the cells of a healthy blood vessel lining actually produce oestrogen locally (Simpson 2003) which acts directly to reduce inflammation in those cells. The action of oestrogen does not therefore depend on circulating levels in the wider system and it is therefore important to keep damaging inflammation down in these tissues in order to support oestrogen production.
Another important question concerns how long to take HRT. Since it may protect against inflamammatory damage that can be associated with hormonal changes some suggest that HRT may be taken indefinitely. Lisa Mosconi in the book ‘The Menopause Brain’ uses research evidence, including brain scans, to suggest that the perimenopausal years are a time similar to puberty where the brain massively rewires itself to adjust to the new hormone levels in the body. She does not describe this as a decline but rather an adjustment to the new normal just as happened in puberty (albeit with a younger body more resilent to the stresses of this huge change). The question for which there is currently no answer in conventional healthcare is whether it is therefore wise to use long term HRT to inhibit this natural change….an interesting debate!
Finally, something that hasn’t been discussed widely is the role of other hormones in menopausal women’s bodies. Follicle stimuating hormone and Luteinizing hormone follow a cyclical pattern of secretion before menopause but after this become elevated. Recent studies have suggested a role in good cognitive health (Mey, Bhatta & Casadesus, 2021) and prevention of metabolic syndrome (Lee et al., 2022).
Recommendations for good menopausal health:
An anti-inflammatory diet based on protein, good fats, veg, berries and slow release carbohydrate is crucial for reducing inflammatory insulin and middle weight gain that is increased with high carbohydrate intake and fluctuating blood glucose.
Practices that offer short-term stress to the body also modulate the inflammatory response e.g. in the form of intermittent fasting, high intensity interval training, cold shower/wild swimming.
Strength training is also important for building muscle which is more metabolically active and reduces inflammatory insulin, as well as for bone health (impact training is beneficial here).
A good quality multi supplement plus separate magnesium supplement may be needed for guaranteeing good levels of antioxidant and anti-inflammatory, bone building, glucose balancing, stress reducing, energy supporting nutrients.
Foods and herbs contain multiple phytonutrients that help to reduce inflammation directly and indirectly.
Many herbs are of particular benefit in menopause both generally for reducing inflammation and additionally for individual symptoms:
• Direct anti-inflammatories and antioxidants include turmeric, marigold, red clover, rosemary, rosehip, hawthorn, ginger, green tea, ginkgo…..
• Herbs also help to reduce inflammation by supporting optimal elimination via the lymphatic system (e.g. red clover, Echinacea) and liver (e.g. dandelion root, artichoke leaf).
• Supporting good digestive function also reduces the absorption of inflammatory substances from the gut (e.g. chamomile, fennel, dandelion, ginger).
• Nourishing dry tissue with good fats, good digestion and herbs such as Shatavari and red clover help to keep fluids moving and reduce inflammatory congestion.
• Strengthening ‘adaptogens’ (e.g. Shatavari, Astragalus, Ashwaganda) help to make the body more resilient to stress and therefore reduce inflammation, particularly given the additional stress on the system of hormonal changes in menopause.
• Mood issues can be helped with herbs that help to balance and strengthen a stressed nervous system (e.g Ashwaganda, St John’s Wort, rosemary).
• Cognitive issues / brain fog may be helped by supporting good cerebral circulation (e.g. rosemary, ginkgo, Astragalus).
• Cardiovascular protection from hawthorn berry and Astragalus that also protects the endothelial lining of blood vessels and therefore supports local protective oestrogen production.
• Bone health is also supported by herbs such as horsetail and black cohosh.
• Finally, herbs can offer hormone support and boost the effect of remaining oestrogens that continue to be produced in smaller amounts in the body (e.g. red clover, soy, wild yam, shatavari).
To conclude, menopausal changes are a huge inflammatory stress on the body which must undergo major change in response. HRT is helpful for alleviating menopausal symptoms and it may also be protective for future health, particularly bone health. However this may be more beneficial to the large percentage of the population with existing underlying inflammatory health conditions such as diabetes (further evidence is urgently needed to test this proposition further). For those minority of women with no inflammatory conditions, significant stresses on their bodies or symptoms associated with menopause, there may be a lack of benefit from HRT and it may actually be associated with health risks. Crucually, in re-framing menopause as a natural, albeit stressful, change which can be supported with a healthy lifestyle and diet etc, it can therefore be viewed not as a hormone deficiency but as a route to the next stage of life.
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