Hormone Replacement Therapy for an “At Risk” Population: What You Should Know Before Starting or Dismissing Use

by Corinne Berg, MSN, RN, PHN

Perimenopause and menopause can be challenging—physically, emotionally and mentally. While some women transition through menopause smoothly, others experience significant symptoms that disrupt daily life. The good news? With the right provider and individualized care, menopause can be far more manageable.

As someone with a BRCA2 mutation, I’ve taken proactive steps to reduce my cancer risk. In 2020, at age 35, I had my fallopian tubes removed (risk-reducing salpingectomy), a procedure shown to reduce ovarian cancer risk, despite keeping my ovaries. I hoped this would buy me at least a decade before what I called the "big" surgery: the removal of my ovaries (oophorectomy) or a full hysterectomy.

In early 2021, I didn’t feel like myself. I was unusually irritable, especially with my family. I also began experiencing adult acne despite my skincare routine. A provider started me on a low-dose birth control pill to balance my hormones and help my skin, and for a time, it helped.

In 2023, at age 39, I had my first hot flash. I was no longer sleeping well, plagued by vivid dreams, early waking, frequent migraines and restlessness. I developed headaches, dry skin, joint pain (even in my fingers after crocheting) and unexplained aches in my legs and shoulders. Although I remained active, my waistline slowly grew. One day, I glanced at my watch and noticed a resting heart rate of 117 beats per minute—double my usual. After asking for a referral to a cardiologist and undergoing imaging and a stress test, my heart was deemed healthy, yet my irregular heartbeat remained unexplained.

I kept seeing doctors, but none of the symptoms seemed to connect. Emotionally, I started to feel down again. I suspect my chart probably listed "anxiety" or "depression" near the top. I was repeatedly offered medications, but nothing addressed the root of the problem.

Since I still had my ovaries and uterus, I was doing routine ultrasound surveillance twice a year. Then, polyps were discovered—first in my cervix, then in my uterus. The procedures were painful, and the waiting period for biopsy results was stressful for my family and me.

For my 40th birthday in 2024, a friend gave me the book Hormone Repair Manual: Every Woman's Guide to Healthy Hormones After 40. Within the first chapter, it hit me: I wasn’t alone—I was in perimenopause, even though it started before age 40. As a nurse, I felt I should have recognized the signs. How could I have known that they would start so soon?

I read that perimenopause and menopause are often overlooked or misunderstood, and that symptoms can last around 10 years. I soon learned how much misinformation exists—especially around treatment.

What BRCA carriers should know about hormones

Several studies suggest that women with BRCA mutations reach menopause earlier than non-carriers. This led me to revisit one of the most influential studies on hormone replacement therapy (HRT): The Women's Health Initiative (WHI).

The Women’s Health Initiative Hormone Study

The Women's Health Initiative (WHI) Hormone Replacement Therapy (HRT) study, funded by the National Institutes of Health and launched in the 1990s, was one of the largest and most influential studies on hormone therapy in postmenopausal women. In 2002, the combined estrogen-progestin portion of the study was stopped early due to increased risks of breast cancer, stroke and blood clots. The specific hormone types were conjugated equine estrogen and medroxyprogesterone acetate–a combination not commonly used today.

The media response was swift and alarming. Millions of women stopped hormone therapy abruptly. Fear of HRT became widespread, and many healthcare providers grew reluctant to recommend it. To this day, I often hear women say, “I can’t take hormones—they cause cancer!”

The full story is more nuanced. While the study provided important data, it didn’t account for other hormone types, different doses, delivery methods (like patches or gels) or the timing of hormone initiation.

Updated understanding: The timing hypothesis

Subsequent analyses have revealed something critical: Timing matters.

The “timing hypothesis” suggests that starting hormone therapy closer to the onset of menopause—within 10 years or before age 60—can be safer and more beneficial. Women in this group had fewer risks and even some protective benefits, including:

• Reduced risk of heart disease
  
  
• Preservation of bone density
  
  
• Lower risk of type 2 diabetes
  
  
• Decreased colon cancer risk (in some studies)
  
  
• Significant relief from hot flashes, sleep disturbances, mood changes, brain fog and vaginal dryness

While HRT is not recommended for the prevention of chronic disease, it remains the most effective treatment for moderate to severe menopausal symptoms. For many women, starting HRT during perimenopause can significantly improve symptom management and quality of life.

Finding the right provider: The Menopause Society certified practitioners

Unfortunately, not all healthcare providers are trained in menopause management. That’s why it’s important to seek out specialists who are certified by The Menopause Society. These Menopause Society Certified Practitioners (MSCPs) have demonstrated expertise in women’s midlife health and can guide you through safe, evidence-based treatment options—especially if you’re considered “at risk” due to genetic mutations, have a family history of cancer, or you experience early or surgical menopause.

Final thoughts

I’m now a couple of months out from my “big” surgery (full hysterectomy) and currently using an estradiol patch. My symptoms are much more controlled—and I haven’t had a single hot flash since. It’s been a relief to feel more balanced and like myself again.

Menopause is a natural stage of life, not a disease. But that doesn’t mean you have to suffer through it. If you’re approaching menopause or have a genetic predisposition like BRCA, don’t let outdated studies or misinformation stop you from exploring your options. HRT isn’t right for everyone, but it’s worth a conversation with a certified provider to understand what might work best for you.

There are also non-hormonal approaches that can help manage symptoms, such as cognitive behavioral therapy, lifestyle changes, herbal supplements and targeted nutrition. Some women find relief through acupuncture, mindfulness practices or physical activity, despite being tired. While these options may not replace HRT for everyone, they can be a part of a holistic, individualized care plan.

You deserve individualized, compassionate care. Understanding your body and your choices is the first step to reclaiming your well-being.

Recommended Resources and References

Book: Briden L. Hormone Repair Manual: Every Woman's Guide to Healthy Hormones After 40. Pan Macmillan Australia; 2021.

Book: Haver MC. The New Menopause: Navigating Your Path Through Hormonal Change with Purpose, Power, and Facts. Rodale Books; 2024

Menopause Chicks: http://Menopausechicks.com/ offers a supportive community and resource hub for women navigating menopause

Mayo Clinic: Menopause hormone therapy: Is it right for you? https://www.mayoclinic.org/diseases-conditions/menopause/in-depth/hormone-therapy/ART-20046372

The North American Menopause Society: https://www.menopause.org

Menopause Society Provider Directory: https://portal.menopause.org/NAMS/NAMS/Directory
A useful resource for finding a menopause specialist.

Manson JE, Aragaki AK, Rossouw JE, et al. Menopausal hormone therapy and long-term all-cause and cause-specific mortality: the Women’s Health Initiative randomized trials. JAMA. 2017;318(22):2224-2233. doi:10.1001/jama.2017.18261

National Institute for Health and Care Excellence. Menopause: diagnosis and management (NG23). NICE; 2015. Updated 2023. Accessed June 17, 2025. https://www.nice.org.uk/guidance/ng23

The Endocrine Society. Treatment of symptoms of the menopause: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2015;100(11):3975-4011. doi:10.1210/jc.2015-2236

Women's Health Initiative. WHI.org. https://www.whi.org Accessed June 3, 2025.

Corinne Berg, MSN, RN, PHN (Cori) is a Master ’s-prepared Registered Nurse at Mayo Clinic and an appointed Instructor in Nursing at the Mayo Clinic College of Medicine and Science. Passionate about health education, she is dedicated to empowering patients and communities with knowledge drawn from personal experiences and education. Additionally, Cori has contributed as a science writer for FORCE.