Should I Take Hormone Therapy in Perimenopause or Menopause If I Feel Fine?

By: Dr. Jackie Piasta, DNP, WHNP-BC, MSCP

No Hot Flashes, No Problem, Right? Well…Not So Fast.
I’m often asked this question in casual conversations with friends, on social media, and in clinic visits:

"If I feel fine, do I really need hormone therapy?"

It’s a great question, but a layered one.

The textbook answer to this question is NO. If you are not having symptoms, mainly vasomotor (hot flashes and night sweats), you do not NEED to take menopausal hormone therapy (MHT).

But…experts know the real answer should be individualized and is more nuanced than this.

What Is Hormone Therapy Really For?

Traditionally, hormone therapy has been prescribed to treat moderate to severe menopausal symptoms.

That includes:

• Hot flashes and night sweats (vasomotor symptoms)

• Vaginal dryness, pain with sex, and urinary issues (genitourinary syndrome of menopause)

• FDA-approved use: preventing osteoporosis in high-risk women

• Premature ovarian insufficiency (that’s menopause onset prior to the age of 40)

If you check any of those boxes, HT is one of the most effective tools we have.

But more and more, women who feel “fine” are asking a different question:

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“Should I consider hormone therapy for prevention, performance, or long-term health, even if I’m not symptomatic?”

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What Does the Research Say?

Here’s where it gets interesting. The conversation around hormone therapy shifted dramatically after the early 2000s, when the Women’s Health Initiative (WHI) sparked widespread fear. But we now know that the WHI data findings were misinterpreted and misreported to the mainstream media. Plus, the study used hormone varieties that we just really don’t reach for anymore: (conjugated equine estrogen and medroxyprogesterone acetate) and studied older women well past menopause with pre-existing conditions.

Newer data tells a different story. Key findings include:

• Timing matters: Starting HT within 10 years of menopause or before age 60 may support heart and brain health.

• The ELITE trial showed that women who began HT within 6 years of menopause had less arterial plaque than those who waited.

• HT may reduce insulin resistance, lowering the risk of pre-diabetes and Type 2 diabetes.

Translation? The earlier you start, the more protective benefits HT may offer, especially for your heart, brain, bones, metabolism, and overall vitality.

What About Cancer Risk?

Understandably, cancer, especially breast cancer, is a huge concern. But this risk must be viewed in context.

• The slight increase in breast cancer seen in WHI was associated with older formulations, specifically the progestin component—Provera (medroxyprogesterone acetate).

• Modern regimens like transdermal estradiol + micronized progesterone carry a much lower risk, if any.

• Estrogen-only therapy (for women without a uterus) may decrease breast cancer incidence and mortality.

If you’re navigating these fears, I highly recommend the book Estrogen Matters by Dr. Avrum Bluming. It offers a science-backed, myth-busting perspective on the real risks and rewards of HT.

So… Should I Start HT Even If I Feel Fine?

Here’s how I think about it: hormone therapy isn’t just symptom relief. It’s a strategic wellness decision.

If your goals include:

• Preventing bone loss and fractures

• Supporting brain health and memory

• Maintaining lean muscle and strength

• Improving recovery, sleep, and sexual health

• Boosting cardiovascular resilience

… then HT may be worth considering even in the absence of classic symptoms.

This isn’t about chasing youth, it’s about investing in function and quality of life as you age.

Don’t Forget Testosterone

While not FDA-approved for women in the U.S., testosterone therapy is used off-label to:

• Improve sexual desire

• Support energy, mood, and cognition

• Preserve lean body mass

It’s effective, it’s safe when dosed correctly, and it’s backed by decades of global data.

Thinking Proactively? Here’s Where to Start:

1. Get a detailed personal and family history.
   Include tools like the Tyrer-Cuzick model for breast cancer risk. Consider genetic testing if appropriate.

2. Define what “success” looks like.
   When you’re not miserable, your wins may be subtle: better sleep, stronger workouts, improved HRV, mental clarity, steady libido.

3. Choose your therapy intentionally.
   Don't default to the lowest dose possible. Choose what aligns with your goals, values, andphysiology, and be prepared for trial and error. You may need to try several different forms, routes and/or doses before we get it just right.

4. Reassess regularly.
   Your therapy may need to change or be tweaked with time to fit your goals and long-term health needs.

Final Thoughts: You Don’t Need to Be in Crisis to Deserve Care

The idea that we only deserve support when we’re suffering is outdated, and frankly, dangerous. We no longer live in the same world our grandmothers did. We’re juggling careers, caregiving, and high expectations while aging in a world full of environmental and emotional stressors.

So no, feeling “fine” isn’t a reason to skip the conversation. It’s a reason to lean in early, with curiosity and intention. You deserve to feel amazing, not just "fine."

In health partnership,

Dr. Jackie