MENOPAUSAL HORMONE THERAPY IN PERIMENOPAUSE AND MENOPAUSE: INDICATIONS, BENEFITS, RISKS, AND INDIVIDUALIZED CARE

Menopausal hormone therapy remains an effective option for bothersome symptoms, yet prescribing continues to be influenced by polarized interpretations of its benefits and risks. This critical narrative review examines its role during perimenopause and after menopause, integrating pivotal randomized trials, observational studies, systematic reviews, and recent recommendations. Systemic therapy is the most effective treatment for vasomotor symptoms and prevents bone loss and fractures during use. In symptomatic women without contraindications, initiation before age 60 or within 10 years of menopause generally provides a more favorable benefit-risk context than later initiation. This timing does not guarantee individual safety or establish an indication for cardiovascular prevention. Risks vary with baseline health, estrogen formulation, route, progestogen exposure, and treatment duration. Evidence suggesting a lower venous thromboembolic risk with transdermal rather than oral estrogen is predominantly observational; comparative breast safety data for different progestogens are similarly limited. Improvements in sleep or metabolic markers should not be converted into independent indications for weight management or diabetes prevention. Perimenopause require a separate assessment of contraception, abnormal bleeding, and endometrial protection. Local treatment is usually more proportionate for isolated genitourinary symptoms.