Menopause Hormone Therapy (HRT): Benefits, Risks & Safety

Hormone therapy—also called menopausal hormone therapy or HRT—is the most effective treatment for bothersome menopause symptoms such as hot flashes and night sweats.

It can also help prevent bone loss and may improve sleep and quality of life when menopause symptoms are disrupting daily life.

But hormone therapy is not right for everyone.

The decision depends on your symptoms, age, time since menopause, whether you have a uterus, and your personal medical history.

For many healthy women who are younger than 60 or within 10 years of menopause onset, the overall benefit-risk balance is generally favorable when hormone therapy is used for appropriate symptoms and there are no contraindications.

This article explains how menopause hormone therapy works, the main types, potential benefits and risks, and what to discuss with your OB-GYN.

What Does Menopause Hormone Therapy Do?

During menopause, the ovaries produce substantially less estrogen. This change contributes to symptoms such as hot flashes and night sweats and also accelerates bone loss.

Systemic hormone therapy replaces estrogen and, when needed, provides a progestogen to protect the uterine lining.

Hormone therapy can:

• Reduce hot flashes and night sweats
• Improve sleep disrupted by hot flashes
• Improve menopause-related quality of life
• Help prevent bone loss
• Reduce fracture risk while treatment is being used
• Improve some genitourinary symptoms

A 2023 JAMA review found that systemic estrogen alone or combined with a progestogen reduces the frequency of vasomotor symptoms by approximately 75%.

For women whose symptoms are significantly affecting their quality of life, hormone therapy can therefore be an important treatment option.

The Two Main Types of Menopause Hormone Therapy

The most important distinction is whether you still have a uterus.

Estrogen-only therapy

Women who have had a hysterectomy may be candidates for estrogen-only therapy.

Because there is no uterus, there is generally no uterine lining that needs protection from systemic estrogen.

Estrogen plus a progestogen

Women who still have a uterus generally need both estrogen and a progestogen when using systemic estrogen.

Estrogen stimulates the uterine lining. A progestogen helps protect against excessive endometrial growth and reduces the risk associated with unopposed systemic estrogen.

The exact hormone, dose, and schedule are individualized.

How Is Hormone Therapy Given?

Menopause hormone therapy is available in several forms.

Oral estrogen

Estrogen is taken as a pill.

Transdermal estrogen

Estrogen can be absorbed through the skin using:

• Patches
• Gels
• Sprays

The route matters.

Evidence suggests that lower-dose transdermal estrogen may have a lower risk of venous blood clots than oral estrogen for some women. The choice should take into account age, dose, cardiovascular and clotting risk, and other medical factors.

That does not mean a patch is automatically the right or safest choice for every woman.

When Is Hormone Therapy Most Favorable?

Timing matters.

For healthy women with bothersome menopause symptoms, the benefit-risk balance is generally most favorable when hormone therapy is initiated:

• Before age 60, or
• Within 10 years of menopause onset

The Menopause Society identifies this group as generally having a favorable benefit-risk ratio when there are no contraindications.

This is not a strict age cutoff.

A woman who is 60 or older may still be an appropriate candidate in certain circumstances. However, starting systemic hormone therapy for the first time substantially later after menopause requires a more individualized discussion because the absolute risks of cardiovascular disease, stroke, blood clots, and other conditions may be higher with increasing age and time since menopause.

What Are the Benefits of Hormone Therapy?

Hot flashes and night sweats

Systemic hormone therapy is the most effective treatment for vasomotor symptoms such as hot flashes and night sweats.

For women whose symptoms interfere with sleep, work, exercise, or daily life, reducing these symptoms can make a substantial difference.

Bone health

Estrogen helps maintain bone density.

Menopause hormone therapy prevents bone loss and reduces fracture risk while treatment is being used.

However, hormone therapy is not automatically the best osteoporosis treatment for every woman. Bone-health decisions should be based on individual fracture risk and other factors.

Quality of life

When hot flashes, night sweats, and sleep disruption are significant, treating those symptoms can improve overall comfort and quality of life.

Understanding the Risks

Hormone therapy has potential risks, but those risks vary according to:

• Age
• Time since menopause
• Type of hormone
• Dose
• Route of administration
• Whether a progestogen is included
• Personal medical history

It is therefore not accurate to describe hormone therapy as either universally “safe” or universally “dangerous.”

Blood clots and stroke

Systemic hormone therapy can increase the risk of venous blood clots and stroke.

The risk can vary according to the formulation, dose, and route. Lower-dose transdermal estrogen may have a more favorable clot-risk profile than oral estrogen for some women.

Breast cancer

The relationship between hormone therapy and breast cancer depends on the type and duration of therapy.

