Menopausal Hormone Therapy: A Narrative Review of Contemporary Evidence

Menopausal hormone therapy (MHT) remains the most effective treatment for vasomotor and genitourinary symptoms of menopause; however, its use declined sharply following the publication of the Women's Health Initiative (WHI). Misinterpretation and limitations of WHI findings have led to persistent misconceptions and underutilization of MHT. This expert opinion aims to clarify evidence-based approaches to MHT selection, safety, and individualized management. This article was informed by a structured narrative review of the literature with the aim to contextualize evolving pharmacotherapeutic evidence and inform clinical decision-making. PubMed/MEDLINE, Embase, and the Cochrane Library were searched for studies published from 2002 to 2025. Key opinion statements were developed through expert consensus and paired with a synthesis of contemporary evidence to form recommendations. A critical appraisal of the WHI and subsequent analyses demonstrates that age at initiation, timing since menopause, and hormone formulation utilized significantly influence outcomes. Contemporary data support the preferential use of transdermal estradiol due to its lower risk of venous thromboembolism and favor oral micronized progesterone (MP) over synthetic progestogens when endometrial protection is required. Individualization of therapy-including formulation, route, and dosing-is emphasized as central to optimizing the benefit-risk profile. Current evidence supports the safety of low-dose vaginal estrogen for genitourinary syndrome of menopause including in cancer survivors. Further evidence highlights potential cardiovascular and cognitive benefits when MHT is initiated within 10 years of menopause. Clinicians caring for menopausal women should promote individualized, evidence-based MHT through education, therapeutic selection, shared decision making, and ongoing monitoring. Continued research is needed to refine dosing targets, evaluate long-term preventive outcomes, and expand evidence for modern formulations beyond WHI-era therapies. Ultimately, MHT should be viewed not as a one-size-fits-all therapy, but as a personalized, evidence-informed strategy that supports the health and quality of life of menopausal women.