Table of Contents
Hormone replacement therapy (HRT) is one of the most effective tools available to protect a woman’s bones through menopause and beyond, yet it remains one of the most misunderstood. For two decades, the long shadow of the 2002 Women’s Health Initiative left many women, and many physicians, wary of hormones. That picture has now changed substantially. In November 2025, the U.S. FDA removed the boxed warning from menopausal hormone therapy products, reflecting a broad scientific re-evaluation of the benefits and risks of HRT, especially when it is started at the right time.
To bring you the current expert view, I sat down with Dr. Adriana Orcesi Pedro at the World Congress on Osteoporosis in Prague. Dr. Pedro is a gynecologist with more than 35 years of clinical experience, an Associate Professor in the postgraduate program at the University of Campinas in Brazil, a certified Menopause Society practitioner, and a current advisory board member of the International Osteoporosis Foundation (IOF). What follows is a guide to hormones and bone health built around that conversation, followed by my own experience with HRT, and how my thinking has evolved over the years.
This is educational information, not medical advice. Decisions about HRT should always be made with a qualified physician who knows your full health history.
What Is Hormone Replacement Therapy (HRT)?
When physicians speak about hormone therapy, or, more precisely, menopausal hormone therapy (MHT), they are referring to a whole family of options: different hormone types, doses, delivery routes, and regimens. Each combination carries its own potential benefits and side effects, which is why Dr. Pedro stresses individualization. Hormone therapy is never one single thing. (You’ll also see the terms “hormone therapy,” “hormone replacement therapy,” and “menopausal hormone therapy” used interchangeably; they refer to the same broad category.)
The hormones at the center of it are the ones the ovary stops producing at menopause. The ovary makes estradiol, progesterone, and androgens. When ovulation ends, estradiol and progesterone fall to very low levels (androgens continue to be produced by the adrenal gland). HRT replaces what has been lost, and each hormone plays a distinct role. A woman who has had a hysterectomy needs only estradiol, because the main job of the progestogen in HRT is to protect the lining of the uterus (the endometrium).
Can HRT Reverse or Prevent Osteoporosis?
Dr. Pedro’s answer to this question is precise and worth understanding exactly.
When you start hormone therapy, estradiol uncouples bone formation from bone resorption during the bone remodeling process. Estradiol slows the breakdown of bone, producing a net positive in the balance between the two. In practical terms, a woman on HRT stops losing bone and preserves the bone she has. She will not dramatically rebuild bone, so “reverse” is the wrong word, but the outcome that matters most is that HRT genuinely prevents fractures.
Dr. Pedro offers an analogy. High blood pressure is asymptomatic, but we treat it to prevent the heart attack. Osteoporosis is the same: a woman can live with low bone density, but what we want to prevent is the fragility fracture. The stakes are real: after a hip fracture, roughly one in five patients dies within the first year, and many survivors lose the independence and mobility of everyday life.
This is also why “start early” is the theme that runs through everything Dr. Pedro says. Bone lost at menopause is not easily recovered. The best strategy is to avoid losing it in the first place, or to step in as soon as loss begins. Even a woman who starts later, who already has osteoporosis, can still the reduce the risk of an osteoporotic fracture.
When Should a Woman Start HRT for Bone Health?
For most women, the conversation should begin during the menopausal transition (perimenopause), not after menopause is complete. You do not need to wait a full year without a period to start. As soon as the hormonal fluctuations and symptoms of this stage begin, HRT can be considered, depending on your symptoms and your risk of bone loss.
Two factors should move this conversation up your priority list.
- The first is family history, genetics accounts for roughly 60% of your risk of bone loss. If your mother, grandmother, or sister has osteoporosis, that belongs in the discussion with your doctor.
- The second is timing of screening. Too often, by the time bone density is finally measured, it is already very low because the woman waited years. Dr. Pedro’s advice: as soon as menstrual irregularity begins, see your doctor, review your clinical risk factors, and request a bone density (DEXA) scan. Waiting until 60 or 65, when many public screening programs begin, is, in her words, extremely late.
Is It Too Late to Start HRT After 60 or 70?
