HRT & TRT: The evidence, the risks and the German reality

For most women who start HRT before 60 or within 10 years of menopause because of bothersome symptoms, the benefits outweigh the risks.^[14] Doctors backed away from it for years because of one trial that was read too broadly. In 2002 the Women's Health Initiative (WHI) reported more breast cancer, heart disease and stroke in women on hormones than in women on a placebo.^[1] Yet the women in that trial were 63 on average, and many were 10 or more years past menopause.^{[1, 43]} So the warning landed on someone the trial had hardly studied: the 51-year-old with hot flashes.

WHI enrolled 16,608 women aged 50 to 79 and gave them a daily hormone pill or a placebo.^[1] The pill combined conjugated equine estrogens (CEE, sold as Premarin) with medroxyprogesterone acetate (MPA), a synthetic progestin. The trial was stopped early after about five years.^[1] A second arm tested CEE alone in women who had had a hysterectomy, and its results, published in 2004, looked quite different.^[2] Read across each row of the table: estrogen alone lost the breast and heart signal but kept the stroke risk.

Source: WHI trials.^{[1, 2]}

Those percentages translate into small absolute numbers. For every 10,000 women on the combined pill each year, there were about 8 extra breast cancers and 8 extra strokes.^[1] Blood clots in the lungs roughly doubled, about 8 extra cases.^[1] Against that stood about 5 fewer hip fractures and 6 fewer colorectal cancers in the same 10,000 women.^[1] On balance, the trial concluded that CEE plus MPA should not be started or continued to prevent heart disease.^[1]

That conclusion was applied far more broadly than the trial, which had tested one regimen in one population. Prescriptions for Prempro, the combined pill WHI used, fell by about two thirds within a year.^[3] Total US hormone prescriptions dropped from about 90 million in 1999 to a projected 57 million in 2003.^[3] The authors read this as practice reacting quickly to new evidence of harm.^[3] But the reaction did not sort women by age or symptoms, so 51-year-olds with night sweats stopped alongside 70-year-olds without any.

Later follow-up of the same women refined the picture rather than reversing the facts. After 13 years, women on estrogen alone had significantly less breast cancer than women on placebo, while the combined arm still had more.^[4] After 18 years, the two trials together showed no difference between hormones and placebo in deaths from any cause, heart disease or cancer.^[5] About 27% of women had died in each group.^[5] During the treatment years, women who started in their 50s fared better on mortality than women who started in their 70s.^[5]

In our view, WHI was right about the regimen it tested in women around 63, and the mistake lay in applying it to everyone else. Later analyses showed that some of its harms depend on regimen and age. Others still stand: the raised risks of clots, stroke and, with CEE plus MPA, breast cancer.^{[1, 5, 43]} The Menopause Society, the International Menopause Society and the German S3 guideline for doctors all reflect that more careful reading.^{[14, 15, 17]} The Menopause Society also sees a less favourable balance for women who start after 60 or more than 10 years after menopause.^[14]

US regulators have since changed the labels along the same lines. In November 2025 the FDA announced it would remove the boxed warnings on heart disease, breast cancer and dementia from menopausal hormone products.^[36] A boxed warning is the most prominent warning on a US drug label. On 12 February 2026 the FDA approved the first changed labels, for six products, and more are being updated (as of October 2026).^[57] The warning on endometrial cancer, a cancer of the womb lining, stays for systemic estrogen-only products.^[36] The FDA also said its labelled advice will be to start before 60 or within 10 years of menopause.^[36] The change applies only in the US, and German product information still lists breast cancer, blood clots and stroke as risks.^[48] That start-before-60 advice rests on the idea that timing matters, which two randomised trials after WHI set out to test.

Starting HRT soon after menopause may slow changes in the artery wall, but that does not yet show protection against heart attacks or strokes. The clearest test of timing is the ELITE trial in 643 healthy postmenopausal women. They took oral estradiol (1 mg a day) or a placebo for a median of about five years.^[11] Women with a uterus also used a vaginal progesterone gel, or a placebo gel.^[11] The researchers compared women whose menopause lay less than 6 years back with women 10 or more years past it.^[11]

In the early group, estradiol slowed the thickening of the neck artery wall compared with placebo. That thickening is a marker of how fast artery disease progresses.^[11] In the late group, estradiol made no difference.^[11] Calcium in the heart arteries did not differ in either group, and a thinner artery wall is not a prevented heart attack.^[11] So the timing idea holds on this stand-in measure, while the question about heart attacks and strokes stays open.

