Women's Longevity Hub

HRT Decision Framework

An interactive, evidence-based tool to help you evaluate whether hormone replacement therapy is appropriate for your situation. Answer 7 questions, then receive a personalized summary you can bring to your doctor.

This tool does not replace medical advice. It organizes the evidence and your personal factors into a clear framework for an informed conversation with your healthcare provider.

Step 1 of 7

Where are you in the menopausal transition?

This determines the timing window, which is one of the most important factors in HRT risk/benefit analysis.

Select the option that best describes your current situation.
Early perimenopause — cycles changing but still relatively regular
Late perimenopause — skipping periods, significant symptoms
Post-menopause, within 10 years of last period (or under 60)
Post-menopause, more than 10 years since last period (or over 60)
Surgical menopause (ovaries removed)
Step 2 of 7

What symptoms are you experiencing?

Select all that apply. The severity and type of symptoms help determine how strongly HRT may benefit you.

Hot flashes / night sweats
Sleep disruption
Mood changes / anxiety / depression
Brain fog / cognitive difficulties
Vaginal dryness / urogenital symptoms
Joint pain / stiffness
Bone density loss (osteopenia / osteoporosis)
Low libido
No significant symptoms currently
Mild — noticeable but manageable
Moderate — affecting daily life or sleep
Severe — significantly impairing quality of life
Step 3 of 7

Cardiovascular risk factors

These factors influence the cardiovascular risk/benefit profile of HRT — especially estrogen formulation choice.

Hypertension (high blood pressure)
High cholesterol / elevated ApoB
Type 2 diabetes or prediabetes
Current smoker
BMI over 30
Family history of early heart disease (before 55 in male / 65 in female relative)
None of the above
Step 4 of 7

Cancer history & risk factors

Personal and family cancer history is a key factor in HRT decision-making — particularly for breast cancer.

No personal history of cancer
Personal history of breast cancer
Personal history of endometrial cancer
Personal history of other cancer (not breast/endometrial)
No family history
Distant relative (aunt, grandmother)
First-degree relative (mother, sister)
Known BRCA1/BRCA2 mutation carrier
Step 5 of 7

Blood clotting risk factors

Venous thromboembolism (VTE) risk is a key differentiator between oral and transdermal HRT formulations.

Personal history of DVT or pulmonary embolism
Known clotting disorder (Factor V Leiden, etc.)
Family history of blood clots
Prolonged immobility / recent major surgery
None of the above
Step 6 of 7

Uterine status

Whether you have a uterus determines whether progesterone must be combined with estrogen (to protect the endometrium).

Yes — uterus intact
No — prior hysterectomy
Step 7 of 7

Your priorities

What outcomes matter most to you? This helps frame the conversation with your provider.

Relief from vasomotor symptoms (hot flashes, sweats)
Bone density preservation
Cardiovascular protection
Cognitive health / neuroprotection
Sleep quality improvement
Sexual health / vaginal comfort
Overall longevity / biological age reduction
Your Personalized Summary

HRT Decision Framework Results

Based on your answers, here is an evidence-based summary of the considerations, formulation guidance, and discussion points for your healthcare provider.

Important: This tool provides educational information only. It is not a medical recommendation or diagnosis. HRT decisions should be made in partnership with a qualified healthcare provider who can evaluate your complete medical history, perform physical examinations, and order appropriate laboratory testing. The information presented here is based on current evidence-based guidelines from the North American Menopause Society (NAMS), the Endocrine Society, and peer-reviewed literature.

Method, limits and how to read your result

How it works

Answer questions about where you are in the menopause transition, your symptoms, and your heart, cancer, clotting and uterine history, and the framework summarises how current evidence applies to your situation. It follows the 2022 North American Menopause Society position statement, which judges the benefit-risk ratio favorable for women under 60 or within 10 years of menopause who have bothersome hot flashes or need to prevent bone loss and have no contraindications (reference 1).

Limits

It is a decision aid for a conversation with your clinician, not a prescription. It cannot weigh every personal factor, and risks depend on the type, dose and route of therapy: every type except vaginal estrogen was linked to some excess breast cancer risk (reference 3), and starting estradiol early did not change memory or thinking compared with starting later (reference 4).

How to read your result

The result groups your answers into factors that favor, caution against or rule out hormone therapy. Hormone therapy is the most effective treatment for hot flashes (reference 2), so if symptoms affect your life and no red flags appear, it is worth discussing options and routes, such as patches, with your clinician.

The evidence behind this tool

For women under 60 or within 10 years of menopause without contraindications, the North American Menopause Society judges the benefit-risk balance favorable for treating hot flashes and preventing bone loss; starting later carries greater absolute risks of heart disease, stroke and blood clots.1 In a Cochrane review of randomized trials, hormone therapy reduced hot flash frequency by about 75%.2 A worldwide analysis found breast cancer risk raised even in the first 1–4 years of use (relative risk 1.60 for estrogen plus progestogen and 1.17 for estrogen alone), with larger increases after longer use.3 Hormone therapy is not a proven way to protect the brain: two trials that started it soon after menopause found no effect on cognition.4,5 Timing also matters when menopause is caused by surgery or other medical treatment: in a 2026 meta-analysis of 36 studies covering about 2.6 million women, such menopause before age 45 was associated with higher cardiovascular mortality (hazard ratio 1.20) and all-cause mortality (1.15), with no excess when it happened at 45 or later. These are associations, not proof that hormone therapy removes the risk.6

The US label has also changed: in November 2025 the FDA asked manufacturers to remove cardiovascular disease, breast cancer and probable dementia from the boxed warning, while keeping that information elsewhere in the labeling and keeping the endometrial cancer boxed warning for systemic estrogen-alone products; the first updated labels were approved in February 2026 (FDA, November 2025; FDA, February 2026). The trial evidence above is unchanged.

References

  1. 1“The 2022 Hormone Therapy Position Statement of The North American Menopause Society” Advisory Panel. "The 2022 hormone therapy position statement of The North American Menopause Society." Menopause. 2022;29(7):767-794. PubMed · DOI
  2. 2Maclennan AH, et al. "Oral oestrogen and combined oestrogen/progestogen therapy versus placebo for hot flushes." Cochrane Database Syst Rev. 2004;2004(4):CD002978. PubMed · DOI
  3. 3Collaborative Group on Hormonal Factors in Breast Cancer. "Type and timing of menopausal hormone therapy and breast cancer risk: individual participant meta-analysis of the worldwide epidemiological evidence." Lancet. 2019;394(10204):1159-1168. PubMed · DOI
  4. 4Henderson VW, et al. "Cognitive effects of estradiol after menopause: A randomized trial of the timing hypothesis." Neurology. 2016;87(7):699-708. PubMed · DOI
  5. 5Gleason CE, et al. "Effects of Hormone Therapy on Cognition and Mood in Recently Postmenopausal Women: Findings from the Randomized, Controlled KEEPS-Cognitive and Affective Study." PLoS Med. 2015;12(6):e1001833; discussion e1001833. PubMed · DOI
  6. 6Armeni E, et al. "Age at Iatrogenic Menopause and Cardiovascular Morbidity and Mortality: A Systematic Review and Meta-Analysis." JAMA Netw Open. 2026;9(10):e2637545. PubMed · DOI
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