When should a woman start BHRT?
Most women initiate BHRT when symptoms of perimenopause or menopause materially affect sleep, mood, vasomotor stability, cognition, libido, or musculoskeletal health — typically in the 40s to early 50s. The current evidence base supports initiation within ten years of menopause for the strongest risk-benefit profile.
Full answer
BHRT is typically initiated when symptoms of perimenopause or menopause — vasomotor (hot flashes, night sweats), sleep fragmentation, mood lability, cognitive haze, libido decline, joint and musculoskeletal symptoms, vaginal and urinary changes — meaningfully affect daily function. The current evidence base supports the strongest risk-benefit profile when initiation occurs within roughly ten years of menopause or before age 60 (the 'timing hypothesis'). Earlier initiation is appropriate in surgical menopause and select premenopausal contexts. Initiation always follows a provider-reviewed assessment, the standardized biomarker panel, and review of personal and family history (cardiovascular, oncologic, thromboembolic). Waiting for severe symptoms is not required and is rarely the optimal strategy.
Educational. Not a substitute for individualized provider review.
- BHRT pathway — Primary source · oMeds
- Reviewed by Dr. Laura Purdy, MD, MBA · Clinical Director, oMeds · Last reviewed 2026-05-29