Interview with Ami Armstrong, Storyteller Investigating the Truth About HRT, Menopause and Breast Cancer

For decades, women were told a very simple, very frightening story: hormone replacement therapy causes breast cancer. That message landed so hard that an entire generation avoided estrogen and progesterone, often while struggling through perimenopause and menopause without meaningful support.

Ami Armstrong joins Dr. Thais Aliabadi and Mary Alice Haney the deeper issues of these treatments. The full story of HRT, breast cancer risk, and the Women’s Health Initiative is much more complicated. It involves a landmark research effort, a study population that does not reflect every woman seeking menopause care today, different hormone formulations than many prescribed now, and a media narrative that favored relative risk over actual numbers. 

Table of Contents

• Why We Need to Revisit the Women’s Health Initiative
• The Long History of Women Being Treated as an Afterthought
• How Estrogen Was Marketed Before It Was Feared
• What the Women’s Health Initiative Actually Studied
• The Timing Hypothesis and Why Age Matters
• The 2002 Press Conference That Changed Menopause Care
• Relative Risk Versus Absolute Risk: The Numbers We Need to Understand
• How We Can Become Better Interpreters of Health Headlines
• Women’s Health Is Not a Niche Topic

Why We Need to Revisit the Women’s Health Initiative

Why did this subject feel important enough to build an investigative series around?

We kept hearing the same thing from extraordinary physicians, OB/GYNs, and menopause specialists: “Because of the Women’s Health Initiative, women are afraid of hormone therapy.” It was startling because the study’s title sounds like something that should have advanced women’s health. In many ways, it did begin with exactly that intention.

Our mothers and grandmothers were often told that estrogen or HRT definitively caused cancer. Many women did not take hormones because they believed the risk was settled science. Yet when we looked more closely, we found a study with a far more nuanced history, one that was dramatically reshaped by how findings were communicated to the public.

This is why Ami Armstrong created It’s Not a Purse, beginning with the series A Study on Trial: The Women’s Health Initiative Revisited. The goal is not to pretend medicine has no risks. Every medication and every intervention has potential risks. The goal is to make sure fear is not standing in for informed, individualized medical care.

What does the phrase “the SHE MD effect” mean?

It started as a joke during a post-dinner walk. We were following a simple health tip learned through one of these conversations and thought, “Okay, this is the SHE MD effect.” But it grew into something bigger.

The effect is what happens when women get usable health information and begin asking better questions. It can mean learning about genetic testing, understanding a symptom that has been dismissed for years, recognizing that painful periods are not normal, or realizing that brain fog and sleep disruption in perimenopause are not simply things we have to endure.

Information changes outcomes. That is the whole point. Women have been left behind too often in research, in medical messaging, and in the standard of care. Knowledge gives us a better chance to advocate for ourselves alongside a trusted clinician.

The Long History of Women Being Treated as an Afterthought

Before the Women’s Health Initiative, how were women left out of medical research?

In 1977, the FDA issued guidance excluding women of childbearing potential from early-phase drug trials. On the surface, that may have sounded protective. In practice, it contributed to a system where women were excluded from research while still being prescribed medications that had primarily been studied in men.

That is not protection. Erasure is not protection.

The policy followed understandable concern about harmful drug exposures, including thalidomide and diethylstilbestrol, known as DES. But instead of creating better systems for carefully studying women, pregnancy, fetal outcomes, and female biology, the system often avoided women altogether. We ended up being treated like smaller versions of men, including when it came to medication dosing and safety data.

By the late 1980s, the National Institutes of Health encouraged researchers to include women, but encouragement did not move the needle. Real change required legislation. The NIH Revitalization Act of 1993 made the inclusion of women and minorities in NIH-funded clinical research a requirement.

Who was Dr. Bernadine Healy, and why does her role matter?

