Hormone Therapy for Menopause Symptoms

What is hormone replacement therapy (HRT)?

Hormone replacement therapy, or HRT, is a treatment that helps people with symptoms of menopause.

Healthcare providers also call it hormone therapy (HT), especially when you receive treatment after age 50. Most often, hormone replacement therapy (HRT) is the term providers use when you receive the treatment at a younger age, especially before age 40.

As you transition to menopause, your ovaries stop making high levels of estrogen. This can cause uncomfortable symptoms like:

• Hot flashes.
• Night sweats.
• Vaginal dryness and painful sexual intercourse.
• Mood swings, depression or irritability.
• Insomnia.
• Leaking pee.

HRT replaces the hormones that your body isn’t making enough of. Once your hormone levels rise, most people find relief from their symptoms. HRT can also help with bone loss (osteoporosis and osteopenia), a common condition in people assigned female at birth (AFAB) who don’t have enough estrogen.

Whether you should consider taking HRT is a discussion to have with your healthcare provider. While hormone therapy reduces menopausal symptoms, it comes with risks. You should discuss the risks and benefits of hormone therapy with your provider to determine if it’s right for you.

Is hormone therapy the same as hormone replacement therapy?

When treating symptoms of menopause, your provider may use the terms interchangeably. But there can be slight differences between the two.

Hormone therapy (HT) is a broader term, which means it may apply to any type of treatment involving hormones. For example, hormone therapy for cancer or to treat certain hormonal imbalances. When people say hormone replacement therapy, they’re usually talking about menopause. But when people say hormone therapy, they aren’t always talking about menopause.

The term your provider uses may also have something to do with your age. When you’re closer to the natural age of menopause, they may use the term hormone therapy.

On the other hand, hormone replacement therapy (HRT) usually means the hormones are replacing the natural hormones your body is no longer making, especially for people in their 30s or early 40s. The important difference is that HRT can have different risks depending on your age.

What are the two types of hormone replacement therapy (HRT)?

There are two main types of HRT: estrogen therapy and combination therapy (estrogen and progesterone). Your healthcare provider will discuss each type with you and recommend what form will work best for you based on your symptoms, medical history and preferences.

Estrogen therapy

Estrogen therapy involves taking only estrogen. Healthcare providers most often prescribe a low dose of estrogen to begin with. Estrogen comes in many forms, like:

• Pills that you swallow by mouth.
• A patch that sticks to your skin.
• A gel that you apply to your skin.
• A ring that you wear inside your vagina.
• A cream that you apply to your vagina.
• Tablets that you place inside your vagina.
• A spray that you apply to your arm.

If you’ve had a hysterectomy (surgery to remove your uterus), your provider typically recommends estrogen-only therapy. This is mainly because estrogen taken alone has fewer long-term risks than HT which uses a combination of estrogen and progesterone.

Combination therapy (estrogen progesterone therapy or EPT)

This form of HRT combines doses of estrogen and progesterone (also called progestin, which is the name for all hormones that act like progesterone, including synthetic ones). People who still have a uterus need a progestin.

Progestins help reduce your risk of uterine cancer, which is higher when you take estrogen only. During your reproductive years, cells from your uterine lining shed during menstruation. When you stop getting your period and the lining stops shedding, estrogen can cause an overgrowth of cells in your uterus, a condition that can lead to cancer.

Combination therapy typically comes in a pill or skin patch, but can also come in an IUD (intrauterine device) that your provider places inside your vagina.

Ways to take HRT

There are two additional terms that describe how you take hormone therapy: systemic and local.

• Systemic hormone therapy: Systemic therapy means the product gets into your bloodstream and then travels to the organs and tissues it needs to get to. Examples of systemic products include pills, patches, sprays and gels. These products tend to work for hot flashes, night sweats and most of the common symptoms of menopause.
• Local hormone therapy: Local therapy means you apply the product to a specific area. An example of a local therapy is a vaginal cream, ring or tablet (tablets melt inside your vagina). This is especially helpful when your main symptom is vaginal dryness. Local therapy tends to come in a much lower dosage.

How does hormone replacement therapy (HRT) work?

As you approach menopause, your ovaries shrink and stop producing estrogen and progesterone. Not having enough of these hormones in your body is what causes your menopausal symptoms. HRT works by giving you those lost hormones back. But HRT comes with both health benefits and risks, which may be higher in some people. Your healthcare provider can help determine if the benefits of HRT outweigh the risks.