The second trial, KEEPS, did not confirm even the artery benefit. It treated healthy women who were within three years of their last period for four years.^[12] They took low-dose oral CEE, an estradiol patch or placebo, with cyclic micronized progesterone or placebo pills alongside.^{[12, 13]} Artery wall thickness grew at the same rate in all three groups, although some heart risk markers improved.^[12] KEEPS used lower doses than WHI and was too small to detect differences in heart attacks or strokes.^[12]

Deaths and heart attacks are what the Danish DOPS trial did count. It randomly assigned 1,006 recently menopausal women to hormone therapy or no treatment.^[42] After 10 years, the combined total of deaths, heart failure admissions and heart attacks was lower in the hormone group.^[42] But DOPS was small for that kind of question and open-label, meaning the women knew what they took.^[42] WHI also looked at heart events in women who started within 10 years of menopause, but it was not designed to test timing.^[43] So no large blinded trial, where women do not know what they take, has yet shown that early HRT prevents heart attacks, strokes or heart deaths.^[42]

The brain results show no benefit from starting early either. KEEPS-Cog, a side study of KEEPS, followed women for an average of under three years.^[13] It found no effect of hormones on memory, attention or other thinking tests.^[13] Oral CEE slightly eased depressive and anxiety symptoms, while the patch did not.^[13] In the earlier WHI Memory Study of women aged 65 and older, CEE plus MPA increased dementia cases rather than preventing them.^[4]

For a woman in her 50s, the case for HRT therefore rests on her symptoms, not on preventing heart disease or dementia.^{[11, 13, 42]} The balance of benefits and risks is best when she starts before 60 or within 10 years of menopause.^[14] Once she has started, there is no fixed stop date. The Menopause Society sees no reason to stop routinely at 65 if symptoms persist, as long as she and her doctor review the choice regularly.^[14]

HRT treats menopause symptoms well and protects bone in selected women, but it has not been shown to prevent heart disease, dementia or ageing.^{[1, 13, 14]} Hot flashes and night sweats are the main reason to start it. The Menopause Society calls hormone therapy the most effective treatment for them and for vaginal dryness and painful sex.^[14] If you are still working out which of your symptoms are menopausal, the perimenopause guide covers stages and symptoms first.

What HRT is established for

• Hot flashes and night sweats. In placebo-controlled trials, HRT cut the number of hot flashes by about 75%.^[44] German product information names symptoms that affect quality of life as the reason to start HRT at all.^[48]
• Vaginal dryness and painful sex. Doctors call this the genitourinary syndrome of menopause, and unlike hot flashes it tends to get worse over time without treatment.^[14] The usual first step is low-dose vaginal estrogen, in Germany for example Vagifem, Estring or the estriol cream OeKolp. So little of it reaches the blood that no progestogen, the womb-protecting second hormone, is needed.^[14] Systemic HRT, which reaches the whole body, can ease dryness too. For preventing recurrent urinary infections, though, only vaginal estrogen has shown a benefit, while oral estrogen did not reduce infections in trials.^[45]
• Bone. In WHI, the combined pill cut hip fractures by about a third.^[1] In Germany, estradiol is licensed to prevent osteoporosis (bone thinning) in postmenopausal women at high fracture risk who cannot tolerate or must not take other licensed bone drugs.^[48] For those women, bone protection can be a reason for HRT even without hot flashes.
• Premature or early menopause. In some women the ovaries stop working before 40, which doctors call premature ovarian insufficiency, and others reach menopause early. Both groups go without estrogen for longer, and that longer gap is linked to a shorter life and more heart, bone and brain problems.^[58] For premature ovarian insufficiency, the German S3 guideline recommends explaining the importance of hormones, as HRT or a combined pill, at least until the natural age of menopause, unless there is a contraindication.^[17] A 2026 joint paper of the gynaecology federation FIGO and the International Menopause Society calls timely, adequately dosed and long-term hormone therapy a foundation of care when there is no contraindication.^[58] Here hormones replace what is missing years too early, which is a different situation from HRT at the usual age of menopause.