Many women only learn about HRT years into menopause and assume they have missed their chance. The research of the past two decades points to a “window of opportunity”: the period in which a woman gains the fullest long-term benefit from hormone therapy: before age 60, and within 10 years of menopause. Starting inside this window means the downstream effects of low estradiol, on the heart, on metabolism, on bone, have not yet taken hold. HRT essentially maintains a woman at the level of health she had when she started, rather than trying to undo damage already done.
But the window is not a hard cutoff. A woman over 60 is not automatically disqualified. If she is healthy, her physician can assess her cardiovascular risk, weigh the benefits and risks of starting at her age, and support her in an informed decision.
Can You Stay on HRT for the Long Term?
There is also encouraging evidence for staying on HRT longer. Dr. Pedro highlighted a large study published in the journal Menopause (1) (Baik and colleagues, 2024) that drew on the records of more than 10 million Medicare women aged 65 and older over a 14-year period. Compared with never using hormones or stopping before 65, women who continued estrogen-alone therapy past 65 had significant reductions in all-cause mortality (about 19%), as well as in breast, lung, and colorectal cancer and several cardiovascular outcomes. (Estrogen-only therapy is the regimen for women without a uterus; for women taking estrogen plus a progestogen, the same study found a modest increase in breast-cancer risk, which the authors note can be reduced with low-dose transdermal or vaginal delivery.)
The study’s authors are careful about its limitations, as it is observational rather than a randomized trial, but it suggests that the old assumption that hormones must be stopped at 65 is no longer well supported. As always, the decision must be individualized and revisited at regular follow-up appointments.
What's the Best HRT for Osteoporosis? Where It Fits Among Bone Drugs
A major theme at the 2026 IOF World Congress on Osteoporosis in Prague was managing bone health across the entire lifespan, rather than treating osteoporosis only once it appears. Dr. Pedro places hormone therapy clearly within that picture:
For a woman in her postmenopausal years who is under 60, within 10 years of menopause, and has no contraindications, hormone therapy is the first option.
The reasoning comes down to time. The other osteoporosis drugs are excellent, some are anabolic and genuinely build bone, but they are time-limited treatments, used for one, two, or at most around five years. If a woman starts a potent osteoporosis drug at 50 and finishes at 55, what protects her bones until she is 85? Hormone therapy has no fixed time limit; she can use it into her 60s and beyond, and reserve the more potent drugs for later in life when she may truly need them.
The exception is a woman with a fracture or at high risk of one. There, HRT can be combined with another drug, for example, a short course of an osteo-anabolic agent that actively builds bone (such as romosozumab, sold as EVENITY) to build bone up, with hormone therapy maintaining that gain over the long term.
The combination also works in reverse: a woman already on HRT who enters a period of accelerated bone loss (from illness or cancer treatment, say) can add a bone drug for that period while continuing her hormones. What Dr. Pedro cautions against is reaching for a very potent osteoporosis drug as the starting point for a younger woman who has no contraindications to hormones.
Estrogen: What It Does, and Choosing a Dose
Estrogen is the central component of hormone therapy. It relieves the vasomotor symptoms of menopause (hot flashes and night sweats) and the psychological and emotional symptoms; it maintains genitourinary health, easing urinary urgency and incontinence and preventing vaginal dryness and painful intercourse; it helps maintain the collagen in your skin; and it prevents bone loss and osteoporosis. As Dr. Pedro summarizes: estradiol does a great deal of good across the whole body.
On estrogen dosage Dr. Pedro recommends the following: the principle is to match the dose to the woman:
- A very young woman, for example, someone who reaches menopause before 45, needs a higher dose, to keep her estrogen at a level appropriate for her age.
- A woman in her postmenopausal years is usually given the lowest effective dose, typically the low or standard dose.
- An older woman is usually started on the lowest dose.
For symptom relief, the standard or low dose is enough. For bone, there is a dose–
response relationship: even the lowest dose protects bone, but higher doses offer greater protection.
Hormone therapy
What estrogen does — and how the dose is set
“Estradiol does a great deal of good across the whole body.” Dr. Adriana Orcesi Pedro, MD
Where estrogen helps
Hot flashes & night sweats
Calms the vasomotor symptoms of menopause.
Mood & wellbeing
Eases the psychological and emotional symptoms.
