Menopause Topics:
Hormone therapies (HT), sometimes mistakenly called hormone replacement therapy, are the prescription drugs used most often 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 estrogen and progestogens, that are lost during the menopause transition. Hormone therapy is FDA-approved as a first-line therapy for the relief of bothersome hot flashes and is shown to be the most effective treatment. In particular, the benefits particularly outweigh the risks for HT when used in early menopause to relieve vasomotor symptoms (VMS), hot flashes, 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 high-enough levels to have significant effects in widespread areas, which is needed to treat symptoms of menopause 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 for both moisturizing and rebuilding tissue. Very little goes into blood circulation, so the risks are far lower.
Systemic hormones include estrogens, either the same or similar to the estrogens the body produces naturally, and progestogens, which include progesterone — the progestogen 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 breast cancer risk usually doesn’t rise until after about 5 years with estrogen plus progestogen therapy (EPT) or after 7 years with estrogen alone.
Is Hormone Therapy Safe?
For most women, experts agree that HT helps to control moderate to severe menopause symptoms such as hot flashes when initiated within 10 years of onset of menopause or under age 60 years.
You and your healthcare professional need to balance your individual benefits and risks based on your medical history. For example, if you don’t 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 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, symptom severity, preferences, available treatment options, and cost considerations.
There are risks associated with HT, including:
- Stroke — Both ET and EPT increase the risk of stroke. That risk goes away, however, soon after you stop taking hormones.
- Blood clots — 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 didn’t have a hysterectomy and still have a uterus, you need to take EPT. If you have already had uterine cancer (also called endometrial cancer), it’s not a good idea to take HT, although a progestogen by itself might be an option. Discuss this with your healthcare professionals.
- Breast cancer — If you are wondering whether HT causes cancer, there is some good news for women who use ET. Women can use ET for 7 years before the breast cancer risk increases. The risk goes up after 3 to 5 years for women who use EPT. Their risk might be lower if they take micronized progesterone intermittently and start HT early.
But there are plenty of benefits, as well, including:
- Reduced symptoms — Lessening of hot flashes, night sweats, vaginal dryness and the poor sleep, irritability, and “brain fog” that go with them.
- Vaginal symptom relief — Including thinning tissue and dryness and the consequences, such as painful intercourse. (If you take low-dose oral or transdermal HT, you may need to add a vaginal estrogen to get relief.)
- Ease overactive bladder — You might see relief from your frequency issues and maybe even recurring 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 could lower your risk of cardiovascular disease.
- Reduce your diabetes risk — Scientific evidence shows 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 can be made.
Although 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 Adverse Effects of Hormone Therapy?
Hormone therapy can 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 switching the form of HT you use may decrease adverse events.
You may ask whether HT causes weight gain. Although it’s a common problem for midlife women, associated with both aging and hormone changes, HT is not associated with weight gain. It may even lower the chance of developing diabetes.
Stopping 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 change to nonpill forms of HT. Hot flashes may or may not return after you stop HT.
Although not proven by studies, slowly decreasing your dose of estrogen over several months or even over several years may reduce the chance that your hot flashes will return. You and your healthcare professional will work together to decide the best time to stop HT.
If very bothersome hot flashes 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 duration of use and as you age, 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’ve heard about 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 mean 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 custom mixed. There are many well-tested, FDA-approved hormone therapy products that meet this definition and are commercially available from retail pharmacies in a variety of doses. This allows you and your doctor to customize your therapy.
Are custom-compounded hormones more effective than bioidentical hormones?
Custom-compounded hormones are not safer or more effective than approved bioidentical hormones. They are not tested for safety and effectiveness or to prove that the active ingredients are absorbed appropriately or provide predictable levels in blood and tissue.
In fact, they may not even contain the prescribed amounts of hormones, and that can be dangerous. For example, when the 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 of endometrial cancer and possibly breast cancer.
Videos & Podcasts
The Menopause Society is proud of its comprehensive video series for women and healthcare professionals on important midlife health topics.
View the entire video & podcast series
The Menopause Society 2023 Nonhormone Therapy Position Statement
Chrisandra L Shufelt, MD, MS, MSCP
Hormone Therapy: Discussing the Risks and Benefits with Your Patients
Jewel M Kling, MD, MPH, FACP, NCMP
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