Dr. Bernadine Healy was the first woman director of the NIH, appointed in 1991. She was an esteemed cardiologist from the Cleveland Clinic, a major medical leader, and a true disruptor. She recognized the enormous gap in women’s health research and proposed something bold: a “moonwalk for women.”

That language was brilliant. If the country could send astronauts to the moon and bring them home, surely it could also study the complexity of female biology. The Women’s Health Initiative was designed as a major effort to understand disease prevention in postmenopausal women, not as a simplistic study of hot flash treatment.

The WHI was a $500 million initiative with more than 160,000 women enrolled. It included observational research on nutrition and vitamin D, as well as randomized, controlled, blinded clinical trials. Its ambitions were huge because the need was huge.

How Estrogen Was Marketed Before It Was Feared

Why does the cultural history of estrogen matter to the HRT conversation?

Because women’s health products have so often been marketed through shame, fear, and objectification. We grew up with advertisements suggesting women needed to be “fresh” at all times, even though many products marketed for intimate hygiene could disrupt vaginal health and contribute to the exact problems they claimed to solve.

Then there was the 1966 book Feminine Forever, which promoted estrogen as a way to maintain youthfulness and femininity. Estrogen was even marketed to husbands with deeply insulting imagery of women being returned to a cheerful, younger version of themselves.

That messaging understandably turned many feminists away from estrogen. They were not interested in taking a medication to look younger for someone else. But this cultural backlash also meant many women did not receive clear information about potential health benefits, risks, or the role hormones could play in quality of life.

We have to separate the old, patronizing beauty messaging from the real medical conversation. Aging is not something to be ashamed of. At the same time, symptoms that affect sleep, cognition, mood, bone health, sexual health, and daily function deserve serious medical attention.

What the Women’s Health Initiative Actually Studied

What was the WHI designed to investigate?

The Women’s Health Initiative was focused on preventing disease in women who were in menopause or beyond it. The research examined questions around cardiovascular disease, osteoporosis, cognition, nutrition, and other long-term health outcomes.

It was not primarily designed to answer the question many women care about today: “Can hormone therapy help me manage perimenopause symptoms at the time they begin?” That distinction matters enormously.

The study included several groups:

• A placebo group receiving inactive pills.
• An estrogen-only group for women who had undergone hysterectomy.
• An estrogen-plus-progestin group for women who still had a uterus.
• Large observational components focused on factors such as nutrition and vitamin D.

The median age of participants in the hormone trial was 63, and the youngest participants were 50. These women were not necessarily newly menopausal. Many were well beyond the transition. Researchers at the time did not yet understand what is now commonly called the timing hypothesis.

What hormones were used in the WHI?

This is one of the most important details in the entire conversation. The WHI did not use the same hormone formulations that many patients are prescribed today.

The estrogen-plus-progestin arm used conjugated equine estrogen, derived from pregnant mares, together with a synthetic progestin. The progestin used was not bioidentical progesterone. It was selected because it was common, relatively inexpensive, and easy to manufacture.

Today, clinicians may prescribe different forms of estrogen and progesterone, including bioidentical hormones. Route matters, formulation matters, dose matters, timing matters, and personal medical history matters. One study of one set of formulations in an older cohort cannot automatically answer every question about every modern HRT regimen.

For a broader discussion of individualized menopause care, symptoms, and hormone therapy options, explore this clinical guide to menopause nutrition and hormone therapy.

The Timing Hypothesis and Why Age Matters

What is the timing hypothesis?

The timing hypothesis refers to the growing understanding that the timing of menopausal hormone therapy matters. When treatment is started within roughly 10 years of menopause onset, the balance of benefits and risks may differ from starting treatment much later.

The WHI investigators were working with the information available to them in the 1990s. They were studying an older population in part because conditions such as osteoporosis and cardiovascular disease are more common after menopause. But the study design means its results should be interpreted in the context of the participants’ ages and timing since menopause.

Dr. Howard Hodis and the ELITE study became an important part of the effort to examine this question. The work supported the idea that women who begin treatment closer to menopause may experience different outcomes than women who start much later.

