HJAR Jan/Feb 2026

HEALTHCARE JOURNAL OF ARKANSAS I  JAN / FEB 2026 11 Cultural messaging amplified these themes. The bestselling book Feminine For- ever , written by gynecologist Robert Wilson, portrayed estrogen as a way to maintain or restore femininity and sexual vitality at every age. The book heavily emphasized sexuality as central to a woman’s identity — a perspective now understood as culturally biased and medically simplistic. Notably, the writing and promotion of Feminine Forever were later revealed to have been funded by the manufacturer of Premarin, underscor- ing the blurred lines betweenmarketing and medical guidance in that era. By the 1970s, important safety con- cerns emerged when studies showed a four- to eightfold increase in endometrial cancer among women with a uterus who used unopposed estrogen. This discovery reshaped prescribing practices, and by the 1980s it became standard to pair estrogen with a progestin in women who retained their uterus to mitigate this risk. Despite earlier missteps, confidence in hormone therapy grew through the 1980s and 1990s as clinicians increasingly viewed it as beneficial for symptom relief, bone health, and even cardiovascular protec- tion. By the mid-1990s, hormone therapy had become one of the most commonly prescribed treatments in women’s health, with nearly 40% of menopausal women in the United States using it. Professional guidance reflected this enthusiasm; at one point, the American College of Obstetri- cians and Gynecologists (ACOG) even rec- ommended hormone therapy for all meno- pausal women, regardless of whether they experienced vasomotor symptoms. Then came 2002 and everything changed. The initial media coverage of the Wom- en’s Health Initiative (WHI) study reported, inaccurately, that the trial was stopped early because estrogen therapy increased breast cancer risk. The impact was immediate and profound. Prescriptions fell by more than 60% almost overnight, and millions of women discontinued therapy abruptly. Lost in the headlines was the actual magni- tude of risk: In the combined hormone ther- apy arm (conjugated equine estrogens plus medroxyprogesterone acetate), the increase in breast cancer amounted to 0.08% per year — or eight additional cases per 10,000 women annually. Despite the small abso- lute risk, nuance was overshadowed by fear. Equally overlooked was another critical detail: The average age of participants was 63, more than a decade beyond the typical age at which hormone therapy is initiated. Many women in the study had cardiovas- cular risk factors that would prompt care- ful consideration — or avoidance — of sys- temic hormone therapy today. Moreover, in the estrogen-only arm, the group most rel- evant to women without a uterus, long-term follow-up demonstrated a 23% reduction in breast cancer incidence, a finding rarely highlighted in early reporting. Despite these findings, the initial messag- ing created a lasting stigma. For 20 years, hormone therapy suffered from a reputa- tion problem that far outweighed its true risks. Providers who trained after 2002 often received minimal — or no — formal educa- tion inmenopausal care. Patients with debil- itating symptoms were frequently told to “ride it out,” despite evidence showing that hormone therapy remained the most effec- tive treatment for vasomotor symptoms and provides additional benefits for bone health, sleep, mood, and the genitourinary system. The impact on women’s health was substantial: • Up to 80% of women experience vaso- motor symptoms, often for years. • Only 20% to 25% receive hormone therapy, despite its safety and efficacy for appropriately selected patients. • More than 1 million women enter menopause each year in the United States, yet access to trained meno- pause specialists remains limited. This disconnect — between evidence and perception, need and access — set the stage for renewed scientific inquiry and regula- tory reassessment. After years of reanaly- sis, updated guidelines, and stronger real- world data, the FDA ultimately convened a roundtable to reassess the boxed warning placed on estrogen products more than two decades earlier. What followed reshaped the landscape of menopause care. The FDA Reexamines Hormone Therapy: A Turning Point in Modern Menopause Care Two decades after the WHI reshaped perceptions of hormone therapy, mount- ing evidence and widespread clinical expe- rience made it clear that a reassessment was overdue. The reanalyses of WHI data, combined with large observational stud- ies, consistently demonstrated that age at initiation, baseline health, and type of ther- apy profoundly influence risk. Professional organizations — including the NorthAmeri- canMenopause Society (NAMS), ACOG, the Endocrine Society, and international meno- pause societies — updated their guidelines accordingly, all emphasizing that hormone therapy is safe and appropriate for most healthy, symptomatic women under age 60 or within 10 years of menopause onset. As this modern evidence base “Hormone therapy has a long and complicated history — one shaped as much by culture, marketing, and communication as by scientific discovery.”