By Gila Pfeffer and Jessica Zucker
They’re everywhere these days. The glowing midlife women announcing that hormone replacement therapy (HRT) — or menopausal hormone therapy (MHT) — have resurrected their libidos, eradicated their night sweats, and done their taxes (ok, not that). Menopause, we’re told, is no longer a grim biological prank. It’s a renaissance. A glow-up. Something to relish, nay, brag about.
But for women with certain medical histories such as breast cancer, blood clots, or stroke risk, systemic hormone therapy is often considered unsafe or, at the very least, complicated. In an age when HRT is marketed as the end-all be-all, that exclusion can feel like being locked out of a club you didn’t even want to go to, but suddenly very much do.
As two breast cancer survivors, we’ve watched this HRT obsession with equal parts irritation and envy. Gila, who has a long family history of breast cancer, was diagnosed at 34. After a regimen of chemotherapy and having her ovaries removed, she was thrust into menopause years before any of her peers. The juxtaposition of being a young mom of four and a menopausal woman was confusing, isolating, and physically draining. Jessica was diagnosed with hormone receptor-positive breast cancer at 47, with two kids underfoot. Despite taking Tamoxifen, she still has monthly periods and — contrary to common assumptions — was not thrust into menopause by the estrogen blocker. Her oncologist has told her in no uncertain terms that HRT is not an option despite her ongoing struggles with crushing brain fog, perimenopause-induced anxiety, and consistent broken sleep. Now in our 50s, we are watching from the sidelines while the rest of the midlife universe is seemingly splashing around in a cool, clock-rewinding swimming pool of hormone therapies.
Other women for whom HRT is off the table also struggle with physical symptoms as well as emotional and psychological impacts.
Harlynne was 41 when she was diagnosed with triple positive breast cancer. Treatment catapulted her into menopause overnight. Now she’s managing hot flashes, mood swings, and bone loss. “It’s almost like my body and hormones failed me, like I am ‘less of a woman’,” she said.
Jenny, now 40, was diagnosed with triple negative breast cancer at 37 and carries the BRCA1 mutation. She was advised against HRT based on recurrence concerns. “Now that menopause has entered the conversation, I feel a bit cheated,” she said.
Hormone therapy can be remarkably effective, particularly for vasomotor symptoms like hot flashes and night sweats. It also helps prevent bone loss and can improve vaginal dryness and painful sex, not to mention its mood stabilizing properties. For some women, it truly is transformative. The key word here being “some.”
Dr. Eleanora Teplinsky, a board-certified medical oncologist, describes the decision to use MHT after breast cancer as “individual and nuanced.” Much of the data on hormone therapy after breast cancer, she explains, is outdated and predates modern formulations and treatments. “Limited data do not demonstrate an increased risk of recurrence in hormone receptor–negative breast cancer, but findings remain conflicting in hormone receptor-positive disease.”
Dr. Teplinsky emphasizes two critical truths: MHT is effective, and it is not magic. “Responses to MHT can be variable,” she told us. “We have many excellent non-hormonal options for both short- and long-term management of menopausal symptoms. Lifestyle factors (diet, exercise, sleep, stress management, alcohol use, and others) play a critical role in symptom burden and overall health. These measures remain foundational even when MHT is used.”
Dr. Anna Barbieri, a board-certified gynecologist and menopause practitioner at the Carolyn Rowan Center for Women’s Health and Wellness, echoes that sentiment. Hormone therapy, she says, “is not one-size-fits-all.” For some, it’s a “game changer.” For others, it only partially alleviates symptoms, especially complex ones like libido, energy, and sleep.
“It is currently often painted as the ‘silver bullet’ for anything and everything,” she said. “That is just not the case. Dose, formulation, route of administration, and timing all matter enormously.”
Systemic estrogen therapy has generally been avoided in women with a history of estrogen receptor-positive breast cancer. But many women can safely use local vaginal estrogen or DHEA for genitourinary symptoms (related to the genital and urinary system). “Equally important, there are evidence-based non-hormonal treatments for many menopause symptoms including vasomotor symptoms, sleep disturbance, sexual health concerns, and bone health that deserve far more attention and validation for this population.”
Dr. Barbieri worries that “the current conversation steers too far toward fear: the fear that we cannot age well or be healthy without HRT, which simply isn’t true.”
The menopause rebrand was meant to be liberating. But for those of us who are limited in our options for tackling symptoms, it can feel isolating.
For women who have already endured illness or medical trauma, being told — again — that their bodies are the exception can reopen old wounds. Add to that the cultural pressure to “optimize” midlife. If menopause is now a self-improvement project, what does it mean if you can’t choose the premium upgrade?
Perhaps the more radical act is resisting the narrative that hormones are the only path to vitality.
Hormone therapy remains the most effective, gold-standard treatment for hot flashes and night sweats. But it does not guarantee boundless energy, eternal youth, or a restored 25-year-old libido. Some women discontinue it because of side effects — breast tenderness, bleeding, risk of blot clots and stroke, mood changes — or because it simply doesn’t live up to the hype.
Other options exist. Non-hormonal prescription medications, including certain SSRIs and SNRIs, gabapentin, and newer neurokinin-3 receptor antagonists, can significantly reduce hot flashes. Cognitive behavioral therapy has strong evidence for improving sleep and reducing distress related to vasomotor symptoms. Vaginal moisturizers and lubricants, pelvic floor physical therapy, and localized hormonal options can address painful intercourse. Weight-bearing exercise and adequate calcium and vitamin D remain pillars of bone health.
Do these options have the sheen and sex appeal of our favorite Gen X celebrity slapping an HRT patch on her chiseled tricep before heading out for a run? No. But they are grounded in evidence.
Women in midlife deserve accurate information, individualized care, and freedom from shame — whether they choose HRT, cannot take it, or simply don’t want it. The glossy narrative may sell supplements and telehealth subscriptions, but it risks flattening the complexity of our bodies and histories.
We are not arguing against hormone therapy. We are arguing against a monoculture of menopause.
Gila Pfeffer is a humor writer, breast cancer prevention advocate and public speaker. Her award-winning memoir NEARLY DEPARTED: Adventures in Loss, Cancer and Other Inconveniences has been described as heartbreakingly hilarious and lifesaving. Gila’s writing has appeared in the New York Times, The New Yorker, McSweeney’s, Today.com, Oprah Daily and more. Her monthly FEEL IT ON THE FIRST campaign on Instagram uses tongue-in-cheek humor to encourage women to prioritize their breast health. She lives in NYC and London.
Jessica Zucker is a Los Angeles-based psychologist specializing in reproductive health and the author of the award-winning books NORMALIZE IT: Upending the Silence, Stigma, and Shame That Shape Women’s Lives and I HAD A MISCARRIAGE: A Memoir, a Movement. Her writing has appeared in The New York Times, The Washington Post, New York Magazine, Vogue, and Harvard Business Review, among others. She’s been featured on NPR, CNN, The Today Show, and Good Morning America and earned advanced degrees from New York University and Harvard University.