Genitourinary health
Reduces urinary urgency and incontinence; prevents vaginal dryness and painful intercourse.
Skin
Helps maintain the skin’s collagen.
Bone
Prevents bone loss and osteoporosis.
Matching the dose to the woman
Early menopause (before 45)
Higher dose
Keeps estrogen near the level that’s normal for her age.
Postmenopausal years
Low–standard dose
The lowest effective dose — enough to relieve symptoms.
Older woman
Lowest dose
Started low, with overall cardiovascular risk in mind.
For symptoms, a low or standard dose is usually enough. For bone, the effect is dose-related: even the lowest dose protects bone, and higher doses protect more — one factor a physician weighs alongside age and overall health.
Dosing is always individualized with your physician. Educational information, not medical advice.
Do You Need a Blood Test Before HRT?
One practical question this raises: do you need blood tests to find the “right level”? Dr. Pedro’s answer is no. The guide is clinical: if your hot flashes and night sweats have settled, your level is where it needs to be. And because regulated, approved estrogen products (those cleared by the FDA, or ANVISA in Brazil) have fully characterized pharmacology, the physician already knows what blood level a given dose produces. Routine testing is unnecessary. This is quite different from pharmacy-compounded products, where dosing is far less predictable.
Oral vs. Transdermal Estrogen (and Who Should Avoid the Pill)
Worldwide, the most commonly used form of HRT is oral, it is easy and inexpensive. But the medical recommendation today favors the transdermal route, and the reason is the liver.
Swallowed estrogen is absorbed through the intestine and passes directly through the liver, the “first pass.” There it raises several factors that are unfavorable for some women: clotting factors that create a more thrombotic profile; a protein that can unbalance blood pressure in women who already have hypertension; and sex hormone binding globulin (SHBG), which binds testosterone and lowers the free, bioavailable testosterone that supports a woman’s sexuality.
Transdermal estrogen, available as a gel, a patch, or a spray, bypasses the liver and behaves more like the body’s own hormone, delivering the full benefits without those first-pass effects.
This is why current recommendations steer toward transdermal delivery, and away from oral estrogen, particularly for women with obesity (who already carry a higher clot risk), women with high blood pressure, women with high triglycerides (which oral estrogen raises), women with sexual-health concerns, and older women who carry more cardiovascular risk overall.
There is also news on the horizon for women who prefer a pill. A newer estrogenic steroid called estetrol, already available in some countries as a contraceptive, does not appear to cause the liver-related effects of conventional oral estrogen, and may become available for menopause more widely. As a new drug, it is likely to launch at a higher price.
Progesterone: Why It's Needed and How It's Delivered
For a woman with a uterus, taking estrogen means also taking a progestogen to protect the endometrium. There are several ways to do this:
- Oral micronized progesterone, taken by mouth, it does not stress the liver and is the most commonly prescribed route. It also has a mild sedative effect that many women find helps their sleep when taken at night.
- Vaginal progesterone, the same natural progesterone delivered vaginally; effective, though many women dislike ongoing vaginal insertion, so the oral route is usually preferred.
- Transdermal synthetic progesterone known as norethisterone (patch), a patch combining estradiol with norethisterone acetate, a synthetic progestogen that also acts on the estrogen receptor, giving a synergistic effect on symptom relief and good bone outcomes even at the lowest estrogen dose. (There is currently no natural progesterone available transdermally, only norethisterone.)
The Mirena IUD: An Ally in Perimenopause
One option many women know only as a contraceptive is genuinely useful in the menopausal transition: the Mirena IUD. It is especially helpful for perimenopausal women who develop heavy or irregular uterine bleeding. A gynecologist can insert the Mirena for contraception or to manage that bleeding, and the same device can then serve a second role as a woman moves through menopause.
Because the Mirena releases levonorgestrel, a progestogen, directly into the uterus, it provides the endometrial protection that estrogen therapy requires: her physician simply prescribes the estrogen separately, and the Mirena covers the progestogen side. It is licensed for this endometrial-protection role for four years, and menopause guidelines (such as the Faculty of Sexual and Reproductive Healthcare) support its use for up to five years before it needs replacing.
The Mirena is also an excellent choice for women who get side effects from systemic progestogens, low mood, water retention, or PMS-like symptoms, because it acts mainly inside the uterus rather than throughout the body.
