Hormone Replacement Therapy for Menopause

What is hormone replacement therapy? 

Menopause is the time in your life when menstruation slows down and stops. It can be a normal part of aging, or it can be caused by surgery or illness. During menopause, your hormones' levels begin to change. This can cause symptoms like:

• Hot flashes

• Night sweats

• Vaginal dryness

• Mood changes

Why trust us

Our Author:

Sarah Gupta, MD

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Sarah Gupta, MD, is a board-certified physician. In addition to a diverse clinical practice, Dr. Gupta has worked with a number of biotech companies on the cutting edge of medical innovation and has helped develop the world’s first at-home vaginal microbiome test. This guide is based on the best information on menopause and hormone replacement therapy currently available in the international literature.

For many people, menopause symptoms are mild. But sometimes, symptoms can have a huge impact on your day-to-day life. Fortunately, hormone replacement therapy (HRT) — also known as menopausal hormone therapy — can help. HRT replaces the hormones that your body makes less of during and after menopause: estrogen and progesterone.

HRT was a routine treatment until about 20 years ago, when the Women’s Health Initiative raised some concerns about safety. But since that time, we’ve learned more about the risks and benefits of HRT. And these days, experts agree that for most healthy, relatively young people, the benefits of HRT outweigh any risks.

Experts also agree that people going through menopause need facts. With this, in mind here’s a guide to HRT: what it is, how it works, and the risks and benefits, so you can have the facts you need to decide whether HRT is right for you.

Are you in menopause?

Menopause is technically defined as the point when you’ve gone 12 months without having a period (and its absence was not caused by another condition, like pregnancy). Most people in North America usually experience menopause between the ages of 40 and 58. But menopause-related hormone changes can begin as early as your 30s and 40s — a time that is sometimes called “perimenopause.”

During perimenopause, you may notice some changes in the frequency and length of your periods. You may also have some menopause symptoms. When your periods stop, you have completed menopause. For many people, this is a process that can take several years.

There are a wide variety of symptoms that can occur during menopause. Hot flashes are especially common. Other symptoms include:

• Sleep problems

• Night sweats

• Vaginal thinning and loss of elasticity

• Vaginal dryness and irritation

• Dry skin, eyes, or mouth

• Frequent urinary tract infections (UTIs)

• Mood changes or anxiety

• Poor concentration or “brain fog”

Unfortunately, there’s no simple test to confirm whether you are in perimenopause or menopause. Hormone tests can sometimes be helpful, but they don’t always give you a straight answer — especially since your hormone levels can vary naturally throughout the month.

Many people are able to identify that they are in menopause based on their age and symptoms. It can be helpful to talk it over with your provider, to confirm that your symptoms are related to menopause instead of another condition (like hypothyroidism).

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How does hormone replacement therapy work?

Your period is controlled by reproductive hormones made by your ovaries. As your ovaries age, they slowly stop making hormones. This causes your periods to slow down and eventually stop.

HRT replaces two of the key hormones made by your ovaries: estrogen and progesterone. In your body, these replacement hormones work just like the estrogen and progesterone that your ovaries make. Increasing your hormone levels can help reduce menopause symptoms and can have other health benefits as well.

HRT can be dosed in different ways. Dosing may depend on whether you are still having a regular period. Two common approaches are:

• Cyclical dosing: This is for people who have menopausal symptoms but still have a period. Different doses of hormones may be used during certain weeks of your menstrual cycle.

• Continuous dosing: This is usually for people who have completed menopause (have not had a period for 12 or more months). In continuous dosing, you take the same dose of hormones every day without a break.

What types of hormones are typically used in HRT?

HRT is usually either estrogen alone or estrogen plus progestin (progesterone). These different treatments are called:

• Estrogen-only HRT: This treatment includes estrogen, but no added progestin. It is usually only for people who have had their uterus surgically removed (hysterectomy). Estrogen-only medications are also sometimes used directly in the vagina.