What HRT is not established for

• Preventing heart disease. WHI concluded that combined hormones should not be started or continued to prevent heart disease.^[1] The Menopause Society sees a less favourable balance after 60 or more than 10 years past menopause,^[14] and ELITE's artery benefit was on a marker, not on heart attacks.^[11]
• Preventing dementia. KEEPS-Cog found no effect on thinking in recently menopausal women,^[13] and in the WHI Memory Study, in women aged 65 and older, CEE plus MPA increased dementia cases.^[4]
• Living longer. After 18 years of WHI follow-up, deaths from any cause were unchanged, neither higher nor lower.^[5]
• Depression. Hormones may ease mood symptoms around menopause, and oral CEE slightly eased depressive symptoms in KEEPS,^[13] but HRT is not an established treatment for major depression.

If you cannot take hormones

For women who cannot or do not want to take hormones, two non-hormonal pills are now licensed in the EU. The first is fezolinetant (Veoza), approved since December 2023. In the SKYLIGHT 1 trial, it cut the frequency and severity of hot flashes more than placebo.^[41] The second, elinzanetant (Lynkuet), has been licensed since 17 November 2025 for moderate to severe hot flashes in menopause. It is also licensed for hot flashes caused by anti-hormone therapy after breast cancer.^[54] Ask your pharmacy whether it is available in Germany yet (as of October 2026).

Fezolinetant comes with liver checks. Liver tests are required before the first tablet and every month for the first three months, then as your doctor judges. Treatment is not started if liver values are clearly raised.^[53] Stop and call your doctor at once if you notice yellow skin or eyes, dark urine, itching or marked tiredness.^[53] Veoza must also not be combined with moderate or strong CYP1A2 inhibitors. That group of drugs includes combined pills containing ethinylestradiol and the antidepressant fluvoxamine.^[53] Veoza must not be taken in pregnancy, and combining it with systemic estrogen HRT is not recommended either.^[53] So it is an alternative to hormones rather than an add-on.

There is also an option without any pill. NICE, which writes clinical guidance for England, recommends cognitive behavioural therapy (CBT), a structured talking therapy, for hot flashes and low mood.^[34]

Women with a uterus who take estrogen need a second hormone, a progestogen, because estrogen alone thickens the lining of the womb.^{[14, 48]} For breast cancer risk, observational studies favour micronized progesterone over most synthetic progestins, although no randomised trial has compared them. Observational means that the studies followed women on the treatment they chose rather than assigning one. Micronized progesterone is finely ground and molecularly identical to the progesterone your body makes. Synthetic progestins such as medroxyprogesterone acetate (used in WHI), norethisterone acetate, levonorgestrel and dienogest are related but different molecules.

The main evidence for that preference comes from the French E3N cohort, which followed about 80,000 women for about eight years.^[8] Estradiol with most synthetic progestins was linked to a higher risk of both common types of breast cancer, ductal and lobular.^[8] Estradiol with micronized progesterone showed no clear overall increase.^[8] That reassurance had limits even within E3N. With longer use of micronized progesterone, the risk of one tumour type rose: estrogen-receptor positive, progesterone-receptor negative cancer.^[8] Lobular cancer showed a trend that did not reach significance. Estradiol with dydrogesterone, another progestogen, sat in between, with a raised risk of lobular cancer.^[8]

A 2018 expert review, also based on observational data, found that estrogen with micronized progesterone did not raise breast cancer risk for up to five years of use.^[9] Beyond five years, it found limited evidence of a rise.^[9]

Other large datasets are less tidy, which is why this is a preference and not a proven difference. The UK Million Women Study linked current use of estrogen plus a progestogen to about twice the breast cancer risk of never use.^[7] Estrogen alone came with about 30% more, and the specific progestogen made little difference.^[7] Over 10 years of use, that meant about 5 extra breast cancers per 1,000 women on estrogen alone and about 19 per 1,000 on combined HRT.^[7] The 2019 worldwide pooled analysis then found a raised risk with every systemic combined regimen from the first years of use.^[35] Because both are observational, women who chose HRT may have differed in other ways from women who did not.

In German-speaking countries, women with a uterus who need systemic estrogen commonly get micronized progesterone, sold as Utrogest (Besins) or Famenita (Exeltis). Their German labels give 200 mg at bedtime on at least 12 to 14 days a month, in the second half of each cycle.^{[65, 66]} The UK label of Utrogestan also lists 100 mg at bedtime on days 1 to 25.^[49] Taking 100 mg every night without a break is common practice too. The capsules are taken at bedtime and not with meals, because they can make you drowsy.^{[49, 65]} Utrogest contains soya phospholipids and must not be used with a soya or peanut allergy.^[65] Famenita lists no soya among its ingredients,^[66] and for other brands, check the leaflet.

