The Menopause,
Sexuality & Vitality

Fear around hormone therapy is common — and understandable.

Much of what we have been told about hormones comes from outdated studies, simplified messaging, and misinformation that conflates old oral synthetic hormones with newer body identical hormones.

This summary clarifies what the evidence actually shows, and why hormone therapy today is not the same as hormone therapy of the past.

Hormones are often discussed as a single category.

This is inaccurate and unnecessarily frightening.

From a cancer-risk perspective synthetic oestrogen and synthetic progesterone may carry increased risk of cancer over the long term. This combination is no longer used. However, body identical oestrogen and progesterone have not been shown to increase risk of cancer and have shown improved quality of life and physical health.

When people talk about HRT this refers to oestrogen and progesterone. However there are 5 main types of hormones that are prescribed for The Menopause symptoms:

• Transdermal body identical estrodiol (oestrogen). Patch or a gel
• Micronised progesterone (oral capsule, can used vaginally if too sedating)
• Vaginal estriol (cream or pessary vaginally)
• DHEA (dehydroepiandrosterone) (vaginal pessary)
• Testosterone: female specific dose Androfeme cream

Separating hormones — rather than treating them as one entity — changes the conversation entirely.

Much of the fear around hormones comes from the Women’s Health Initiative (WHI), published in 2002.

The WHI studied:

• Synthetic conjugated equine estrogens (derived from horse urine)
• Synthetic progestins (not body-identical progesterone)
• Mostly oral formulations
• Many women who were well past menopause, often 10–20+ years later

The WHI did not study:

• Body-identical transdermal oestrogen, or vaginal oestrogen
• Micronised progesterone or testosterone
• Women starting therapy in perimenopause
• Hormone use for sexual health, bone protection, or quality of life in later years

Applying WHI findings to modern hormone therapy — at any age — is biologically inaccurate.

When WHI data is analysed by age and timing, women who started hormones earlier showed a very different risk profile.

In women under 60 or within ~10 years of menopause, WHI analyses found:

• No increase in overall mortality
• Lower rates of heart disease
• Fewer heart attacks
• Strong protection against bone loss
• Significant reduction in hip and osteoporotic fractures
• Reduced bowel cancer incidence
• Lower all-cause mortality
• No increase in breast cancer deaths

These benefits were observed despite the use of older synthetic hormones, which is often overlooked.

Some WHI analyses showed a small increase in breast cancer diagnoses in certain hormone users.

Crucially:

• There was no increase in breast cancer mortality
• In estrogen-only users, breast cancer incidence was lower
• Earlier detection and more frequent screening likely explain diagnosis differences

An increase in diagnosis does not equal an increase in death — a distinction rarely explained.

A common and damaging message is:

“Hormones are fine if you start early, but unsafe if you’re older.”

This is not supported by evidence. There is hardly any evidence on body identical hormones commenced in older people. Tragedy: The boomers really suffered.

However, The WHI showed in older women :

• No increased risk of cardiovascular event, cardiovascular mortality or all cause mortality in women who initiated synthetic HRT more than 10 years after provided they were regularly scanned.

We simply do not have evidence of harm from modern bio identical hormone therapy for people with ovaries in their 60s, 70s, or 80s.

Absence of evidence is not evidence of danger.

Many people start low dose body identical oestrogen gel or patch transdermally (through the skin) for bone and body health and low does progesterone for anxiety and sleep and testosterone cream for bone health, preparation for surgery and vaginal estriol for vaginal and bladder health in there 60s, 70s and 80s.

The WHI Memory Study found an increased dementia risk only when hormone therapy was started after age 65.

This does not apply to those who:

• Start hormones in perimenopause
• Start closer to menopause

The increased risk appears linked to late initiation with synthetic oral hormones, not to hormone therapy itself.

Menopause is often medically induced through surgery or medication treatment. Oophorectomy and oestrogen suppressing medication send people with ovaries into immediate menopause: Symptoms are often sudden and severe.

After hysterectomy, even when ovaries are preserved, menopause can occur sooner due to:

• Reduced ovarian blood supply
• Disrupted ovarian–brain signalling
• Early loss of progesterone production

Older practice was to only prescribe oestrogen to those who no longer had a uterus. However, we now know that micronised progesterone is essential for calming the brain via gaba receptors and can help with nervous tension, anxiety, and sleep.

Hormone therapy after cancer is often discussed as if all hormones carry the same risk. They do not.

From a clinical perspective, it is essential to separate estrodiol (oestrogen) from other hormones, as their effects on cancer risk are very different.