Hormones and Bone Quality (Not Just Density)
Bone health is not only about quantity. The microarchitecture of bone, its quality and structure, matters just as much as its density. Hormone therapy helps preserve a healthy bone structure, maintaining quality as it was earlier in life.
This is clinically important. Some women with scores in the osteopenic range still fracture because of poor bone quality, while others with osteoporotic-range scores have good-quality bone and do not. This is borne out in the research: a study of menopausal hormone therapy by Dr. Georgios Papadakis at Lausanne University Hospital (2) found that HRT improved not only bone mineral density but also bone microarchitecture, and that the benefit to microarchitecture and density persisted even two years after stopping.
Bone quality can be difficult to measure, which is why Dr. Pedro reminds her patients that the goal of treatment is not to watch a density number climb. The goal is to maintain bone strength and avoid the fracture.
Bone Health Across a Woman's Lifespan
People tend to think about osteoporosis only in older age, or after a fracture, or at menopause. Dr. Pedro argues for a different mindset: lifelong bone care.
It starts in childhood with good nutrition, calcium and vitamins. It becomes critical in adolescence: peak bone mass is reached by about age 18, and during puberty a girl gains 80–90% of her total bone mass, the bone she will carry for life. A strong peak bone mass at puberty is one of the best protections against future fractures. Yet many teenagers avoid dairy, and get little exercise or sun; a teenager actually needs about 30% more calcium than an adult woman.
Important health choices continue through adulthood. Some contraceptive methods support bone mass better than others, pregnancy and lactation raise calcium and vitamin D needs, and then through menopause and the later years. (For young athletes, it’s worth knowing that contraceptive choices which suppress menstruation, such as Depo-Provera, can come at a cost to bone during the very window when bone should be built.)
The takeaway: hormones are one of four levers on bone health, alongside genetics, nutrition, and exercise. You can’t change your genetics, but the other three are within your influence, and they work together.
Bone health
A lifetime of bone: built early, protected for life
Most bone is banked before adulthood. Dr. Pedro’s case for lifelong bone care starts with how bone mass changes across a woman’s life.
Peak bone mass is reached by about age 18–30, and most of it — 80–90% — is laid down during puberty. (A teenager needs roughly 30% more calcium than an adult woman.) The higher that peak, the longer bone stays above the fracture-risk threshold as it declines after menopause — which is why a strong peak is one of the best protections against future fractures.
Four levers on bone health
You can’t change your genetics, but nutrition, exercise, and hormones are within your influence — and they work together. Educational information, not medical advice.
Finding the Right Physician
Finding the right physician to help you with HRT can be a challenge. Dr. Pedro’s first recommendation is to see a gynecologist. Before starting HRT, a physician needs to check the breasts and mammogram, review the Pap smear, and assess the endometrium and any risk factors for endometrial cancer, all of which gynecologists are trained to evaluate, and hormone prescribing is second nature to the specialty.
Her second recommendation is to look for a practitioner certified by The Menopause Society (formerly the North American Menopause Society), which administers a rigorous certification exam and lets you search certified practitioners by location. These practitioners are found worldwide, and the major guidelines, the American and the International Menopause Society’s, are closely aligned with the evidence described throughout this guide.
This matters because medical education has lagged. Dr. Pedro notes that even in gynecology and obstetrics residency, time spent on menopause and hormone therapy is very short, a gap that patient advocacy is now helping to close. In the UK, the “Menopause Warriors” movement and the British Menopause Society (whose slogan is “Start the Conversation”) successfully pushed for a full menopause course in the medical school curriculum. The lesson Dr. Pedro returns to is that informed, proactive women change medicine: knowledge is power, the power to decide what you want and to ask more of your physician.
Two Common Worries: Weight and Muscle
Will HRT make me gain weight? No. Hormone therapy does not cause weight gain, aging and menopause do. Without the protection of estrogen, women tend to gain fat in the abdomen, the worst type for cardiovascular risk. If anything, the metabolic and energy benefits of HRT can make it somewhat easier to lose weight for a woman who maintains her exercise and diet, and the fat she carries tends to follow a hip-and-thigh distribution rather than the abdomen.
