Anyone with ovaries and a uterus will eventually go through menopause. On the surface, menopause means you’ve stopped having menstrual cycles for at least a year — which in turn means you're no longer able to get pregnant. But when you dig deeper, menopause is a time when your body stops producing reproductive hormones, resulting in a drop in levels of estrogen. Low levels of hormones are the culprit for the hot flashes and vaginal dryness typically linked to menopause. But with hormone replacement therapy (sometimes called menopausal hormone therapy) or alternative treatment options, you’re not stuck with these uncomfortable symptoms.
In this article, we'll break down what you need to know about hormone replacement therapy and whether it’s an option to discuss with your doctor. Before we get into it, here are the biggest takeaways:
- Hormone replacement therapy is a type of treatment that boosts estrogen and/or progesterone hormone levels to relieve menopause symptoms when your body doesn't make enough of the hormone.
- There are different types of hormone replacement therapy. The most common treatments involve increasing estrogen hormone levels.
- There are also different ways to take your hormone replacement therapy. The most common method is taking a daily pill.
- Research on the side effects of hormone replacement therapy is still ongoing, but there has been data suggesting it may increase the risk of blood clots, heart disease, and some cancers. That said, for many people, the benefits may outweigh the risks.
- Hormone replacement therapy is best for people with ovaries who are younger than 60 with less than ten years post-menopause. But hormone replacement therapy may cause more harm than good for people with certain preexisting health conditions.
First things first: What's happening to your hormones before and after menopause?
Menopause is marked by no menstrual cycles after at least a year. Since cycles have come to a stop, there are no more developing eggs producing estradiol (an estrogen). As estradiol levels decline, uncomfortable symptoms can arise. These are some of the more common ones:
- Hot flashes
- Vaginal dryness
- Vaginal burning or irritation
- Pain during sex
- Sleep problems
Since decreased hormone production is the cause of these symptoms, treating them may involve hormone replacement therapy (HRT).
What is hormone replacement therapy (HRT)?
Hormone replacement therapy (HRT) is a medical treatment that increases hormone levels to relieve menopause symptoms. But because everyone experiences menopause differently (you might feel more hot flashes while your friend has night sweats or trouble sleeping), hormone therapies come in all shapes and sizes.
Here’s a rundown of the different types of HRT available for treatment of the symptoms of menopause:
- Hormones: Recommendations may be made for estrogen-only or combined hormone therapy (estrogen plus progestin) at various doses (depending on age and needs).
- Forms: Estrogen therapy is available via pills or tablets (taken by mouth), skin patches (applied to the thigh or belly), vaginal creams or vaginal tablets, or a vaginal ring, skin gel, or nasal spray. Progesterone therapy is available in pills, skin patches, vaginal creams, vaginal suppositories, or the intrauterine device (IUD).
Why are estrogen and progesterone often taken together?
If you've gone through menopause and still have your uterus (meaning you haven't undergone a hysterectomy), progesterone (as progestin, the synthetic form) will often be recommended alongside estrogen to reduce the risk of endometrial cancer (aka uterine cancer). Since a rise in estrogen tells your body to thicken the endometrium (uterine lining) in preparation for the implantation of a fertilized egg, taking estrogen on its own may encourage the growth of endometrial cells — leading to that increased risk of cancer. Research suggests that progestins can block this effect.
There's also some evidence that progestins could help with treating hot flashes.
When are people prescribed hormone replacement therapy (HRT)?
Hormone replacement therapy may be recommended (but isn't always) for people with menopause to help with treatment of difficult menopausal symptoms. But that doesn’t mean you need hormone therapy when you reach that time in your life.
When should you consider hormone therapy? That depends. "If hot flashes are your primary concern, estrogen in pill or patch form will be very effective in reducing the frequency and severity," explains OB-GYN and Modern Fertility medical advisor Dr. Eva Luo, MD, MBA. "But if vaginal dryness is your primary concern, then estrogen in vaginal cream, ring or tablet form may be most effective in providing a localized dose of estrogen to the affected area."
For those who don't want to take HRT, the American College of Obstetricians and Gynecologists (ACOG) also recommends a few alternatives:
- Over-the-counter vaginal moisturizers and lubricants for vaginal dryness
- Antidepressants for hot flashes
- Selective estrogen modulators (like tamifoxen), which block the effects of estrogen on certain tissues, for hot flashes or pain during sex
- Dehydroepiandrosterone (DHEA), a daily vaginal insert, for pain during sex
- Gabapentin (a pain and seizure medication) for hot flashes or sleep problems
- Clonidine (a blood pressure medication) for hot flashes and sleep problems
- Plant and herbal supplements (those these haven't been as rigorously tested for safety or effectiveness)
What are the other benefits and risks of taking hormone replacement therapy (HRT)?
In 2002, the Women's Health Initiative (WHI), which was initiated by the National Institutes of Health, published a randomized controlled trial (the gold-standard in clinical research) with 16,608 postmenopausal women (ages 50-79) to evaluate the benefits and risks of HRT in the US. Participants either took estrogens and progestin or a placebo. After around five years of taking HRT, here's what they found:
- There was a decreased risk of bone fractures and colon cancer.