These licensed progesterone capsules are often called bioidentical, which only means that their hormone matches the one your body makes. Licensed estradiol patches and gels such as Estramon or Gynokadin are bioidentical too, and all of them are ordinary approved medicines. US-style compounded bioidentical hormones, mixed to an individual recipe, are something else: pellet implants, custom troches (lozenges) and saliva-tested protocols. A 2020 report of the US National Academies advised against their routine use, because doses are inconsistent and safety data are missing.^[31] So when a gynaecologist in Germany, Austria or Switzerland says "bioidentisch", she usually means the licensed, evidence-based products, not compounded pellets, troches or saliva-test protocols.^[31]

Yes: observational data suggest blood clots are less common with estrogen patches and gels than with estrogen pills. A 2015 meta-analysis, which pooled observational studies, compared the two routes directly.^[10] Oral estrogen carried about 1.6 times the risk of venous thromboembolism, meaning clots in the deep veins or the lungs.^[10] For deep vein thrombosis, a clot in a deep vein, the risk was about twice as high.^[10] Stroke looked slightly higher with pills in a single study, and heart attack risk did not differ. The authors rated the certainty of all of it as low.^[10]

The likely reason is the route through the liver. A pill passes through the liver before it reaches the rest of the body. In KEEPS, oral CEE raised the inflammation marker CRP and SHBG, the protein that carries sex hormones in the blood.^[12] A patch or gel goes through the skin straight into the bloodstream and skips that first pass. In German-speaking countries, estradiol has also largely replaced CEE, the older estrogen used in WHI and KEEPS.

The German S3 guideline turns the clot finding into advice. Women should be told that pills carry a higher clot risk than transdermal estrogen, which goes through the skin.^[17] Oral combined therapy may also raise the risk of ischaemic stroke, the kind caused by a blocked artery, while transdermal estrogen does not.^[17] The Menopause Society agrees that non-oral routes and lower doses may lower the risk of clots and stroke, though direct randomised comparisons are lacking.^[14] In practice, transdermal estradiol with micronized progesterone is common in German-speaking countries. Observational data support that choice, though neither guideline names it as a default.^{[8, 9, 10]}

Which route suits you depends on which kind of clot history you have, and the two groups below are easy to mix up.

• No systemic HRT at all, patches and gels included: a previous or current venous thromboembolism, a known thrombophilia (an inherited or acquired tendency to clot), or an active or recent arterial thrombosis such as a heart attack or angina.^[48] Any exception is a specialist decision.
• Transdermal estradiol preferred when HRT is otherwise suitable: risk factors such as a BMI over 30, smoking, age over 60 at the start, long immobility or a family history of clots.^{[10, 17]}

Without any of these risk factors, low-dose oral estradiol with micronized progesterone is a reasonable choice for women who prefer pills. Between patch and gel it is mostly a matter of taste: a gel is easier to adjust, and a patch is set and forget. Gynokadin gel, for example, goes on the arms and shoulders once a day and needs a few minutes to dry before you dress.^[48]

Women should consider testosterone for one reason only: clinically significant low sexual desire after menopause, which doctors call hypoactive sexual desire disorder (HSDD). The 2019 Global Consensus on testosterone for women found this to be the only evidence-based indication.^[19] The leading endocrine and menopause societies endorsed it.^[19] For bone, mood, thinking, wellbeing, body composition or energy, it found insufficient data, and an earlier review had reached the same view on low desire.^{[18, 19]} Marketing that sells testosterone to women for energy or body shape therefore goes beyond the evidence. What does help women age well is covered in the longevity guide for women.

Even for low desire, no testosterone product for women is approved by the EMA, the EU's medicines agency. A testosterone patch, Intrinsa, was licensed across the EU from 2006 until it was withdrawn for commercial reasons in 2012.^[55] In 2025 the UK regulator MHRA licensed AndroFeme, a testosterone cream, for low sexual desire after menopause. That licence does not apply in the EU, Germany, Austria or Switzerland.