Will it affect my muscle and strength? HRT helps a woman maintain muscle, but to gain muscle you have to exercise. This matters most in the context of sarcopenia, the age-related loss of muscle. Weight-bearing exercise and strength training make all the difference for a healthier older age. Hormones support the foundation; the work builds on it.
Learn Osteoporosis Exercise in 7 Days
Sign up below for my free seven day email course on osteoporosis and exercise. You will learn the fundamentals of safe and effective exercise if you have osteoporosis or osteopenia.
Free Email Course
My Own Experience: How My Approach Has Evolved
I’ve been on HRT for many years, and the benefits have been real for me. I’ll share them honestly below. I also want to be candid about how my thinking has changed, because the landscape has moved a great deal since I first wrote about this topic.
When I started, the path I was offered leaned heavily on compounded bio-identical hormones from a compounding pharmacy, with frequent blood testing to chase an “optimal” hormone level.
Finding a physician comfortable with any of it meant a long search and, eventually, a four-hour train trip to a specialist. Today the picture is different and, frankly, simpler. As Dr. Pedro explains above, FDA-approved bio-dentical products, micronized progesterone (e.g., Prometrium) and the estradiol patch among them, now make pharmacy compounding largely unnecessary for most women, and routine blood-level testing isn’t needed because approved products have predictable, well-characterized dosing.
If I Was Starting HRT Today
If I were starting today, I would begin with a certified menopause practitioner and approved MHT products rather than the compounding route I first took. What hasn’t changed is why I value HRT. Four benefits stand out for me:
- Strength. A major reason I started was to protect my bones and muscles. My genetics, petite build, and Caucasian background put me at high risk, I was losing bone at around 5% a year, at the very top of the range. Since starting, I feel stronger, my stamina in training has improved, and my bone density scores stopped declining.
- Bone quality. Consistent with the Papadakis research above, HRT supports not just density but the underlying structure of bone, the quality that ultimately protects against fracture.
- Sleep. After menopause and hot flashes disrupted my sleep, progesterone helped restore the deep, uninterrupted sleep I’d had before. (If sleep is your struggle, I’d also point you to Richard’s review of The Sleep Solution and, if needed, a sleep specialist.)
- Intimacy. After more than 30 years of marriage, this mattered to us, and HRT made a genuine difference to how engaged and present I feel.
My experience is mine, not a prescription. But I share it because the lived reality of HRT, alongside the science, is part of an honest picture. The decision is yours to make with a qualified team who knows your history.
Conclusion
For the right woman, under 60 or within 10 years of menopause, without contraindications, hormone therapy is a first-line option for protecting bone, and it can be continued well beyond the old assumptions about stopping at 65. It won’t dramatically rebuild bone, but it preserves what you have and, most importantly, prevents fractures, while supporting sleep, strength, intimacy, and overall quality of life.
The current science, reflected in the FDA’s 2025 removal of the boxed warning (3), is far more reassuring than the message many women absorbed two decades ago.
If you take one thing from this guide, let it be Dr. Pedro’s recurring point: start the conversation early, and have it with someone who truly knows hormones. Bring your family history, your risk factors, and your questions. And remember that hormones are one of four levers, alongside genetics, nutrition, and exercise, so whatever you and your physician decide, your bones will thank you for staying active and well-nourished too.
Frequently Asked Questions: HRT and Bone Health
Can HRT reverse osteoporosis?
Not exactly. Hormone therapy slows the breakdown of bone and preserves the bone you already have, producing a net positive in bone balance — but it does not dramatically rebuild lost bone, so “reverse” is the wrong word. What matters most is that HRT prevents fractures. Even a woman who already has osteoporosis can benefit, because preventing the fragility fracture is the real goal of treatment.
Can HRT prevent osteoporosis?
Yes. Because estrogen loss at menopause is the main driver of rapid bone loss, replacing estradiol slows that loss and helps maintain bone strength. The benefit is greatest when HRT is started early — during the menopausal transition or within 10 years of menopause — since bone lost at menopause is difficult to recover.
Is it too late to start HRT after 60 or 70?
