Once upon a time, people used to think that hormone replacement therapy after menopause was a risk-free proposition. In fact, way back when, some doctors thought that every woman ought to go on hormones at menopause and stay on them for the rest of her life. Then came the Women’s Health Initiative, raising questions about the safety of these hormones, and women got scared. I have many patients who come to me terrified of taking hormones, and as a result they have suffered with severe hot flashes, insomnia, mood swings, and vaginal dryness.

But the truth is somewhere in the middle: These hormones are too big a risk for some women, but can be a big help for others. So it’s worth noting that a recent consensus statement, published on behalf of seven international menopause and women’s health societies, has deemed hormone replacement therapy (HRT) to be relatively safe in women who are under 60 years of age or within 10 years of menopause. Here are some of the highlights of the statement:

– HRT may prevent osteoporosis-related fractures in women who are at risk of these debilitating bone breaks.

– The use of estrogen-only hormone replacement can help in the prevention of heart disease.

– When these hormones are taken orally (as opposed to being used in skin patches, for instance), they can increase the risk for blood clots and stroke.

– Women who use a combination of estrogen and progesterone may have a slightly higher risk for breast cancer.

I am glad that the relative safety of HRT for women under 60 has been acknowledged. But even this consensus statement makes the therapy seem a little riskier than it is when it’s prescribed with care. Why do I say this? The societies’ statement expresses caution regarding the use of estrogen and progesterone in combination. However, the clinical studies on which they based their opinion actually used progestin, not progesterone—and there is a big difference between the two.

Progestin is a synthetic hormone. This type of hormone is known to increase the risk for blood clots, fluid retention and high blood pressure. Natural progesterone is the “feel good” hormone of pregnancy. It reduces inflammation, acts as a natural diuretic and helps to keep blood vessels dilated so that blood can flow smoothly. Women can get a bioidentical version of progesterone (not progestin) by prescription, and that is what I recommend to my patients who need it. I do not recommend progestin, which is also called Provera.

As for estrogen, I agree that the oral form increases a woman’s risk of blood clots and other problems. Because of that, I recommend using estrogen in a transdermal (through-the-skin) form—in a gel or patch. It can also be used under the tongue. Any of these routes will help to avoid blood clots.

Many women breeze through menopause. The rest of us have symptoms that can be debilitating (in addition to making us hard to live with). The key, if you are in the latter category, is to find a doctor who understands the benefits and risks of HRT and realizes the need for a good quality of life. Then, the two of you can find a treatment that works for you.