If your doctor prescribes it

Without a product for women, doctors prescribe a testosterone gel made for men at a much lower dose. That is off-label use, meaning outside the uses the drug is licensed for. Doses are product-specific and set by the doctor. UK specialist guidance starts at about 5 mg of testosterone a day, and the table shows what that means for each gel.^[52]

Sources: UK specialist guidance and product information^{[50, 52]}

Whichever gel is used, the target is a blood level within the normal range for premenopausal women. Your doctor measures it before the start, again 3 to 6 weeks later and then about every 6 months. Each check also looks for signs of too much testosterone, such as acne or excess hair.^{[19, 52]} The effect can take 3 to 6 months to judge. If there is no benefit by six months, the Global Consensus advises stopping.^{[19, 52]}

The men's gels are not licensed for women, and their label warns of masculinising effects.^[50] At female doses, the most common side effects are excess hair growth, acne and weight gain, while voice deepening and hair loss are rare.^[52] Long-term data on heart and breast safety are limited.^[52] To protect others, let the gel dry, wash your hands afterwards, and avoid skin contact with partners and children.^{[50, 52]} The Global Consensus does not recommend compounded testosterone either. Its one exception is a carefully manufactured product dosed to premenopausal levels when no approved equivalent is available.^[19] Pellets, injections and anything that pushes levels above that range are not recommended.^[19]

In Germany this treatment is normally paid privately, on a private prescription. Statutory insurance covers off-label use only in narrow exceptions, such as a serious illness with no other treatment.^[60] The treatment belongs with an endocrinologist or a gynaecologist experienced in hormone therapy who checks blood levels, rather than with a direct-to-consumer telemedicine platform.

TRT, short for testosterone replacement therapy, is justified when a man has symptoms of deficiency and a low testosterone level confirmed on two separate mornings.^[21] The Endocrine Society asks for clearly and consistently low levels, measured in the morning while fasting with accurate tests.^[21] The European Association of Urology (EAU) uses the same morning, fasting, two-occasion rule.^[39] Typical symptoms are low libido, erectile dysfunction, loss of body hair, less muscle mass and strength, fatigue and low mood.^[21] If you are weighing TRT as part of a wider plan, the men 40-plus guide shows where hormones sit next to the bigger levers.

What counts as low depends on the guideline, and the table compares three common cut-offs for total testosterone.

Sources: guidelines^{[21, 22, 39]}

The right limit also depends on the test your laboratory uses. The Endocrine Society's figure applies to labs with tests standardised to the US CDC method, and other labs use their own reference range.^[21] In European practice, a man below about 12 nmol/L with persistent symptoms is a candidate for TRT. That applies especially to low libido, erectile problems that do not respond to PDE5 inhibitors such as sildenafil, or unexplained muscle loss.^[39] The benefit of treatment is larger below 8 nmol/L, and above 12 nmol/L TRT is generally not indicated.^[39] SHBG, the protein that carries testosterone in the blood, can be off because of obesity, thyroid disease or older age. In that case, or when the result is borderline, the Endocrine Society recommends measuring free testosterone, the part not bound to that protein.^[21]

A confirmed deficiency is not yet a prescription. The guideline recommends a further work-up to find its cause before treatment, and it advises against starting TRT in men with.^[21]:

• plans to father a child soon
• prostate or breast cancer
• a palpable prostate nodule or hardening (induration)
• PSA (a prostate blood marker) over 4 ng/mL, or over 3 in men at higher risk, without further urological evaluation
• a raised hematocrit (the share of red blood cells in the blood)
• untreated severe sleep apnoea (breathing pauses during sleep)
• severe lower urinary tract symptoms
• uncontrolled heart failure
• a heart attack or stroke within the last 6 months
• thrombophilia (a tendency to form blood clots)

For men who qualify, the benefit is real but narrower than the marketing. The Testosterone Trials gave 790 men aged 65 or older with low testosterone a testosterone gel or placebo for one year^[20] Sexual activity, desire and erectile function improved moderately.^[20] Physical function barely changed, with a small walking benefit that showed up only when all three sub-trials were pooled.^[20] Vitality did not improve and mood lifted only slightly,^[20] so "the energy you had at 25" is not what the trial found.

Real deficiency is also less common than ads suggest. In the European Male Aging Study of 3,369 men aged 40 to 79, only about 2% met a strict definition of late-onset hypogonadism.^[24] It required at least three sexual symptoms plus low total and low free testosterone.^[24] The much higher figures that circulate online count low blood levels alone, without the symptoms that the guidelines require before treatment.