The greatest long-term benefit comes from starting within the “window of opportunity” — before age 60 and within 10 years of menopause. But this is not a hard cutoff. A healthy woman over 60 is not automatically disqualified; her physician can assess her cardiovascular risk and weigh the benefits and risks of starting at her age. A large 2024 study of more than 10 million older women also found that those who continued estrogen-alone therapy past 65 had lower mortality and better cardiovascular outcomes than those who stopped, though such observational findings should be individualized with your doctor.
What is the best HRT for osteoporosis?
There is no single “best” — the right choice is individualized. That said, current medical recommendations favor transdermal estrogen (gel, patch, or spray) over oral, because it bypasses the liver and avoids the first-pass effects on clotting, blood pressure, and triglycerides. For a woman with a uterus, an estrogen is paired with a progestogen (such as oral micronized progesterone) to protect the endometrium. The best regimen depends on your age, health history, and symptoms, chosen with a qualified physician.
Is HRT a first-line treatment for osteoporosis?
For a woman who is under 60, within 10 years of menopause, and has no contraindications, hormone therapy is considered a first option for protecting bone. Unlike many osteoporosis drugs — which are typically used for only one to five years — HRT has no fixed time limit, so it can protect bone over the long term while more potent drugs are reserved for later in life if needed.
What dose of estrogen is needed for bone protection?
Bone responds to estrogen in a dose-dependent way: even the lowest dose offers protection, but higher doses protect more. For relief of hot flashes and night sweats, the standard or low dose is usually enough. A very young woman who reaches menopause early needs a higher dose appropriate for her age, while older women are usually started on the lowest dose.
Do I need blood tests to monitor my hormone levels on HRT?
Generally, no. With regulated, approved hormone products the dosing is well characterized, so the physician already knows what level a given dose produces. The practical guide is clinical: if your hot flashes and night sweats have settled, your level is where it needs to be. Routine blood-level testing is usually unnecessary for approved products.
Oral or transdermal estrogen — which is safer?
Transdermal estrogen is generally preferred on safety grounds because it bypasses the liver. Oral estrogen raises clotting factors, can affect blood pressure in women with hypertension, and raises triglycerides. Transdermal delivery is particularly recommended for women with obesity, high blood pressure, high triglycerides, or higher cardiovascular risk, and for older women.
How long can a woman stay on HRT?
There is no fixed stopping date. HRT can be continued for as long as the benefits outweigh the risks for the individual woman, reviewed at regular follow-up appointments. The older assumption that hormones must be stopped at age 65 is no longer supported by the evidence, though every decision should be individualized with your physician.
Will HRT make me gain weight?
No. Hormone therapy does not cause weight gain — aging and menopause do. Without estrogen, women tend to gain abdominal fat. HRT can actually make it somewhat easier to manage weight alongside good diet and exercise, and tends to favor a hip-and-thigh fat distribution over the abdomen.
About Dr. Orcesi Pedro
Dr. Adriana Orcesi Pedro is a gynecologist with more than 35 years of clinical experience and a recognized authority on menopause, osteoporosis, and bone densitometry. She earned her medical degree, master’s, doctorate, and Habilitation (Livre-Docência) in Tocogynecology, and is a Professor of Postgraduate Studies in the Department of Tocogynecology at the University of Campinas (UNICAMP), where she practices in the Gynecology Division at CAISM.
Since 2017 she has served as President of the Specialized Commission on Osteoporosis of FEBRASGO (the Brazilian Federation of Gynecology and Obstetrics Associations) and is an advisory member of the International Osteoporosis Foundation (IOF). She has published more than 60 peer-reviewed articles, two books, and ten book chapters.
Margaret Martin
Further Readings
References
- Baik SH, Baye F, McDonald CJ. Use of menopausal hormone therapy beyond age 65 years and its effects on women’s health outcomes by types, routes, and doses. Menopause. 2024;31(5):363–371. doi:10.1097/GME.0000000000002347
- Papadakis G, Hans D, Gonzalez-Rodriguez E, et al. The benefit of menopausal hormone therapy on bone density and microarchitecture persists after its withdrawal. J Clin Endocrinol Metab. 2016;101(12):5004–5011. doi:10.1210/jc.2016-2695
- U.S. Food and Drug Administration. FDA requests labeling changes related to safety information to clarify the benefit/risk considerations for menopausal hormone therapies. November 10, 2025.
Comments