Combined estrogen-progestogen therapy has been associated with an increased breast cancer risk with longer use in some studies.

Estrogen-only therapy has a different risk profile. The evidence from major trials has not shown the same breast cancer signal seen with combined estrogen-progestogen therapy.

Your personal breast cancer history and other risk factors should therefore be considered before treatment.

Heart disease and dementia

Hormone therapy should not be prescribed solely to prevent heart disease, dementia, or other chronic diseases. The USPSTF recommendation against hormone therapy for primary prevention applies to asymptomatic postmenopausal people considering HT specifically for prevention—not to women using hormone therapy to treat bothersome menopause symptoms.

Who May Not Be a Candidate for Systemic Hormone Therapy?

Systemic hormone therapy may not be appropriate for women with certain medical conditions, including a history of:

• Breast cancer or certain other hormone-sensitive cancers
• Unexplained vaginal bleeding
• Blood clots such as deep vein thrombosis or pulmonary embolism
• Stroke
• Heart attack or certain cardiovascular conditions
• Certain liver diseases

This is not a complete list.

Your OB-GYN should review your individual medical history before prescribing systemic hormone therapy.

What If Menopause Happens Early?

Menopause occurring before age 45 is considered early menopause, while menopause occurring before age 40 is generally considered premature ovarian insufficiency when the appropriate diagnostic criteria are met.

Early loss of estrogen can have important consequences for bone and cardiovascular health.

For women with early menopause or primary ovarian insufficiency, hormone therapy may be recommended until around the usual age of natural menopause when there is no contraindication.

This is a different clinical situation from a woman beginning hormone therapy later in life for typical age-related menopause symptoms.

How Long Can You Take HRT?

There is no universal five-year cutoff for menopause hormone therapy.

Some women use treatment for a relatively short period. Others continue to have significant symptoms for much longer.

Current menopause guidance emphasizes:

• Individualized treatment
• Periodic reassessment
• The appropriate dose
• The appropriate route
• The individual’s changing health risks

There is also no requirement that every woman automatically stop hormone therapy at age 60 or 65. Treatment should be reassessed over time rather than stopped solely because an arbitrary time limit has been reached.

What About “Bioidentical” Hormones?

The term bioidentical hormones can be confusing.

Some FDA-approved menopause medications contain hormones that are chemically identical to hormones produced naturally by the body, including certain forms of estradiol and progesterone.

What about compounded bioidentical hormones?

Compounded hormones are custom-prepared by a compounding pharmacy.

They are not FDA-approved, and ACOG states that high-quality evidence supporting their safety and effectiveness is lacking. ACOG recommends FDA-approved menopause hormone therapies over compounded bioidentical hormone therapy when an appropriate FDA-approved option exists.

So:

FDA-approved bioidentical hormone ≠ compounded hormone.

“Natural” or “bioidentical” does not automatically mean safer.

What About Vaginal Estrogen?

Systemic hormone therapy and low-dose vaginal estrogen are different treatments.

Systemic hormone therapy circulates throughout the body and is primarily used for symptoms such as hot flashes and night sweats.

Low-dose vaginal estrogen is primarily used for vaginal and urinary symptoms associated with genitourinary syndrome of menopause.

If your main concern is vaginal dryness, irritation, painful intercourse, or certain urinary symptoms, you may not need systemic hormone therapy.

Menopause Vaginal Dryness & Genitourinary Symptoms: Causes and Treatment

Questions to Ask Your OB-GYN About HRT

Before starting hormone therapy, consider asking:

• What symptoms are we treating?
• Do I need systemic hormone therapy?
• Do I still have a uterus?
• Do I need both estrogen and a progestogen?
• Would a pill, patch, gel, or another form be appropriate?
• What are my individual risks?
• Would transdermal estrogen be appropriate for me?
• How long should I initially try treatment?
• When should we reassess?
• What should I do if I experience vaginal bleeding?
• Are there non-hormonal alternatives?

The goal is shared decision-making, based on your symptoms, health history, risks, and preferences.

The Bottom Line

Menopause hormone therapy can be a highly effective treatment for women experiencing bothersome hot flashes, night sweats, and other menopause-related symptoms.

For many healthy women who are younger than 60 or within 10 years of menopause, the overall benefit-risk balance is generally favorable when there are no contraindications.

But hormone therapy is not one-size-fits-all.

The right treatment depends on your symptoms, whether you have a uterus, your age and timing of menopause, your personal medical history, and your preferences.

The goal is not simply to prescribe hormones. It is to choose an appropriate treatment, understand the potential benefits and risks, and reassess the plan as your health and symptoms change.