• Combined HRT (estrogen and progestin): This treatment includes both estrogen and progestin. Most people take combined HRT if they have a uterus. This is because too much estrogen can increase the risk of uterine cancer; the progestin balances out the estrogen and protects the uterine lining from growing too quickly.

Estrogen

Estrogen is the go-to hormone treatment for menopause symptoms. It can either be given as a whole-body (or “systemic”) medication, or it can be placed directly in the vagina.

• Whole-body estrogen: This type of estrogen can be taken by mouth, given as a shot or implant, or applied to your skin. It contains high doses of estrogen that circulate throughout your body. It can help with many menopause symptoms and with bone thinning.

• Vaginal estrogen: This type of estrogen is put directly in your vagina. It can be applied as a cream, or as a hormone-releasing device. This type of medication mostly stays in the vagina, and doesn’t circulate as widely throughout your body — which means it doesn’t have the same risks as whole-body estrogen. It can help with vaginal and urinary menopause symptoms at any age.

Progestin (progesterone)

Progestin is mostly used as an add-on treatment with whole-body estrogen. If you have a uterus, and are using whole-body estrogen, you may also need to take progestin to protect yourself from endometrial (uterine lining) cancer. You might not need to take progestin if you have had your uterus removed or are using only vaginal estrogen. A levonorgestrel intrauterine device is another option for protecting the lining of your uterus.

What are the different types of HRT medications?

There are four different types of HRT medications:

• Estrogen medications

• Progestin (progesterone) medications

• Combination estrogen and progestin medications

• Combination estrogen and other medications

These medications are available in many different forms, including:

• Pills

• Shots

• Gels

• Creams

• Implants

• Vaginal devices

Many of the FDA-approved medications listed here are biologically identical to your body’s own hormones.

Oral medications

Skin patches

Injections

Estrogen gel, cream, or spray

Vaginal estrogen

Is hormone replacement therapy safe?

What are the risks of HRT?

Just like any medication, HRT has some risks. But overall, the bottom line is encouraging: When HRT is started before age 59, or within 10 years of menopause, the benefits seem to outweigh risks.

Depending on your personal history and hormone use, HRT may increase your risk for:

• Stroke: Estrogen-only HRT and combined HRT can both increase your risk of having a stroke. But if you start HRT early, this risk is very low — in fact, in some cases, HRT may even have a protective effect. In a large study, there was no increased risk for stroke in people who started HRT within 5 years of starting menopause. The risk also goes away once you stop taking hormones.

• Blood clots: In a large study, oral HRT increased the risk of serious blood clots by 43%. However, blood clots do not seem to be a risk if you use an estrogen injection, or an estrogen that is absorbed through your skin (like a gel, cream, spray, or patch).

• Uterine cancer: Estrogen can encourage the lining of your uterine to grow, increasing your risk for uterine cancer. Taking progestin at the same time may lower this risk. Low-dose vaginal estrogen may also have a lower risk for uterine cancer than body-wide HRT.

• Breast cancer: HRT can increase your risk for breast cancer, but only if you take it for a long time. Breast cancer risk only increases after 7 years on estrogen-only HRT, and after 3 to 5 years on combined HRT. This risk may be even lower with some types of progesterone.

In addition, you are also more likely to have complications from HRT if you:

• Are age 60 or older

• Entered menopause more than 10 years ago

• Are obese (Body mass index, or BMI, greater than 30)

• Are diabetic, or have a history of insulin resistance

• Have high cholesterol

• Have metabolic syndrome

• Have high blood pressure

• Smoke cigarettes

• Have a personal or family history of blood clots

If I do take HRT, how can I reduce my risks?

If you do decide to use HRT, there are ways to limit your risks. One approach is to keep your hormone use as low as possible. For example:

• Use the lowest dose of estrogen that will provide you with relief.

• If you only have vaginal symptoms, consider using a vaginal estrogen (rather than a body-wide medication). Vaginal estrogen usually circulates throughout your body at a lower level.

