| Seated on a long white couch in front of a studio audience, Oprah Winfrey brought up a subject once considered taboo. “Let’s talk about all the confusion around hormone replacement therapy,” Winfrey said during her recent special on menopause airing on Hulu. The fact that Winfrey was discussing the topic at all is a sign of how much attitudes have changed around hormone therapy, which are drugs that replace estrogen that a woman’s body stops making after menopause. Since the 1960s, women have been taking hormones to reduce menopause symptoms. But in 2002, researchers halted a study of 16,000 women, supported by the National Institutes of Health, after finding that taking a combination of estrogen and progestin led to a higher risk of breast cancer, strokes and other risks. A media firestorm ensued. A Time magazine cover story declared hormone therapy “riskier than advertised.” The New York Times called the study’s findings “a shock to the medical system.” Over the next two decades, among women in their 50s and early 60s, its use plummeted by 88%. In recent years, researchers have found that some of the study’s findings were misinterpreted and applied too widely. Follow-up studies have found the benefits of hormones outweigh the risks for many women under 60 or within 10 years of menopause onset, while the risks of heart attacks and strokes are increased for women starting hormone therapy in their 60s and 70s. Women under 60 with moderate-to-severe menopause symptoms are generally good candidates for hormone therapy, according to JoAnn Manson, a professor of medicine at Harvard Medical School. Those symptoms include hot flashes, joint stiffness, disrupted sleep and night sweats. A lot has changed. Doctors now call it “hormone therapy” and have dropped the world “replacement” because they are not trying to replace what the ovaries used to make, according to Stephanie Faubion, director of the Mayo Clinic Center for Women’s Health. The therapy is also administered differently. While women once took a pill, which has been linked to blood clots, they can now get a different form of estrogen from a patch, gel, spray or vaginal ring, which appear to be safer. More women should be taking hormones, Manson says. Less than 5% of US women use hormone therapy, despite around 20% having symptoms bothersome enough to benefit from it, she says. Many doctors aren’t trained in treating menopausal symptoms or in prescribing hormone therapy, in large part because they stopped learning about it in medical school and training programs after the 2002 study caused alarm. “It’s clearly being underutilized,” Manson says. Now, the topic is getting more attention. Marty Makary, the new commissioner of the Food and Drug Administration, dedicated a chapter of his book Blind Spots, published last year, to the controversial study on hormone therapy, saying “women deserve an apology.” Mary Claire Haver, a doctor with 2.8 million Instagram followers, recently published The New Menopause. She advocates for women taking estrogen in perimenopause, which can begin as early as their mid-30s. There is money to be made. Hims & Hers Health plans to offer menopause treatments by the end of the year. Another telehealth firm, Midi Health, has raised millions of dollars from investors who see promise in its business of prescribing hormone therapy. On its website, the company says it aims to “fill the critical gap in care for millions of women.” The new acceptance of hormone therapy is not only a reinterpretation of an old study. It’s a generational difference. Younger women are more willing to talk openly about the topic than Baby Boomers, Faubion says. “The Gen X and Millennials are starting to enter their mid-40s and are unwilling to suffer,” she says. “They want to talk about and understand solutions.” — Gerry Smith | 