How often do you take hormone replacement therapy?

You typically begin with the lowest effective dose, which means the lowest dose that helps your symptoms. People who lose estrogen too early (before age 40) are usually given higher doses to replace what their ovaries would typically produce for their age.

Estrogen-only therapy is daily. How you apply it (or take it) depends on which type of product you and your provider choose. They’ll make sure you know when and how to use it.

Combined therapy is a little different and you can take it as either continuous-combined therapy or cyclic therapy:

• Continuous-combined therapy: You take both estrogen and progesterone each day in whatever form works best for you.
• Cyclic therapy (or sequential therapy): You take estrogen every day. You take progesterone for 12 to 15 days each month. Because you only take it for a short time, the most common way to take progesterone is in a pill you swallow.

There isn’t a one-size-fits-all approach to HRT. Rather, your healthcare provider will work on a treatment plan unique to you, your symptoms and your health history.

What are the benefits of taking hormone replacement therapy (HRT)?

A main benefit of HRT is that it relieves uncomfortable symptoms of menopause. This can lead to a better quality of life and allow you to get back to activities that you enjoy.

If HRT works for you, it can help with:

• Vaginal dryness and uncomfortable sex.
• Hot flashes and night sweats.
• Estrogen deficiency. If you had to have an oophorectomy (surgery that removes one or both ovaries) before age 45, estrogen therapy can help decrease your risk of getting health conditions associated with low estrogen like osteoporosis.

Other health benefits of taking HRT include:

• Reduces your risk of developing osteoporosis or breaking a bone.
• Improves mood and overall happiness in some people.
• Improves your sleep.
• Combination therapy lowers your risk of colon cancer.
• Reduces your risk of diabetes.

What are the possible risks of taking hormone replacement therapy (HRT)?

While hormone replacement therapy (HRT) can help you get through menopause, it may come with risks. Possible health risks include:

• Increased risk of uterine cancer (only if you still have your uterus and aren’t taking progestin along with estrogen).
• Increased risk of heart disease if you begin using HRT 10 years after menopause starts.
• Increased risk of blood clots and stroke.
• Increased risk of gallbladder disease.
• Increased risk of breast cancer with long-term use in some people.

Many of these possible risks also have to do with your overall health and family history of health conditions. It’s important to discuss your individual risk with your provider.

Risks of HRT are generally lower if you:

• Start HRT before age 60 or within 10 years of menopause. Studies show your risk for complications from HRT is higher if you begin HRT more than 10 years after menopause symptoms begin. Taking HRT in your 40s or 50s is typically not associated with an increased risk of cardiovascular disease.
• Take a progestin if you still have a uterus.
• Find the best type of HRT for you. Work with your provider to find a therapy that best minimizes your risk.
• Live a healthy lifestyle. This includes getting physical activity, managing chronic conditions and maintaining a weight that’s healthy for you.
• Get regular gynecological exams and mammograms.

If you’re thinking about hormone therapy, it’s important to learn as much as you can from your provider. HRT should be an individualized treatment that your provider evaluates often to make sure the benefits outweigh the risks.

Alternatives to HRT

If HRT doesn’t work for you or your provider believes you won’t benefit from HRT, there are alternative options that may help your symptoms. Ask your healthcare provider if any of the following could work for you instead:

• Over-the-counter (OTC) vaginal lubricants.
• Antidepressants for hot flashes.
• Selective estrogen receptor modulators (SERMs) for hot flashes and painful sex.
• Gabapentin, oxybutynin or clonidine to help with hot flashes and insomnia. These medicines are FDA-approved to treat other medical conditions, but they can work well for menopause symptoms.
• Fezolinetant or paroxetine, which are both FDA-approved to treat hot flashes.

Who shouldn’t take hormone replacement therapy (HRT)?

Your healthcare provider may decide HRT isn’t for you if you:

• Have or had breast cancer, ovarian cancer or uterine cancer.
• Have abnormal vaginal bleeding.
• Have had blood clots or are at high risk for them.
• Have a history of stroke, heart attack or increased risk for cardiovascular disease.
• Are pregnant.
• Have gallbladder or liver disease.