• Use HRT mindfully. Consider checking in with your healthcare provider every 3 to 6 months — or at least annually — to talk about your medication, and to re-evaluate your overall health. In some cases, your provider may recommend you taper off of HRT after 2 to 5 years to limit your risks, especially if you have been stable for years. They may also recommend lower doses of hormones as you get older.

If you are concerned about blood clots, you can also consider using a skin-based medication, like a:

• Patch

• Gel

• Cream

• Spray

These types of medication do not seem to have the same risks for serious blood clots that oral medications do. Skin-based and vaginal estrogen treatments may also have a lower risk for stroke than pills and tablets do.

When taking HRT, you should also check in regularly with your healthcare provider, to keep an eye on your overall health. Preventive care exams, including mammograms and pelvic exams, may be especially important while you’re on HRT. Your provider can also support you in managing other chronic conditions that can increase your risk of HRT complications — like diabetes, high cholesterol, and high blood pressure.

Finally, lifestyle choices can help you stay healthy while on HRT. Consider:

• Getting regular exercise

• Eating a diet rich in fruits, vegetables, and whole grains

• Limiting tobacco and alcohol

• Maintaining a healthy weight

Who should not use HRT?

Though HRT is generally considered safe for many people, there are certain groups who may need to avoid HRT. These groups have a higher risk for complications from hormone replacement. This includes people who:

• Are pregnant, or may become pregnant

• Have experienced abnormal vaginal bleeding (not related to menstruation)

• Have active colon, breast, or endometrial (uterine) cancer

• Have recently had a stroke, heart attack, or blood clot

• Have active liver disease

What are the benefits of HRT?

Relief from menopause symptoms

HRT is the most effective treatment for menopause symptoms. Body-wide HRT can help with many symptoms, including:

• Hot flashes

• Poor sleep

• Irritability

• Brain fog

Vaginal estrogen is especially good at helping with vaginal dryness and pain during sex. Vaginal estrogen may also help with urinary tract symptoms, like an overactive bladder and recurrent UTIs.

Protection for your bones and colon

After menopause, many people experience bone loss. This can lead to osteoporosis, a condition where your bones become weak and brittle. People with osteoporosis are more likely to have bone fractures, which can lead to other problems.

Body-wide (systemic) estrogen can help protect you against osteoporosis. Though there are other types of medications that can also help to protect your bones, HRT can be a good option if your osteoporosis medication isn’t working — or if there’s a reason that you can’t take this type of medication. It’s also a great choice for bone protection if you have other symptoms of menopause, like hot flashes, night sweats, or mood changes.

There’s also some evidence that combination HRT (estrogen and progestin together) may reduce your risk for colon cancer.

Lowered risk of heart disease and diabetes

People who start HRT before age 60 (or within 10 years of menopause) may have a lower risk for heart disease and type 2 diabetes later in life. HRT may also help slow down the disease in people who already have type 2 diabetes, or if diabetes runs in their family.

Protection for your brain

For some people, hot flashes are more than just “feeling hot.” In fact, hot flashes may actually have an impact on your memory and thinking skills. There’s also some evidence that using HRT to keep hot flashes under control may actually protect your brain from premature aging.

Protection for people who experience early menopause

Some people go through “early” menopause (before age 45). This may be caused by genetics, an illness, or surgery, or it may not have a clear cause. But no matter what the reason, early menopause means that you won’t naturally be exposed to as much estrogen throughout your lifetime. This can increase your risk for some health conditions, like:

• Osteoporosis (weak and brittle bones)

• Heart disease

• Stroke

• Dementia

• Mood changes

For people who experience early menopause, HRT is recommended to reduce the risk of these complications.

Is it ever too late to start hormone replacement therapy?

HRT should ideally be used in people younger than 60, or who are within 10 years of menopause. For people in these categories, the benefits clearly outweigh the risks. But what if you are outside this window of opportunity? Is it reasonable to still consider using HRT?

