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There's big news about HRT. A major new US guideline says that, for most women under 60, the benefits of hormone therapy outweigh the risks. After more than 20 years of fear about hormones, that's a real shift.
On 15 October 2026, the American College of Obstetricians and Gynecologists (ACOG) released its menopause guideline. ACOG is the main professional body for specialist women's doctors in the United States. It calls this its most comprehensive menopause guidance to date, and it replaces their advice from 2014.
The simple version
In plain English:
- For most women under 60, or within 10 years of their final period, the benefits outweigh the risks
- It's recommended for hot flushes, night sweats and the broken sleep that comes with them
- It covers perimenopause as well as after menopause
- It isn't for everyone
Doctors call hot flushes and night sweats VMS, short for vasomotor symptoms. The guideline is about those symptoms and the sleep problems they cause. It isn't a recommendation to use hormones to prevent heart disease or dementia, and ACOG says the evidence isn't strong enough to recommend for or against MHT for depression.
ACOG also says timing matters: starting before 60, or within 10 years of menopause, is the sweet spot. And it frames the choice as a shared decision between you and your practitioner, based on your symptoms, health history and priorities.
You might hear HRT (hormone replacement therapy) or MHT (menopausal hormone therapy). Same idea. MHT is the newer name Australian bodies use.
Who it isn't for
MHT isn't suitable for everyone. A contraindication is a medical reason not to use a treatment. The main ones include:
- unexplained vaginal bleeding
- breast cancer and some other cancers
- heart disease, a past blood clot or stroke, or a clotting disorder
- liver disease
- pregnancy
Starting after 60, or more than 10 years after menopause, also needs a careful, individualised chat. This is a conversation with your GP or practitioner, not a headline decision.
Why the fear?
If you were around in 2002, you might remember the news. A large US study called the Women's Health Initiative (WHI) stopped early, with scary headlines about breast cancer, heart disease, stroke and clots. Prescriptions dropped around the world, and many women stopped their hormones almost overnight. The fear stuck, for women and for doctors.
So what was the catch? There were three.
1. Age. Most women in the study were already in their 60s. The average age was 63, and most were more than 10 years past menopause. That's a very different group from a 51-year-old with night sweats.
2. What was tested. The WHI tested one tablet that combined:
- conjugated equine oestrogen, a mix of oestrogens taken from the urine of pregnant mares (horses), hence the brand name Premarin (PRE..gnant..MAR..e..ur..IN..e — pregnant mare urine), and
- medroxyprogesterone acetate, a progestin, which is a synthetic (lab-designed) relative of progesterone.
Not body-identical oestrogen. Not a patch or gel. Not body-identical progesterone.
3. How the risk was reported. Headlines quoted relative risk, which is the percentage change. Absolute risk is the real number of extra cases, and it tells a much calmer story. In the WHI, breast cancer went from about 30 to about 38 cases per 10,000 women each year. That's a 26% relative increase, but only about 8 extra cases per 10,000 women a year. There were also about 7 extra heart events, 8 extra strokes and 8 extra clots on the lung per 10,000 women a year. The percentages sounded scary. The actual numbers were small.
So when someone says "the WHI showed HRT causes X", it's worth knowing they're talking about one specific tablet, mostly in women in their 60s and 70s.
Progestogen, progesterone, progestin
If you still have a uterus (womb), oestrogen alone can thicken the lining over time, so a progestogen is usually added to protect it.
- Progestogen = the umbrella word for the family of hormones that act like progesterone — both the progesterone your ovaries make and the lab-made versions
- Progesterone / micronised progesterone = exactly the same chemical structure as the progesterone women have had in their bodies for their whole life prior to menopause. "Micronised" just means ground very fine so your body absorbs it well (Prometrium, on the PBS in Australia)
- Progestin = a synthetic relative (what the WHI used)
Think genuine Gucci vs a good copy. From across the room they look very similar, and both will carry your keys and phone. Up close, the copy isn't made the same way. Body-identical progesterone is the genuine Gucci. A progestin is the good copy: similar, but not the same molecule.
