Menopause topics:
Hormone therapies (HT), sometimes erroneously called hormone replacement therapy, are the prescription medications most commonly used to treat menopause symptoms, such as hot flashes and genitourinary syndrome of menopause (GSM), which includes vaginal dryness after menopause.
What is hormone therapy?
At the most basic level, hormone therapy replaces female hormones, primarily estrogens and progestins, that are lost during the menopause transition. Hormone therapy is approved by the FDA as a first-line therapy 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 when used in early menopause to relieve vasomotor symptoms (VMS), hot flashes, night sweats, and sleep disorders.
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 using pills, patches, sprays, gels, or a vaginal ring, this is known as systemic therapy. Systemic doses are absorbed into the bloodstream at levels high enough to have significant effects over large 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 at both hydrating and rebuilding tissue. Very little reaches the blood circulation, so the risks are much lower.
Systemic hormones include estrogens, the same or similar to the estrogens the body produces naturally, and progestins, which include progesterone (the progestin the body produces naturally) or a similar compound.
Systemic hormones, very effective for 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 generally does not increase until after about 5 years on estrogen plus progestin therapy (EPT) or after 7 years on 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 before age 60.
You and your healthcare professional should balance your individual benefits and risks based on your medical history. For example, if you do not have a uterus and can receive ET alone, your risks are different than 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 affect a woman’s decision to use hormones (and if she uses them, 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, that risk disappears soon after you stop taking hormones.
- blood clots — The risk increases if hormones are taken orally. The risk may be lower if you use transdermal estrogen, such as a patch, gel, or spray.
- uterine cancer — If you did not have a hysterectomy and you still have a uterus, you should take EPT. If you have already had uterine cancer (also called endometrial cancer), it is not a good idea to take HT, although a progestogen alone could be an option. Discuss this with your healthcare professionals.
- breast cancer — If you’re wondering if HT causes cancer, there’s good news for women who use ET. Women can use ET for 7 years before their risk of breast cancer increases. The risk increases after 3 to 5 years for women who use EPT. Your risk may be lower if you take micronized progesterone intermittently and start hormone therapy early.
But there are also many benefits, including:
- Reduced symptoms — Decrease in hot flashes, night sweats, vaginal dryness and the lack of sleep, irritability and “brain fog” that accompany them.
- Relief of vaginal symptoms. — Including tissue thinning and dryness and its consequences, such as painful sexual intercourse. (If you take low doses of HT orally or transdermally, you may need to add a vaginal estrogen for relief.)
- Relieve overactive bladder — You may notice relief from your frequency problems and perhaps even recurrent urinary tract infections with vaginal estrogen.
- Protect your bones — HT at standard doses helps prevent bone fractures in the future. If you are at high risk for bone fractures or have early menopause, you may be able to take hormones sooner or longer. Discuss this with your healthcare professional.
- Reduce your risk of cardiovascular disease —If you start hormone therapy within 10 years of menopause, you may reduce your risk of cardiovascular disease.
- Reduce your risk of diabetes — Scientific evidence shows that women who use HT have a lower risk of developing type 2 diabetes.
It often requires a period of trial and error to arrive at the best dosage and regimen for you. As new therapies and guidelines become available, and your body and lifestyle needs change over time, reassessments and adjustments may be made.
Although HT may not be the right choice for all women, for some the benefits may outweigh the risks, which is why careful consideration with a trained health professional is so important.
What are the adverse effects of hormone therapy?
Hormone therapy may cause breast tenderness, nausea, and irregular bleeding or spotting. These adverse events are not serious but can be bothersome. Reducing your dose of HT or changing the form of HT you use may decrease adverse events.
You may be wondering if HT causes weight gain. Although it is a common problem in middle-aged women, 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 due to concerns about a possible increased risk of breast cancer. Other women may reduce doses or switch to pill-free forms of HT. Hot flashes may or may not come back after stopping hormone therapy.
Although studies have not shown this, slowly decreasing the dose of estrogen over several months or even several years can reduce the chance of hot flashes returning. You and your health care professional will work together to decide the best time to stop hormone therapy.
If very bothersome hot flashes or night sweats return when you stop hormone therapy, you will need to reassess your individual risks and benefits to decide whether to continue hormone therapy. Because there may be greater risks with longer use and as you age, you and your healthcare professional will work together to decide which option is best for you.
Frequently asked questions
Who should not use hormone therapy?
Hormone therapy is not a good option for all women. For some, the risks outweigh the benefits, so careful consideration with a healthcare professional is recommended. 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’ve heard of something called bioidentical hormones. What are they?
The term bioidentical hormone therapy began as a marketing term for custom compounded hormones. But most use the term to refer to hormones that have the same chemical and molecular structure as the body’s natural hormones.
Bioidentical hormones do not have to be custom compounded or mixed. There are many well-tested, FDA-approved hormone therapy products that meet this definition and are commercially available at retail pharmacies in a variety of dosages. This allows you and your doctor to personalize your therapy.
Are custom-compounded hormones more effective than bioidentical hormones?
Custom compounded hormones are no safer or more effective than approved bioidentical hormones. They have not been tested for safety and effectiveness or to demonstrate that the active ingredients are adequately absorbed or provide predictable levels in the blood and tissues.
In fact, they may not even contain the prescribed amounts of hormones, and that can be dangerous. For example, when your progesterone level is too low, you are not protected against endometrial (uterine) 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.
View the entire video and podcast series
Menopause Society Non-Hormonal Therapy Position Statement 2023
Chrisandra L Shufelt, MD, MS, MSCP
Hormone therapy: discussing the risks and benefits with your patients
Jewel M Kling, MD, MPH, FACP, NCMP
Additional resources on this topic
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