For men who do start TRT, the TRAVERSE trial found testosterone no worse than placebo for major heart events.^[25] "No worse" here means within a safety margin set in advance. The men had confirmed hypogonadism and high heart risk and were followed for about three years.^[25] That result eased the earlier fears about heart risk for men like these. But the trial was designed to count heart deaths, heart attacks and strokes together, so it cannot settle the question of deaths on its own. It also did not cover use beyond a few years.^[25]

Those earlier fears came from two observational studies. A 2013 study of US veterans with low testosterone linked treatment to more deaths, heart attacks and strokes. That analysis drew heavy criticism and needed published data corrections.^[26] A 2014 analysis of insurance claims found more heart attacks in the 90 days after a first prescription.^[27] The rise was mainly in older men and in younger men with prior heart disease. The FDA's 2015 label warning on heart risk followed those papers.^[37]

TRAVERSE was built to answer them. It enrolled 5,246 men aged 45 to 80 who had heart disease or high heart risk.^[25] All had confirmed hypogonadism, meaning symptoms plus two morning testosterone levels below 300 ng/dL. They used a testosterone gel, adjusted to reach 350 to 750 ng/dL, or a placebo gel. On average they were treated for about 22 months and followed for about 33.^[25] Heart deaths, heart attacks and strokes combined occurred in 7.0% of men on testosterone and 7.3% on placebo.^[25]

The FDA acted on that result. In February 2025 it told manufacturers to remove the heart-risk language from the boxed warning and add the TRAVERSE results.^[37] Every testosterone label also had to gain a warning that it can raise blood pressure. The label still says testosterone is not approved for low testosterone caused by ageing alone.^[37]

TRAVERSE also found risks that belong in any consent conversation. Each was more common on testosterone than on placebo:

• atrial fibrillation, an irregular heart rhythm: 3.5% on testosterone vs 2.4% on placebo.^[25]
• pulmonary embolism, a blood clot in the lungs: 0.9% vs 0.5%^[25]
• acute kidney injury, a sudden drop in kidney function: 2.3% vs 1.5%^[25]
• clinical fractures (broken bones), in a sub-study: 3.5% vs 2.5%, for reasons that are unclear^[46]
• PSA rises, which were larger, although high-grade cancer, any prostate cancer and biopsies did not differ significantly; men with PSA over 3 were not enrolled^[38]

Because TRAVERSE studied only men with confirmed deficiency, it says nothing in favour of testosterone for men with normal levels, for sport or for anti-ageing^[25] For a man who qualifies, these signals are a reason for monitoring and an informed choice rather than a reason to refuse treatment. For a man with normal levels, they are risks without a proven benefit.

Estradiol, the main estrogen, belongs in a man's body too, which is why routinely lowering it alongside TRT is a poor idea. The drugs used for that are aromatase inhibitors such as anastrozole, which block the conversion of testosterone into estradiol. The best evidence on what they do comes from a 16-week experiment in 400 healthy men aged 20 to 50.^[28] Researchers switched off the men's own hormones with a drug. They then replaced them with different doses of testosterone gel, given with or without anastrozole.^[28] Blocking estradiol raised body fat, while lean mass and strength depended on testosterone, and sexual desire depended on both hormones.^[28]

Parts of online TRT culture still treat estradiol as an enemy to be "crashed", with anastrozole or exemestane taken as a precaution. That experiment points the other way, although no long-term trial in men on TRT exists.^[28] So estradiol on TRT is best judged against symptoms and the lab's own reference range, not against a target number from a forum. A precautionary prescription also sits outside the licence. In Germany, Austria and Switzerland, anastrozole is licensed for breast cancer in women, not for male hypogonadism. Statutory insurance covers off-label use like this only in narrow exceptions.^[60]

Breast enlargement in men (gynaecomastia) is not a reason to reach for an aromatase inhibitor either. European andrology guidelines do not recommend these drugs to treat gynaecomastia in general. Instead, its cause needs a work-up, and long-standing cases are treated surgically.^[47]

Neither HRT nor TRT has been shown to extend life. In WHI, hormone therapy left deaths from any cause unchanged over 18 years.^[5] For TRT, no long trial has shown an effect on survival. Both are licensed to treat symptoms or a confirmed deficiency, not for longevity or healthy ageing.^{[48, 69]}

On the men's side there is a tempting observational number. A 2024 analysis pooled cohort studies, which follow large groups of men over many years. Men whose own testosterone was below about 7.4 nmol/L (213 ng/dL) were more likely to die of any cause. Below 5.3 nmol/L, they were also more likely to die of heart disease.^[29] That threshold sits well below the EAU's 12 nmol/L cut-off for treatment, let alone the "optimal" ranges some clinics promote.