On breast cancer risk, the AMS says micronised progesterone and dydrogesterone "appear safer than most synthetic progestogens." One small but important point: micronised progesterone is identical to our own progesterone, while dydrogesterone is similar, not identical. The AMS also says micronised progesterone and dydrogesterone may be associated with lower risks compared with other progestogens. Long-term research is still limited.
Body-identical vs compounded "bioidentical"
All MHT hormones are made in a lab, including the body-identical ones. AMS calls micronised progesterone such as Prometrium "body-identical" because it has exactly the same chemical structure as the progesterone women have in their bodies for their whole life prior to menopause (Prometrium on PBS). It comes as a regulated, tested, approved medicine.
Compounded "bioidentical" hormones are different. These are custom-made by some compounding pharmacies, often as creams, lozenges or pessaries, and marketed as more "natural". The Australasian Menopause Society (AMS) draws a hard line here: it does not recommend compounded bioidentical hormones in any form. They aren't tested for quality and safety, and progesterone creams aren't reliably absorbed, so they may not protect the uterus.
The words sound alike. The products are not.
Patch, gel or tablet?
Oestrogen can be swallowed as a tablet or absorbed through the skin as a patch or gel (doctors call this transdermal). The route can matter, especially for clot risk. The AMS says patches and gels have minimal or no added clot risk, while tablets double it, although it's still very low (about 1 extra case per 1,000 women). If you have a history or family history of clots, or stroke risk factors, it's worth asking about the route.
The genuine Gucci is now more affordable
The PBS (Pharmaceutical Benefits Scheme) is the government scheme that subsidises many prescription medicines. Prometrium, Estrogel and Estrogel Pro were listed on the PBS from 1 March 2025, the first new MHT listings in about 20 years. Before that, some women were paying up to $650 a year.
Estrogel Pro is a handy combination pack: body-identical oestradiol gel plus Prometrium capsules, together in one box. Going back to the handbags: you can now get the genuine Gucci for about the same price as the copy.
The Australian view
Here at home, the main bodies broadly agree with ACOG.
"The AMS says that for most women with symptoms, the benefits of MHT outweigh the risks, and that the added risk of clots, stroke and breast cancer is very small."
Jean Hailes for Women's Health says the same for healthy women within 10 years of menopause. The Australian Government says MHT is safe and effective for most healthy people.
One difference is worth knowing. ACOG lists a past clot or stroke as a reason not to use MHT, while the AMS says women with stroke risk factors can probably use a patch or gel. If that's you, raise it with your GP or practitioner.
My story
When I was first prescribed MHT, I was given medroxyprogesterone by default, the same type of progestin used in the 2002 study. Nobody mentioned there was another option. I only knew to ask because I'd done my own research.
When I raised body-identical options, the Practitioner told me the only difference was the marketing. That is not right. There is a structural difference: body-identical progesterone has exactly the same chemical structure as the progesterone women have in their bodies for their whole life prior to menopause. A progestin is a synthetic relative — similar, but not the same molecule.
That's why I think education matters so much. It isn't about telling anyone what to take. It's about knowing your options so you can ask good questions.
Questions to take to your GP or practitioner
- Based on my health history, is MHT an option for me?
- If I still have my uterus, is the progestogen you wish to prescribe me a progesterone (body identical) or a progestin (mimic of progesterone)?
- Would a gel oestrogen or a patch oestrogen suit me better than a tablet?
- Is this option on the PBS?
Where I fit
I don't prescribe, recommend or choose treatments. I'm in perimenopause myself, and I help women feel clear and prepared for the conversation with their GP or practitioner, and with the everyday foundations around it, such as food, movement, sleep and stress.
Curious where you're at? Take my menopause quiz: https://www.menocraft.com.au/menopause-quiz
References
1. ACOG. Management of menopause-related vasomotor, sleep, and mood symptoms. Clinical Practice Guideline No. 13. Obstet Gynecol. 2026. https://doi.org/10.1097/AOG.0000000000006428
2. Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women. JAMA. 2002;288(3):321–333. https://doi.org/10.1001/jama.288.3.321
3. Australasian Menopause Society. Risks and Benefits of MHT, information sheet. https://www.menopause.org.au/hp/information-sheets/risks-and-benefits-of-mht-hrt