What are the side effects of hormone replacement therapy (HRT)?

The most common side effects of hormone replacement therapy are:

• Irregular vaginal bleeding.
• Breast tenderness.
• Mood swings.

Less common side effects of hormone replacement therapy include:

• Bloating.
• Headaches.
• Skin discoloration.
• Increased breast density, making mammogram interpretation more difficult.
• Skin irritation under the estrogen patch.

How can I reduce side effects of hormone replacement therapy (HRT)?

Typically, side effects resolve on their own within a few months. In most cases, these side effects are mild and don’t require stopping your HRT. If your symptoms bother you, ask your healthcare provider about adjusting either the dosage or the form of the HRT to reduce the side effects. Never make changes to your medication or stop taking it without talking to your provider.

How long should I take hormone replacement therapy (HRT)?

Generally, most people take HRT for five years or less. But there’s no set length of time, and it can vary depending on the severity of your symptoms, what type of HRT you take and your preferences.

Your provider will continue to monitor you and reevaluate your treatment plan. If you develop a new medical condition while taking HRT, see your provider to discuss if it’s still safe to continue taking HRT.

Does HRT increase my risk for breast cancer?

Taking combined hormone therapy may increase your risk of developing breast cancer, but most studies show that the increase is small (less than 1 in 1,000). Typically, breast cancer risk doesn’t increase until after five years of use. Several factors determine breast cancer risk other than taking HRT.

It’s always best to discuss your personal risk factors for cancer with your provider. They’re the best person to help you understand your individual risk for cancer and other conditions.

Does HRT increase my risk of heart disease?

Scientists continue to learn about the effects of hormones on your heart and blood vessels. Most studies say that when you start hormone therapy closer to menopause (like in your early 50s), there’s less risk of heart disease compared to starting HT after age 60.

Because early loss of estrogen increases the risks of many conditions, including cardiovascular disease, people who lose their estrogen before age 40 are at risk for heart disease if they don’t use hormone replacement therapy (HRT).

This is a complex issue because your risk of heart disease depends on many factors, not just whether you take hormones. Examples include your family history and if you have conditions like high blood pressure or high cholesterol.

It’s always best to talk to your healthcare provider because they can recommend treatment based on your health history.

When should I call my healthcare provider?

Contact your healthcare provider if you have symptoms of menopause that are disrupting your daily life. Your provider can explain treatment options to you, including hormone replacement therapy. It’s important that your provider helps you understand the pros and cons of HRT and how they apply to your unique situation.

Whatever you decide, make sure you arrive at a decision after getting all your questions answered.

Why are some doctors against hormone replacement therapy?

The decision to take hormone replacement therapy is highly personal and complex. It depends on many factors like your health history, your age and your symptoms. Healthcare providers know the risks and benefits of HRT and how to apply them to your unique case.

With that being said, there are times when healthcare providers don’t recommend HRT after evaluating your situation. It’s important to know that they aren’t against HRT because they want you to experience discomfort. Rather, they’re aware of the risks and how those risks may apply to you. If your provider thinks HRT isn’t the right treatment for you, discuss alternative options with them.

Which is better HRT or bioidentical hormones?

Bioidentical hormones are a type of HRT. Compared to other synthetic hormones, they more closely match your body’s natural estrogen and progesterone. There are multiple FDA-approved options to get bioidentical hormones. Sometimes, bioidentical hormones are compounded at a pharmacy. This is called a custom compounded hormone. Compounded hormones aren’t well-studied and healthcare providers are unsure of their long-term effects. For this reason, many providers don’t recommend them.

Still, the decision on which one you should take (or which one is better) is highly personal and based on your symptoms, medical history and what your provider believes is best for you.

A note from Cleveland Clinic

If you’re experiencing symptoms of menopause that are impacting your quality of life, you may be wondering if hormone therapy is an option for you. The decision to try hormone therapy is a personal one. HRT is complex and not for everyone.

It’s important to arrive at your decision to take hormone therapy after discussions with your healthcare provider. Discuss the risks and benefits at an office visit dedicated to this conversation. You’ll need the time to address all your questions and make a decision that’s best for you. Be sure to talk about the pros and cons of the different types and forms of HRT. Even if HRT isn’t right for you, there are other treatment options that your provider may recommend to help treat your menopause symptoms.