Again, this is not an argument that hormones are appropriate for everyone. It is an argument that timing is clinically relevant and that menopause care should not be based on a one-size-fits-all fear response.

Are hot flashes just an uncomfortable nuisance?

Absolutely not. Hot flashes can be disruptive, exhausting, and deeply isolating. They are not simply something to smile through while everyone tells us it is part of getting older.

When estrogen levels are changing, the brain and body are signaling that something real is happening. Some women have minimal symptoms and may not need treatment. Others struggle with sleep loss, cognitive changes, mood symptoms, and intense vasomotor symptoms that affect every part of daily life.

We should not minimize those experiences. There are lifestyle strategies, hormone therapy options, and nonhormonal treatments worth discussing with a qualified clinician. For practical information on symptoms and approaches to care, visit this guide to hot flashes and night sweats.

The 2002 Press Conference That Changed Menopause Care

Why was the estrogen-plus-progestin arm of the WHI stopped early?

Every major clinical trial has a data safety and monitoring board. This board evaluates whether risks are emerging and whether the study is producing the expected benefits. In April 2002, the board flagged that the estrogen-plus-progestin arm was not showing the hoped-for preventive benefits and that there was an increase in breast cancer cases.

By June, a small group of investigators moved toward ending the arm early. The study had originally been intended to continue until 2005, but the estrogen-plus-progestin portion ended three years ahead of schedule.

The controversy was not about whether researchers should report findings. Of course they should. The issue was whether the data were communicated with enough context, whether the full investigator group had sufficient time for rigorous review, and whether the public was given relative-risk headlines without the underlying absolute-risk numbers.

Those questions matter because one press conference on July 9, 2002 changed the way millions of women and clinicians thought about HRT almost overnight.

What happened to HRT use after the news broke?

Hormone therapy use plummeted. In the late 1990s, approximately 15 million American women were using HRT. After the WHI publicity, use dropped by roughly 70% to 85% almost immediately.

Even now, only a small percentage of women experiencing menopause symptoms use menopausal hormone therapy. That shift was not merely an academic outcome. It affected real lives, real symptoms, real sleep, real workdays, real relationships, and real medical decisions.

Relative Risk Versus Absolute Risk: The Numbers We Need to Understand

What was the breast cancer finding, in actual numbers?

This is where the conversation became dramatically distorted. The 2002 media message emphasized a 26% increased breast cancer risk. That number refers to relative risk. Relative risk can sound terrifying when it appears in a headline without context.

But the absolute numbers discussed were these: among 10,000 women over one year, 30 women in the placebo group were diagnosed with breast cancer, compared with 38 women in the estrogen-plus-progestin group. That is a difference of eight women per 10,000 per year.

Eight additional cases per 10,000 women is not nothing. It deserves careful discussion and responsible follow-up. But it is not the same as a broad, absolute statement that HRT causes breast cancer for every woman.

Relative risk tells us how much larger one number is than another. In this example, 38 is about 26% higher than 30. Absolute risk tells us the difference in actual events: eight additional diagnoses per 10,000 women in one year. We need both numbers to understand the data honestly.

Were participants grouped by their individual breast cancer risks?

Not in the way we would want for highly personalized medicine. The study did not stratify women according to known risk factors such as smoking, alcohol use, obesity, family history of breast cancer, or genetic mutations. At the time, today’s genetic testing tools were not available.

By 2007, further analysis that accounted for risk factors showed a more nuanced picture. Investigators reported cardiovascular, bone, and cognitive benefits, while the breast cancer finding remained a subject requiring context and individual risk assessment.

The estrogen-only arm also produced a finding that many people never heard about in the same frightening headlines: decreased breast cancer diagnosis and mortality in that group. That does not mean estrogen-only therapy is right for every person. It does show why combining every hormone therapy question into one scary statement is not responsible medicine.