- There was a slight increased risk of breast cancer, coronary heart disease, stroke, and venous thromboembolic events (i.e., blood clots in the veins).
Then, in 2016, a team of researchers reanalyzed the WHI data and walked away with several key guidelines for prescribing HRT:
- Patient age and the number of years since menopause largely impact benefits and risks.
- For postmenopausal people with symptoms who are under 60 years old or within 10 years of menopause, the benefits of HRT outweigh the risks.
- Early initiation of HRT (within that 10-year window) can decrease the risk of cardiovascular disease and mortality, as well as possibly provide protection against cognitive decline.
- Since combined HRT increases the risk of breast cancer after five years, keeping the therapy to under five years is ideal.
Today, healthcare providers use the above guidelines when suggesting or prescribing HRT to their patients.
Is there anyone who shouldn't take hormone replacement therapy (HRT)?
Not everyone should get HRT. In some cases, the health risks outweigh the benefits:
- People with a family history of breast cancer or the BRCA 1 or 2 gene: Combined hormone replacement therapy carries a small risk of breast cancer. But if you have a history of breast cancer or a breast cancer gene, the risk is even higher. Doctors recommend not undergoing hormone therapy if you happen to have one of the two.
- People with a history of cardiovascular disease: People with a history of atherosclerotic cardiovascular disease (build-up of substances in the arteries), stroke, and blood clots should avoid hormone therapy.
- People with a history of other health conditions: Dr. Luo adds that people with hypertriglyceridemia (high levels of triglycerides in the blood), active gallbladder disease, history of stroke or transient ischemic attack (TIA), acute liver disease, unexplained vaginal bleeding, a high risk of endometrial cancer, and known clotting disorders (like factor V Leiden) shouldn't take estrogen therapy.
For anyone with a history of breast cancer and/or cardiovascular disease, Dr. Luo recommends talking to your healthcare provider. "This requires a calculated discussion on risks and benefits," she explains. "Your doctor may use a risk calculator such as the Breast Cancer Risk Assessment Tool to aid in the discussion."
How might hormone replacement therapy (HRT) change over time?
According to Dr. Luo, you can "expect monitoring when taking HRT and dose adjustments over time." Your treatment doses are based on what stage of menopause you’re in and how severe your symptoms are over time:
- Early menopause: People in early menopause are likely to receive continuous oral or transdermal (through the skin) estrogen doses and 200 mg of oral progesterone per day for the first 12 days of the month. With moderate symptoms, estrogen via skin patches are given at 0.025 mg twice a week or 0.5 mg of estrogen via pills. Severe menopausal symptoms are likely to begin at a higher estrogen dose — 0.05 mg of estrogen skin patches twice a week or 1 mg of estrogen pills daily.
- Later menopause: People who have had menopause for about 2-3 years may start off with 1 mg of a daily estrogen pill or 0.05 mg of estrogen via a skin patch. Progesterone doses would be 2.5 mg per day. At this stage of menopause, having continuous administration of estrogen and progesterone is an increased risk factor for irregular bleeding and breast cancer.
"The goal is to take the lowest possible dose to relieve symptoms for as short a period of time (five years or less and not beyond 60 years) as possible," says Dr. Luo. She adds that if a patient experiences vaginal bleeding, HRT may be stopped and the patient may be evaluated for endometrial cancer.
If you and your healthcare provider decide to discontinue HRT, it’s recommended to stop treatment gradually rather than quitting cold turkey.
How is hormone replacement therapy (HRT) for menopause different from gender-affirming hormone therapy?
While gender-affirming hormone replacement therapy for transgender women is in theory similar to hormone replacement therapy for menopause, there are large differences in the prescription protocol:
- Age at prescription: Gender-affirming hormone replacement therapy may be prescribed at much younger ages.
- The use of ther hormones: Hormones that block the production of "male" sex hormones (aka androgens like testosterone) may also be taken alongside estrogen therapy (and sometimes progesterone therapy).
The bottom line
While menopause isn’t fun for a lot of people, you have options to make the experience less unpleasant. Hormone replacement therapy has been a go-to option for relieving menopausal symptoms. An important thing to keep in mind is that hormone replacement therapy is designed with you in mind. There are many ways to take it and your dose schedule can be adjusted to your needs.
Hormone replacement therapy carries many benefits, but it isn’t risk-free. That said, for many postmenopausal people, the benefits may outweigh the risks. Before you start any treatment for menopausal symptoms, it’s important to talk to your healthcare provider about your symptoms and medical history to see if you’re a candidate for the therapy.
This article was medically reviewed by Dr. Eva Marie Luo, MD, MBA, OB-GYN at Beth Israel Deaconess Medical Center and Clinical Lead for Value at the Center for Healthcare Delivery Science at Beth Israel Deaconess Medical Center.