Those numbers describe men's own testosterone, not testosterone from a prescription. Low testosterone may partly be a marker of poor health rather than its cause. Because the data are observational, they cannot show that raising it would change survival.^[29] Answering that would take a long randomised trial with death as its outcome.

A different group of men shows the same limit. In US Medicare claims data, men with prostate cancer whose testosterone was lowered by androgen deprivation therapy had about 20% more serious heart and vessel events.^[30] That is an association in a specific group, not proof that lower testosterone harms every man. In our view, it does not make raising testosterone in men with normal levels safe either.

Hormones sold beyond their licensed uses, as "hormone optimisation" or "andropause reversal", are a wellness offer rather than a treatment. Before you pay for them, ask the clinic which symptom it is treating and which guideline criterion your blood values meet. Also ask how often your blood count, PSA or hormone levels will be checked.^{[21, 39]}

German statutory health insurance (GKV) pays for prescription medicines within their licensed use.^[70] That covers HRT for menopausal symptoms and TRT once hypogonadism is confirmed.^{[48, 69]} Most patients therefore pay only the prescription co-pay, called Zuzahlung. It is 10% of the price per pack, at least €5 and at most €10, and never more than the price itself.^[59]

Co-pays are also capped for the year. Once yours reach 2% of your gross annual income, the Kasse exempts you for the rest of the year.^[64] For people with a serious chronic illness in long-term treatment who meet the legal conditions, the limit is 1%.^[64] For TRT, the licensed use is set by the Nebido label. It asks for a deficiency confirmed by symptoms and two independent blood tests, without naming a cut-off.^[69] Hormones used off-label or for "wellness" in people without symptoms or a deficiency are paid privately. The self-pay longevity guide covers what else you pay out of pocket.

HRT products in Germany

The table lists the licensed HRT products, and the first row matters because Estradot is no longer sold (as of October 2026).^[63]

Sources: product information and pharmacy listings.^{[10, 14, 48, 49, 63, 65, 66]}

Self-pay prices on a private prescription (Shop Apotheke, 21 October 2026; prices vary).^[63]:

• Estramon 50 µg, 6 patches: from about €17; Estramon Uno 50 µg, 12 patches: about €27
• Gynokadin Dosiergel, 3 × 80 g: from about €43; at the usual 2.5 g (two pump strokes) a day, one 80 g pump lasts about a month^[48]
• Famenita 100 mg, 90 capsules: about €30

TRT products in Germany

For TRT, the choice is mainly between a long-acting injection and a daily gel, and the table shows how each is used.

Sources: product information^{[50, 51, 52, 69]}

Testosterone gel can pass to partners and children through skin contact, so cover the site with clothing and wash your hands after applying.^[50] Self-pay prices on a private prescription (Shop Apotheke, October 2026).^[63]:

• Nebido 1000 mg / 4 ml: about €139 to €174 per ampoule, one every 10 to 14 weeks
• Testogel 50 mg, 3 × 30 sachets: about €200, so about €65 a month
• plus the doctor's fees for consultations, lab tests and injections

Telemedicine and the law in Germany

Since 2024 several telemedicine providers have offered HRT or TRT in German-speaking countries. For women these include Hormone Online Clinic (Dr Sheila de Liz) and Hormonic Care. For men there are Swiss TRT in Switzerland and private urology practices that market TRT under a men's-health label. They are listed here for transparency, not endorsed.

In Germany, the advertising law for medicines (Heilmittelwerbegesetz) bans advertising prescription drugs to the public and limits advertising for remote treatment^[61] Treatment purely by video or phone is allowed in individual cases when a doctor judges it medically justifiable.^[62] That rule sits in § 7(4) of the model professional code for doctors, which becomes binding through each state medical chamber.^[62] Austria and Switzerland have their own rules, and some platforms work only with private prescriptions outside the GKV.

