Do You Really Need HRT in Menopause?
Key Takeaway
Hormone replacement therapy can be highly beneficial in menopause, but not every woman needs it immediately or in the same way.
Whether HRT is appropriate depends on symptom severity, bone health, cardiometabolic risk, adrenal function, body composition, and how well your body is already adapting hormonally.¹²
So, do I need HRT in Menopause?
There is no universal answer.
Some women benefit significantly from hormone replacement therapy, particularly for hot flushes, night sweats, sleep disruption, bone loss, or severe quality-of-life symptoms.
Others experience mild or manageable symptoms and may not require HRT straight away.
The decision depends on how your body is responding to the menopausal transition, what symptoms are present, what risks are emerging, and what support systems are already in place.
HRT is a tool, not a requirement.
The right decision is the one made with full physiological context.
Why Didn’t Anyone Explain this Before?
Menopause is often framed as a hormone deficiency state.
The message many women receive is that oestrogen disappears and must be replaced or decline is inevitable.
Hormone therapy can be life-changing for many women. It reduces vasomotor symptoms, protects bone, and improves quality of life when appropriately prescribed.³
What is often missing from the conversation is nuance.
The female body does not experience menopause as a hormonal cliff. It undergoes an adaptive transition supported by systems that are rarely explained, tested, or discussed.
What “Need” Actually Means in Menopause Care
In clinical practice, “needing” HRT does not mean hormones are absent.
It means symptoms, bone loss, or cardiometabolic risk exceed what the body can reasonably buffer on its own.
HRT is indicated when the benefits outweigh the risks for that individual woman, based on:
Symptom burden
Bone density and fracture risk
Cardiovascular profile
Timing since menopause
Personal and family history
This is why blanket advice fails women.
Oestrogen Does Not Simply Stop
As ovarian oestrogen production declines through perimenopause and menopause, the body relies on non-ovarian pathways to maintain oestrogenic activity.
The Adrenal Pathway
The adrenal glands produce dehydroepiandrosterone (DHEA), an androgen precursor that can be converted into oestrogen within tissues such as skin, fat, bone, and brain.⁴
Peripheral aromatisation
Adipose tissue contains the enzyme aromatase, which converts androgens into estrone, a weaker but biologically active form of oestrogen.⁵
These systems do not replace ovarian oestrogen. They buffer the transition.
Most women are never told they exist.
What Gets Missed When Menopause is Framed as Deficiency
When menopause is reduced to missing oestrogen, other contributors to symptoms are overlooked.
Women may be:
Dysregulated rather than depleted
Chronically stressed
Undereating or overtraining
Losing muscle and metabolic flexibility
Producing hormones but not converting or utilising them well
Hormone therapy alone cannot correct all of these factors.
A Clinical Example, not a Prescription
In my own case, I am in late perimenopause. My follicle-stimulating hormone and luteinising hormone levels are high, reflecting reduced ovarian responsiveness.
This is expected physiology.
What matters is not the absence of ovarian oestrogen, but the presence of buffering capacity elsewhere. My adrenal markers, including DHEAS and morning cortisol, remain robust.
This is not a recommendation. It is an illustration of why testing and context matter more than assumptions.
Why Adrenal Health Influences HRT Decisions
After menopause, the adrenal glands become a primary source of androgen precursors that support tissue-level oestrogen production.⁴
When adrenal function is compromised by:
Chronic psychological stress
Aggressive dieting or under-fueling
Excessive endurance training
Poor sleep
That buffering capacity weakens, and symptoms often intensify.
In these cases, HRT may be helpful, but it is not the only lever that matters.
Body Composition Also Shapes Symptoms
Fat tissue is often discussed only as something to reduce.
In menopause, that framing is incomplete.
Adipose tissue contributes to oestrogen production through aromatisation and supports metabolic adaptation.⁵
At the same time, excess visceral fat increases cardiometabolic risk.⁶
Both extremes matter. Balance matters.
What Shapes Menopausal Symptoms Beyond Oestrogen
| Factor |
Why it Matters
|
|---|---|
|
Adrenal function
|
Provides androgen precursors for tissue oestrogen
|
|
Body composition
|
Influences aromatisation and metabolic reserve
|
|
Muscle mass
|
Protects insulin sensitivity and bone
|
|
Stress load
|
Alters cortisol and hormone conversion
|
|
Nutrition
|
Supports hormone metabolism and resilience
|
When You May or May Not Need HRT in Menopause
| Situation |
What it Often Indicates
|
|---|---|
|
Severe hot flushes or night sweats
|
HRT often beneficial
|
|
Rapid bone loss or osteoporosis
|
HRT or bone-specific therapy
|
|
Persistent symptoms despite lifestyle support
|
Combined strategy
|
|
Mild symptoms with good metabolic health
|
Monitoring and targeted support
|
|
Unclear symptom drivers
|
Further investigation before decisions
|
Important Safety Context
Choosing not to use HRT does not mean avoiding medical care.
Choosing HRT does not mean ignoring lifestyle, metabolic, or bone health factors.
Responsible menopause care integrates hormones when indicated and supports the systems that shape long-term resilience.
From Hormone Panic to Body Literacy
Menopause is not always depletion.
Sometimes it is dysregulation.
Sometimes it is overload.
Sometimes it is a system asking for different inputs.
Your adrenal health, metabolic flexibility, muscle mass, stress exposure, and nutrient status all influence how this transition unfolds.
You deserve a conversation that includes all of that.
Where to Start
If you are wondering whether you need HRT in menopause, the first step is not fear or comparison.
It is assessment.
Understanding what your body is already producing, converting, and coping with allows for informed, individualised decisions rather than default advice.
Hormones are only one piece of the midlife puzzle. To see how HRT fits into a broader clinical strategy for your brain, metabolism, and longevity, read our full Midlife Health Redesign framework.
References
El Khoudary SR et al. Menopause transition and cardiometabolic risk. Circulation.
https://pubmed.ncbi.nlm.nih.gov/33455409/Davis SR et al. Menopause management and individualised care. The Lancet.
https://pubmed.ncbi.nlm.nih.gov/32763215/Hodis HN, Mack WJ. Hormone therapy and clinical outcomes. New England Journal of Medicine.
https://pubmed.ncbi.nlm.nih.gov/36607893/Labrie F et al. Intracrinology and androgen metabolism in women. Endocrine Reviews.
https://pubmed.ncbi.nlm.nih.gov/18230656/Simpson ER. Aromatase and oestrogen biosynthesis in adipose tissue. Endocrine Reviews.
https://pubmed.ncbi.nlm.nih.gov/15294873/Karpe F, Pinnick KE. Adipose tissue and cardiometabolic risk. Nature Reviews Endocrinology.
https://pubmed.ncbi.nlm.nih.gov/25028023/
Clinician Bio
Susan Hunter is a Melbourne-based, double degree qualified women’s healthcare strategist with nearly 20 years of clinical experience in midlife metabolic and hormonal health. Her work focuses on precision diagnostics, root-cause treatment, and long-term healthspan optimisation. View credentials and clinical background on LinkedIn.
