6 things to know about hormone therapy

If you’re going through menopause or perimenopause, you may be experiencing symptoms such as hot flashes, sleep issues, vaginal dryness, or changes in your menstrual cycles. These are all natural parts of the transition, but if these symptoms are affecting your quality of life, effective treatments are available.

There are many options to help you have an easier time as your body moves through this stage, says Erin Mateer, MD, an OBGYN in Tampa, Florida. One of the most effective options is menopausal hormone therapy (MHT), sometimes called hormone replacement therapy (HRT) or hormone therapy (HT).

The MHT formula generally consists of two hormones, estrogen and progestogen. Estrogen relieves menopausal symptoms, explains Dr. Mateer, but it can also cause cells in your uterine lining to overgrow (a condition known as endometrial hyperplasia), which may increase your risk for uterine cancer. So, if you have a uterus, you’ll also need to take a progestogen to counteract uterine overgrowth. If you don’t have a uterus because you’ve had a hysterectomy, you may only need estrogen.

Is hormone therapy safe?

There has been a lot of controversy and misinformation about hormone therapy, so let’s set the record straight. In 2002, the Women’s Health Initiative (WHI)—a trial funded by the National Institutes of Health—reported that women who took MHT had an increased risk of heart attack, breast cancer, blood clots, and stroke. A 2019 follow-up to that study found that the elevated risk of breast cancer, though small, still persisted with estrogen plus progestin treatments. (Estrogen-only treatments were linked to a lower chance of breast cancer in the same study.)

But experts have recently re-examined the 2002 WHI study and found several flaws. For example, the study looked only at orally administered MHT and included only a limited number of women younger than 60 years old, the population best suited to receive and benefit from MHT. Experts now typically recommend short-term use of MHT for certain groups of women who experience moderate-to-severe hot flashes and haven’t responded to behavioral interventions such as exercise, weight management, and dietary changes.

“The pendulum has swung back in the opposite direction,” notes Mateer. “We’re now advising [MHT] for younger women because they may [also] get some protective side benefits when it comes to their heart and bone health.”

MHT can be used to relieve:

• Hot flashes, which can often lead to sleep disturbances
• Genitourinary syndrome of menopause (GSM), which can lead to painful sex, vaginal dryness and itching, vaginal discharge, urinary burning, increased urinary frequency and urgency, and more urinary tract infections

MHT may also offer relief for achy joints and—when used alone or in tandem with an anti-depressant—depression during menopause.

If you’re considering MHT, here’s what you need to know.

Your age matters

The optimal candidate is a person younger than age 60 who is either going through perimenopause or menopause, has no cardiovascular risk factors, and doesn’t smoke. More broadly, MHT is considered safe for most who are within 10 years of the onset of menopause or those younger than 60 who don’t have a history of breast cancer, heart disease, previous blood clots, or stroke or liver disease, among other conditions. Discuss therapy with your healthcare provider (HCP) to be sure you understand the potential risks and benefits.

You should take it for the shortest time possible

If you do decide to take MHT, experts say you should take the lowest effective dose for the shortest amount of time needed to provide relief from symptoms. Talk to your HCP about the dose and duration that makes the most sense for your symptoms and health history.

Most people don’t have any issues going off MHT once they’ve started, though some experts recommend tapering off your doses rather than stopping cold turkey.

There are different forms of MHT

The most common way to take MHT is by taking a pill by mouth, but the therapy is also available in the form of skin patches, rings, and tablets that are placed in the vagina, and even creams and sprays that are applied to the skin. For people who have an increased risk of blood clots, the patch is a better option than a pill. That’s because the hormones in the patch are absorbed directly into the blood through the skin, bypassing the digestive system and the liver, where clotting factors can be affected. This may reduce the risk for blood clots.

If you have only vaginal symptoms such as dryness, the estradiol vaginal ring (Estring) or a tablet placed in the vagina may be good options. “The hormone is broken down by the vaginal cells and stimulates receptors to help relieve dryness and pain,” Mateer adds. There are also vaginal creams that are inserted via an applicator.

One note: If you’re using vaginal estrogen to address GSM, you may not need progestogen, even if you still have your uterus.

Non-hormonal medications may also offer relief

If you and your HCP decide that hormone therapy—in any form—just isn’t right for you, there are other medication options, says Mateer. In 2023, the United States Food & Drug Administration (FDA) approved a non-hormonal oral medication called fezolinetant to treat moderate-to-severe hot flashes due to menopause. Two years later, elinzanetant received FDA approval for treating hot flashes, as well.

Otherwise, while they generally aren’t as effective as MHT, anti-depressants including paroxetine, venlafaxine, desvenlafaxine, citalopram and escitalopram have all been shown to improve hot flashes. An antiseizure medication such as gabapentin or pregabalin, usually taken at bedtime, may offer relief as well.

Black cohosh, an herbal product, is often touted to help with hot flashes, as are plant-derived estrogens called phytoestrogens. But studies haven’t consistently shown that these so-called natural treatments help. It’s best to steer clear of over-the-counter remedies unless you’ve received approval from your HCP.

There are other hormonal options—some are safer than others

While exploring MHT, you may come across the term “bioidentical” or “natural” hormones. These are generally hormones that have the same molecular makeup as the ones you produce in your body, but they come from other sources such as plants. The hormones in traditional HRT are produced in a lab, though they may contain some natural ingredients. The most important thing is to check which ones are approved by the FDA.

And then there are “compounded” hormonal replacement products—customized medications mixed at a pharmacy to meet the customer’s individual needs. Since these treatments are not regulated by the FDA, there’s no guarantee of quality control, and there is no good evidence that compounded hormones work or are safe for long-term use. The American College of Obstetricians and Gynecologists recommends sticking with FDA-approved hormone therapy instead. Compounded products should only be considered if you have an allergy to an inert ingredient in an approved product, or the necessary dose is not available. Always discuss risks and benefits with your HCP before trying a new product or treatment.