Whether paid by the Kasse or privately, testosterone is prescribed far more often than it used to be. According to the Arzneiverordnungsreport, Germany's annual prescription report, prescription volume rose by 415% between 2005 and 2023.^[56] The drug-safety bulletin of the German regulators BfArM and PEI suspects that part of that rise reflects use outside the approved indications.^[56]

Both therapies carry real risks that a consent conversation has to cover, and for some people systemic HRT is not an option at all. German product information rules it out with.^[48]:

• known, past or suspected breast cancer, or another estrogen-dependent cancer
• undiagnosed genital bleeding (bleeding from the vagina without a known cause)
• untreated endometrial hyperplasia (a thickened womb lining)
• a previous or current venous thromboembolism (a clot in a deep vein or the lungs), or a known thrombophilia (a tendency to clot)
• an active or recent arterial thrombosis (a clot in an artery), such as a heart attack or angina
• acute liver disease, or past liver disease while liver values have not returned to normal
• porphyria, a rare metabolic disorder

Risks for women on HRT

Breast cancer. Combined HRT raises breast cancer risk from the first years of use, and the risk rises with duration^[35] The 2019 worldwide pooled analysis found a higher risk with every systemic type of HRT, with a smaller excess for estrogen alone.^[35] Part of that risk persisted for more than 10 years after stopping,^[35] and the EMA updated product labels accordingly in 2020.^[32] The German S3 guideline puts this into numbers. Five years of combined HRT from age 50 means roughly 14 to 20 extra breast cancers per 1,000 women over the next 20 years.^[17] Micronized progesterone may carry less risk than synthetic progestins, based on observational data,^{[8, 9]} but there is no risk-free window.

Blood clots. Oral estrogen is linked to about 1.6 times the clot risk of transdermal estrogen.^[10] A past or current clot or a known thrombophilia rules out systemic HRT, patches and gels included.^[48] Risk factors such as a BMI over 30, smoking or a family history of clots make a patch or gel the preferred form.^{[10, 17]}

Endometrial cancer. Estrogen without a progestogen thickens the womb lining and raises the risk of cancer there, called endometrial cancer. So women with a uterus who take systemic estrogen also need a progestogen.^{[14, 48]} Low-dose vaginal estrogen for dryness does not need one, because very little reaches the blood.^[14]

Stroke. In WHI, stroke rose by about 40% on both combined and estrogen-only therapy.^{[1, 2]} The relative rise did not differ by age or years since menopause,^[43] and the German label says the same.^[48] Because stroke is rare in women in their 50s, the absolute excess is small at that age, and it grows with age.^[48] Oral estrogen may carry more stroke risk than transdermal estrogen.^[17]

Risks for men on TRT

Red blood cells. Testosterone raises the hematocrit, the share of red blood cells in the blood. The usual threshold to pause TRT is a hematocrit above 54%.^[21] The rise is more common with injections than with gels, and in men with sleep apnoea or chronic lung disease.^{[21, 39]} The Endocrine Society advises checking the hematocrit before the start, at 3 to 6 months, at 12 months and then yearly.^[21]

Prostate. In TRAVERSE, PSA, a blood marker from the prostate, rose more on testosterone.^[38] Yet high-grade cancer, any prostate cancer and biopsies did not differ significantly, and men with PSA over 3 were not enrolled.^[38] A palpable prostate nodule is a reason not to start.^[21] So is a PSA over 4 ng/mL, or over 3 in men at higher risk, without further urological evaluation.^[21]

Blood pressure. Since 2025 the FDA has required every testosterone label to warn that it can raise blood pressure. That warning followed studies that measured blood pressure around the clock and found rises across products.^[37] Check your blood pressure before you start and at every follow-up.

Heart rhythm, clots, kidneys and bones. In TRAVERSE, atrial fibrillation (an irregular heart rhythm), pulmonary embolism (a clot in the lungs), acute kidney injury and broken bones were all somewhat more common on testosterone.^{[25, 46]} The reason for the fracture finding is unclear, and TRT has not been shown to prevent fractures.^{[39, 46]} Atrial fibrillation is worth discussing before the start, particularly with high blood pressure, sleep apnoea or a history of heart rhythm problems.

Gel transfer. Testosterone gel can pass to partners and children through skin contact, so cover the site with clothing and wash your hands after applying.^[50]

Whether these risks are worth taking depends on what they buy. They can be worth it for women with bothersome symptoms who start HRT in their 50s with a suitable route and progestogen. The same goes for men with confirmed hypogonadism on monitored TRT, but not for anyone paying that price for anti-ageing.^{[14, 21, 25]} A sensible first step is an appointment where your doctor goes through the contraindications in the product information with you. For men, that appointment should include two morning testosterone measurements.^{[21, 48]}