Estrogen: Individualised Risk–Benefit Assessment

Systemic oestrogen is the only hormone with clear contraindications in some hormone-sensitive cancers.

Use of estrogen requires an individualised discussion, considering:

• Cancer type and receptor status
• Time since treatment
• Dose, route, and timing
• Overall health and symptom impact

Micronised Progesterone: Low Risk Profile

Body-identical (micronised) progesterone has NOT been shown to increase cancer risk.

Risk signals seen in older studies relate to synthetic progestins, not micronised progesterone. Synthetic progestins are no longer used.

Vaginal Estriol: Local, Not Systemic is Very Safe

Vaginal estriol is a vaginal oestrogen that has minimal systemic absorption ( 1 year of vaginal cream is equal to 1 pump of Estrogel). Vaginal estriol has NOT been shown to increase breast or uterine cancer risk. It is essential for good bladder health, vaginal health, and to improve sensitivity to sensual touch and reduce vulva pain and skin conditions.

Vaginal estriol is often appropriate even when systemic oestrogen is contraindicated.

Testosterone: No Evidence of Increased Breast Cancer Risk

Testosterone has NOT been shown to increase breast cancer risk in long term studies of up to 20 years when females use female doses. Long term data also supports the long term safety use of male dose testosterone for transmales. Testosterone does not stimulate breast tissue and may support sexual function, energy, drive, and wellbeing.

It does not stimulate breast tissue and may support sexual function, energy, drive, and wellbeing.

The Menopause Society published a paper on the pros and cons of HRT for women with a history of breast cancer: Menopause Hormone Therapy for Breast cancer patients: what is the current evidence Jan 2026.

The truth about Estrogen & Breast Cancer with dr Ceri Cashell and oncologist Dr Avrum Bluming on health Hormones App

Menopause care does not end with your last period or hot flash. We do not “miss the window” for hormones as not all hormones are the same.

Starting earlier brings broader protective benefits, however starting later can still improve physical comfort, improved sexuality, sleep, stabilise mental health, and quality of life

• Risk is driven by formulation, route, and dose, not age alone
• Even in people with oestrogen contraindications micronised progesterone, vaginal estriol, and testosterone remain safe options for many women at any age.

Sexual activity that once happened automatically may now require different conditions, different behaviour, pacing, and support.

Trying to do sex “the way you always have” often stops working — and many women blame themselves or their relationship rather than recognising that the rules have changed.

Regardless of whether you choose hormones, The Menopause represents a fundamental change to the architecture of the body and mind that once supported sexual function.

Ignoring these changes often reduces interest in sex, block the potential for sexual arousal, may led to painful sex, avoidance of sexual activity, and even affectionate touch. Creating or exacerbating sexual desire discrepancy in your relationship, distress, and negative self-image.

Talking with your partner about making life style and relationship changes may help to smooth out this transition and reduce conflict related to pre-existing expectations.

Everyone is different. Hormone therapy can be profoundly helpful for many people — Hormones can help with:

However if your relationship has serious issues hormones will not make that better.

One of the most distressing trajectories I see is this:

Loss of responsiveness → effortful arousal → pushing through → pain → avoidance

When the body no longer responds easily to touch, many people try harder — mentally or physically. Over time, this can lead to painful sex, which further trains the nervous system to associate sex with threat rather than pleasure.

Painful sex should never be normalised. Pushing through pain does more than cause discomfort. It:

• Teaches the body to shut down
• Teaches partners how to have sex that no longer works
• Teaches women to distrust or devalue their own bodily signals and boundaries

Pain is not a failure. It is information.

Sex is not only about pleasure — it plays a role in bonding and relationship regulation.

When sex is working well, researchers have found it contributes around 15–20% to overall relationship satisfaction and identity. It matters — but it tends to sit quietly in the background, supporting connection without dominating the relationship.

When sex is not working — when there is pain, lack of arousal, desire discrepancy, or ongoing tension about frequency — its psychological weight increases dramatically. What was once a background contributor can begin to overshadow the entire relationship.

This is partly because pleasurable sex and orgasm are associated with the release of neurochemicals such as oxytocin, which support feelings of closeness, trust, calm, and bonding. When orgasm becomes rare or effortful, these bonding experiences occur less often.

Repeated unsatisfying sex — even in long, loving relationships — reduces interest in sex over time and reduces opportunities for relationship strengthening. Sex can begin to feel less like connection and more like another form of emotional labour performed to maintain the relationship.