By   Alan Cassells

In medicine, we love a good heroic story. A patient suffers a serious disease. A drug company produces a brilliant new drug which proves to be beneficial. Lives are saved. Everyone is happy. Another battle won in the war on disease. Science marches triumphantly forward.

But sometimes the real story is less heroic and far more awkward. And the major “advance” comes not from a new drug, but from the opposite: because patients stopped swallowing a drug that never should have been so widely used in the first place.

That is almost certainly the case of breast cancer in North America in the early 2000s.

The pivotal moment came in the summer of 2002 when a major randomized trial, called the Women’s Health Initiative (WHI) was published, aiming to answer a question which physicians had long pondered: was long-term use of hormone replacement therapy, typically prescribed for women going through menopause, good for the heart?

Up to that point, hormone therapy had been marketed as a kind of fountain-of-youth elixir for menopausal women. Promising to protect the heart, keep bones strong, preserve youthfulness, and generally smooth out biological inconveniences of aging, women were prescribed these drugs and stayed on them for years, sometimes for decades. At that time, there was considerable debate about long-term effects, with some experts claiming the heart protective-effects of hormones were so pronounced that even studying the issue was a waste of time.

Launched in 1997, the WHI enrolled more than 16,000 post-menopausal women to test the effects of combined estrogen-progestin. Another arm tested the effects of estrogen alone in 10,000 women who had undergone a hysterectomy. The larger trial was terminated three years earlier than originally planned, once the findings showed an increased risk of breast cancer, heart disease, stroke, and blood clots among participants. The smaller trial was also halted a year earlier than planned due to increased risk of stroke.

That was the day that the music died for hormone therapy.

Or at least we thought.

Within months women stopped taking and physicians stopped prescribing hormone therapy. The everyday use of this class of drugs fell dramatically, by roughly half within a year.

And then something remarkable happened.

Breast cancer incidence in the United States dropped. Some say that the rates had been in decline for several years, but the drop was significant, falling by roughly six to seven percent in 2003. It was one of the sharpest year-to-year declines ever observed. The drop was especially pronounced among women over 50 and in estrogen-receptor positive tumors, precisely the cancers most likely to be stimulated by hormones.

This wasn’t a subtle statistical wiggle. For epidemiologists, this was the sort of signal that almost never happens so cleanly in real life. Usually population health trends are messy, tangled up in dozens of possible explanations. There are long latency periods with cancer yet here a cause and effect appeared almost choreographed.

Drug exposure goes down. Disease incidence goes down, Just like that. Overnight, by stopping a drug we probably saw the most important advance in the fight against breast cancer in the last half century. But….

HRT Revisited

But today? Memories are short, and for many obstetricians, women’s health advocates, and even health reporters, it seems like the lessons from the WHI are being rewritten. The known and proven harmful effects of hormones on women’s health are undergoing a massive rewrite which is stimulating a resurgence in HRT.

This new Hormone Replacement Therapy conversation lately is captured in such articles as this piece from PBS; “How a Decades Old Study Gave Hormone Therapy a Bad Reputation,” which calls the WHI a “flawed” study. Other major media outlets like the New York Times, the Washington Post and TIME Magazine are eagerly celebrating the renewed interest in menopause, emphasizing that women’s health concerns are never adequately dealt with, and that HRT needs a second look.

The media attention was amped last year up when the FDA convened an Expert Panel on Menopause and Hormone Replacement Therapy for Women. That meeting led to the removal of the boxed warnings in November 2025 even though the labels still warn of the risk of uterine and endometrial cancer associated with estrogen-only HRT, which is typically prescribed to people who have had their uterus removed through a hysterectomy.

A lot of the hullabaloo over the removal of the FDA’s Black Box Warning on Hormone Therapy relied on a strange mix of both revisionism (the science has changed) and egalitarianism (women needed “more choice”). For the media, this was an easy sell. 

The rationale used by the FDA committee and hormone aficionados everywhere was that the science has been fully reinterpreted, and “corrected.” Let’s be clear what has happened: there has been new “analyses” of the effects of hormones, but no new original research showing that the previous safety concerns are exaggerated. 

Much of the renewed support for HRT uses the ‘window of opportunity’ argument that suggests that it is safe if a 50-year-old woman takes hormones, but in her 60’s it’s unsafe. Can we really accept that the effects of these drugs on women would be dramatically different at some sort of arbitrary age-related cutoff? That’s the line we are expected to believe.