The short answer: It depends. In certain cases, the risks of HRT might outweigh the benefits. In people who are further out from menopause — like 10 to 20 years, or more — HRT is associated with a higher risk of:

• Heart disease

• Stroke

• Blood clots

• Dementia

Still, there are times when HRT makes sense for older people. About 20% of people have hot flashes into their 60s and 70s; others have osteoporosis that doesn’t respond well to medications. These are examples where HRT could be a reasonable choice. There are also other (lower-risk) options, like antidepressants, estrogen patches, or creams, that can help.

If it has been a while since you went through menopause — or you’re older than 60 — talk to your healthcare provider about what options are right for you. Remember: Hormone treatment isn’t one size fits all. The risks and benefits of HRT are different for different people.

And finally, it’s never too late to use vaginal estrogen. Vaginal estrogen creams, tablets, and rings can help with dryness, pain during sex, and UTI prevention. They also do not increase the risk for cancer, heart disease, or hip fracture — even when used later in life.

What are the side effects of hormone replacement therapy?

Any medication can have side effects, including HRT. Many side effects go away over time as your body adjusts to the medication. Common side effects of estrogen and progestin HRT include:

• Headache

• Diarrhea or vomiting

• Changes in sex drive or ability

• Nervousness

• Brown or black skin patches

• Acne

• Swelling of feet, hands, or legs

• Changes in menstruation

• Breast tenderness or discharge

• Problems wearing contact lenses

Will hormone replacement therapy make me gain weight?

No — this is a myth. HRT does not cause weight loss (or weight gain). In a large review of almost 30,000 women, there was no significant difference in weight between the people who used HRT and people who did not use HRT. In some people, HRT can cause bloating, which can be mistaken for weight gain. This is a side effect that usually goes away with time.

The truth is: Weight gain during and after menopause has more to do with hormonal changes, aging, and diet and lifestyle than HRT. After menopause, many people gain an average of 5 lb. You may find that you gain weight more easily, or in different areas of your body. If weight is a concern, consider adding more physical movement into your daily life or reducing your calorie intake.

Do I need a prescription for hormone replacement therapy?

Yes. In the U.S., HRT is not available without a prescription. Because of the potential risks involved, you should talk with a healthcare provider before starting HRT.

Though it’s possible to get HRT over the internet or through the mail, you should be wary of any online pharmacies willing to sell hormones without a prescription. If you do get your medications online, make sure you use only a provider verified by the National Association of Boards of Pharmacy, like GoodRx.

If you are interested in getting a prescription for HRT, you can talk to your healthcare provider about options. Some people may prefer to work with an OB-GYN or menopause specialist.

You can also consider a telehealth consultation like GoodRx Care — an especially convenient option during COVID-19. There are even menopause-specific telehealth options for managing all of your care from home. If finances are a challenge, many free clinics and Planned Parenthood are offering virtual options during COVID-19.

What if HRT isn’t right for me? Are there other options?

Though HRT is the best overall treatment for many people, menopause symptoms can sometimes be managed with lifestyle changes and home remedies. Non-prescription herbs, supplements, and mind–body treatments may also be worth considering. About 50% of people will use some sort of natural treatment during menopause, and 60% find these treatments at least somewhat helpful. There are also several types of non-hormonal prescription medications that can help.

Keep in mind

Menopause treatments are continuing to evolve. There is ongoing research about HRT, including which hormones, medications, and herbal supplements are most helpful. One example is whether testosterone (another hormone) could be helpful for menopause symptoms, especially low libido. Since testosterone is partially converted to estrogen in your body, it’s not clear yet whether this causes risks to your health.

Many people also have questions about “bioidentical” hormones as an alternative to traditional HRT. Experts do not recommend using these types of hormones. They are not regulated by the FDA, so their quality and safety are not guaranteed. Keep in mind that many FDA-approved options for HRT are actually biologically identical to your body’s own hormones.

It’s also worth keeping in mind that HRT for menopause is easily confused with other types of hormone treatment — in particular with gender-affirming hormone therapy. Though both treatments sometimes use estrogen and progesterone, they are different treatments with different goals.