Women with early menopause have particular reason to seek individualized guidance, because earlier estrogen loss can be associated with broader health concerns. Learn more about the connection between early menopause, cardiovascular risk, and brain health.

How We Can Become Better Interpreters of Health Headlines

What questions should we ask when a scary health headline appears?

We have to stay curious. Headlines are designed to get attention, and relative-risk numbers are almost always more dramatic than absolute numbers. Before we make a medical decision based on a headline, we can pause and ask better questions.

• What is the absolute risk? How many actual events occurred?
• Who was studied? Were participants similar in age, health, sex, and life stage to us?
• What exactly was tested? Was it the same formulation, dose, or route that may be offered today?
• Was the study designed to show causation or association? A correlation does not automatically prove that one factor caused another.
• Were women studied? Were female animals and female cells included in the research?
• What personal risk factors matter? Family history, genetics, age, alcohol use, medical history, and other factors may shape the decision.

We can apply this thinking everywhere. A headline claiming melatonin causes heart attacks may turn out to be describing an association between poor sleep and cardiovascular risk, not proof that melatonin caused the issue. Wellness trends, cold plunges, supplements, and medications all deserve the same critical eye.

What is the right way to think about HRT today?

Not with generalized fear. Not with internet certainty. Not with the assumption that every woman should take it or that no woman should take it.

The right approach is personalized care. We should discuss symptoms, age, time since menopause, uterus status, breast cancer risk, cardiovascular history, medications, family history, genetic information, and personal priorities with a clinician who understands menopause medicine.

There is risk in every treatment. There is also risk in ignoring symptoms, leaving women untreated when they need help, and allowing sensationalized messaging to replace medical nuance.

Women’s Health Is Not a Niche Topic

What do we hope women take away from this conversation?

Women’s health is not niche. We are half the population. It is long past time to treat our bodies, our symptoms, our hormonal transitions, and our health outcomes as central medical issues.

The Women’s Health Initiative began as an ambitious effort to correct a history of exclusion. Its legacy should not be reduced to one terrifying sentence. It should prompt us to demand better research, clearer communication, better clinical training, and medical decisions grounded in our own circumstances.

We do not have to be afraid of knowing our risks. We do not have to accept clickbait as medical advice. We do not have to grit our teeth through symptoms that affect our lives.

Be curious. Ask questions. Know your personal risk factors. Bring the actual numbers into the room. Then work with a trusted clinician to decide what is right for us.

Frequently Asked Questions About HRT, Menopause and Breast Cancer

Did the Women’s Health Initiative prove that HRT causes breast cancer?

No. The estrogen-plus-progestin arm reported more breast cancer diagnoses than placebo, but the findings require context. The reported difference was eight additional diagnoses per 10,000 women per year, and the study involved specific hormone formulations in an older group of women. Individual risk, timing, formulation, and medical history all matter.

What is the difference between relative risk and absolute risk?

Relative risk compares one number to another as a percentage. Absolute risk shows the actual number of additional events. In the WHI discussion, 38 cases compared with 30 cases was described as a 26% relative increase, while the absolute difference was eight cases per 10,000 women over one year.

Why does the timing of hormone therapy matter?

The timing hypothesis recognizes that outcomes may differ when menopausal hormone therapy begins closer to menopause rather than many years later. This is one reason hormone therapy decisions should be individualized with a knowledgeable clinician.

Do women with a uterus need progesterone with estrogen?

Women who still have a uterus are generally evaluated differently from women who have had a hysterectomy. The WHI included an estrogen-only group for women without a uterus and an estrogen-plus-progestin group for women with a uterus. The right regimen depends on individual medical circumstances and should be discussed with a clinician.

Should everyone with menopause symptoms take HRT?

No. Hormone therapy is not appropriate for every person, and not every person needs it. Symptoms, health history, breast cancer risk, cardiovascular factors, age, timing since menopause, and personal goals should all inform the decision.