Menopause topics:
Hormone therapies (HT), sometimes mistakenly called hormone replacement therapy, are the prescription drugs most commonly used to treat menopausal symptoms such as hot flashes and menopausal genitourinary syndrome (GSM), which includes vaginal dryness after menopause.
What is hormone therapy?
At the most basic level, hormone replacement therapy replaces female hormones, primarily estrogen and progestogens, that are lost during menopause. Hormone therapy is FDA-approved as a first-line treatment for the relief of bothersome hot flashes and has been shown to be the most effective treatment. In particular, the benefits outweigh the risks of HT especially when used in early menopause to relieve vasomotor symptoms (VMS), hot flushes, night sweats, and sleep disturbances.
Types of hormone therapy
Systemic and low dose are the two main types of hormone therapy.
- Systemic therapy: When hormones are delivered throughout the body via pills, patches, sprays, gels or a vaginal ring, this is known as systemic therapy. Systemic doses are absorbed into the bloodstream at sufficiently high levels to have significant effects in widespread areas, which is necessary to treat menopausal symptoms such as hot flashes.
- Low dose therapy: Also called vaginal estrogen therapy (ET) for GSM after menopause, this therapy is administered into the vagina and is effective in both moisturizing and rebuilding tissue. Very little enters the bloodstream, so the risk is much lower.
Systemic hormones include estrogens, either the same or similar to the estrogens the body produces naturally, and progestogens, which include progesterone – the progestin the body naturally produces – or a similar compound.
Systemic hormones – very effective against hot flashes – have other benefits, such as protecting bones. They also carry risks, such as blood clots and breast cancer. The risk of breast cancer does not usually increase until after about 5 years of estrogen plus progestagen therapy (EPT) or after 7 years of estrogen alone.
Is hormone therapy safe?
For most women, experts agree that HT helps control moderate to severe menopausal symptoms such as hot flashes when started within 10 years of the onset of menopause or under age 60.
You and your healthcare professional must balance your individual benefits and risks based on your medical history. For example, if you do not have a uterus and can take ET alone, your risks are different from those women who still have a uterus and must use EPT to protect against uterine cancer.
Hormone therapy for women: benefits and risks
Many factors influence a woman’s decision to use hormones—and if she does, which product or regimen is best—to relieve her symptoms. Common factors include age, underlying health, severity of symptoms, preferences, available treatment options, and cost considerations.
There are risks associated with HT, including:
- Stroke — Both ET and EPT increase the risk of stroke. However, this risk disappears soon after you stop taking hormones.
- Blood clots – The risk increases if you take hormones by mouth. The risk may be lower if you use a transdermal estrogen, such as a patch, gel or spray.
- Uterine cancer — If you have not had a hysterectomy and still have a uterus, you must take EPT. If you’ve already had uterine cancer (also called endometrial cancer), it’s not a good idea to take HT, although a progestogen by itself may be an option. Discuss this with your healthcare professionals.
- Breast cancer — If you’re wondering if HT causes cancer, there’s some good news for women who use ET. Women can use ET for 7 years before breast cancer risk increases. The risk increases after 3 to 5 years for women using EPT. Their risk may be lower if they take micronized progesterone intermittently and start HT early.
But there are also plenty of benefits, including:
- Reduced symptoms — Reduction of hot flashes, night sweats, vaginal dryness and the poor sleep, irritability and “brain fog” that accompany them.
- Vaginal symptom relief — Including tissue thinning and dryness and the consequences, such as painful intercourse. (If you are taking low-dose oral or transdermal HT, you may need to add a vaginal estrogen to get relief.)
- Slightly overactive bladder — You may see relief from your frequency problems and maybe even recurrent urinary tract infections with vaginal estrogen.
- Protect your bones — Standard dose HT helps prevent bone fractures later in life. If you are at high risk of broken bones or have early menopause, you may be able to take hormones earlier or longer. Discuss this with your healthcare professional.
- Lower your risk of cardiovascular disease — If you start HT within 10 years of menopause, you can reduce your risk of cardiovascular disease.
- Reduce your diabetes risk — Scientific evidence shows that women who use HT have a lower risk of developing type 2 diabetes.
Often a period of trial and error is required to arrive at the best dose and regimen for you. As new therapies and guidelines become available and your body and lifestyle needs change over time, reevaluation and adjustments may be made.
While HT may not be the right choice for every woman, for some the benefits may outweigh the risks, which is why careful consideration with a knowledgeable healthcare professional is so important.
What are the negative effects of hormone therapy?
Hormone therapy can cause breast tenderness, nausea and irregular bleeding or spotting. These side effects are not serious, but can be bothersome. Reducing your dose of HT or changing the form of HT you use can reduce side effects.
You may ask if HT causes weight gain. Although a common problem for women in midlife, associated with both aging and hormonal changes, HT is not associated with weight gain. It may even reduce the chance of developing diabetes.
Stop hormone therapy
There is no “right” time to stop HT. Many women try to stop HT after 4 to 5 years because of concerns about a potential increased risk of breast cancer. Other women may lower doses or switch to non-pill forms of HT. Hot flushes may not return when you stop HT.
Although not proven by studies, slowly reducing your dose of estrogen over several months or even over several years may reduce the chance of your hot flashes returning. You and your healthcare professional will work together to decide the best time to stop HT.
If very bothersome hot flushes or night sweats return when you stop HT, you will need to reassess your individual risks and benefits to decide whether to continue HT. Because there may be greater risks with longer use, and as you get older, you and your healthcare professional will work together to decide what is the best option for you.
Frequently asked questions
Who should not use hormone therapy?
Hormone therapy is not a good choice for every woman. For some, the risks outweigh the benefits, so careful consideration with a healthcare professional is advised. In general, women who have breast cancer, uterine cancer, unexplained uterine bleeding, liver disease, a history of blood clots, and cardiovascular disease should not use hormone therapy.
I have heard of something called bioidentical hormones. What are they?
The expression bioidentical hormone therapy began as a marketing term for specially formulated hormones. But most people use the term to mean hormones that have the same chemical and molecular structure as the body’s natural hormones.
Bioidentical hormones do not need to be custom compounded or specially mixed. There are many well-tested, FDA-approved hormone replacement therapy products that meet this definition and are commercially available from retail pharmacies in a variety of dosages. This allows you and your doctor to customize your therapy.
Are specially formulated hormones more effective than bioidentical hormones?
Specially formulated hormones are not safer or more effective than approved bioidentical hormones. They have not been tested for safety and effectiveness or to prove that the active ingredients are properly absorbed or provide predictable levels in blood and tissues.
In fact, they may not even contain the prescribed amounts of hormones, and that can be dangerous. For example, when progesterone levels are too low, you are not protected against endometrial (womb) cancer. When estrogen levels are too high, there can be overstimulation of the endometrium and breast tissue, putting you at risk for endometrial cancer and possibly breast cancer.
Videos and podcasts
The Menopause Society is proud of its comprehensive video series for women and health professionals on important midlife health topics.
Watch the entire video and podcast series
Menopause Society 2023 Nonhormone Therapy Position Statement
Chrisandra L Shufelt, MD, MS, MSCP
Hormone therapy: Discuss risks and benefits with your patients
Jewel M Kling, MD, MPH, FACP, NCMP
Additional resources on this topic
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