But look at how that argument is easily confounded. If the drugs show a reduced harm in younger women that’s mostly because, for any disease, younger age usually means lower disease burden. The revisionists discredit the WHI even though there were thousands of women in their 50’s in that trial, and many of them were among those harmed.

A distinction needs to be made here, where one has to examine the exact reason why one is taking hormones. Is it to control menopausal symptoms (especially hot flashes, vaginal dryness) or to prevent diseases of aging (breast cancer, heart disease, dementia)?

The WHI study was aimed at determining the long-term, post-menopausal effects of the drug, and hence it was looking at the second question. As to the first question, hormones are undoubtedly effective for treating menopausal symptoms.

Symptomatic treatment is therefore behind the major push for the drugs these days. One doctor friend of mine told me that “every menopausal woman he knows is taking hormones,” implying that this was both right and natural. Another friend, who is turning 60 this year, just recently told me over coffee she’s been on the drugs for ten years and has no plans for stopping them, as she remembers how bad the sleeplessness and brain fog were when she was in menopause. This was a head-scratcher to me, left me wondering why her doctor isn’t concerned about the recent post-black box warning recommendations that if menopausal women are going to take hormones they should do so in the lowest dose possible, for the shortest period of time possible.

The message here: take these drugs, but not for long, and not in high doses. That’s the pharmaceutical equivalent of someone shouting “Danger!”

What pharmaceutical companies do best is not develop drugs, but develop drug markets and you see this on full display in the current menopausal makeover. With a highly malleable clientele, who have both money and motivation, the key obstacle is convincing prescribers that these women urgently need chemical assistance to get through this tough life transition, and that prescribing hormones is one way to fight back against the manosphere. Were it only so easy…

Revising the HRT market depends on the usual tactics: some high-octane marketing including funding pro-HRT “studies,” selectively publishing data that emphasize HRT’s benefits and downplay the harms, funding direct-to-consumer advertising campaigns wrapped in the justice angle, while sponsoring guideline panels and medical education for your and my doctors. By paying off key opinion leaders, and getting social media influencers slurping on the HRT taps the media serves up this revival as a “feel-good” story of female emancipation. 

Let’s face it, menopause in 2026 is the sort of uplifting health story that the mainstream media has leaped on with uncommon gusto. In Canada, our public broadcaster, CBC, finds the subject so compelling it runs its own series (Small Achievable Goals) about menopause, organizes noontime Menopause Month call-in shows to dive into the many ‘equity’ issues related to menopause (like why are Canadian women paying out of pocket for menopause care from private practitioners?) and produces a litany of programs that are mostly repetitive recitations over the need to counter the “stigma” caused by menopause. We get it. Menopause is clearly not fun for many women and employers who don’t make concessions for suffering women need to be brought into the 21^st century.

The punchline, however, always seems the same: Women are not being taken seriously when it comes to menopause and they’re mad as hell. And no one should stand in their way of getting full access to menopausal treatments, especially those prescribed medications produced by the biggest drug companies in the world. We have a term for this: Pinkwashing. In other words, taking corporate business objectives and painting them in a feminine way in order to show how much you care.

You don’t have to do a systematic review of the mainstream media’s menopause mongering, but even a quick global survey of the main English language outlets can identify some dominant themes. Even though millions of women stopped HRT in 2002, and breast-cancer incidence dropped significantly, not a single story in 2026, as far as I can tell, mentions this fact. It’s curious. Even though most epidemiologists who have examined these data say that all the evidence points towards HRT promoting breast-tumor growth.

The remake of HRT has certainly paid off. Overall HRT demand in North America has grown, driven by what the experts call “increased menopause awareness, guideline updates, and reduced stigma.” Data from insurance claims and health systems show hormone therapy use is steadily rising again after years of decline. Its use among women aged 45–65 increased about 20% between 2020 and 2023. This pink trend is occurring alongside a surge in menopause clinics, telehealth menopause services, and the growing pervasiveness of influencer physicians and social-media menopause advocates.

The HRT market in North America has grown steadily too, worth about $5 billion per year, dominated by drugs like Premarin (branded conjugated estrogens) made by Pfizer. Without any generic competition in the US until late 2025 Pfizer has been able to dominate the market, selling more than $100 million worth of Premarin in 2022 alone. Prempro (conjugated estrogens + medroxyprogesterone,) has been generically available since 2006 or so and has many other generic companies dominating the market due to much lower pricing.

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Via https://brownstone.org/articles/the-biggest-breast-cancer-advance-in-the-last-twenty-years/