Everything You Should Know About Hormone Therapy for Menopause

It’s now generally considered safe, but there are some risks to be aware of.

By Amy NortonReviewed by Sanaz Ghazal, MD

July 22, 2024

A picture of pills of HRT for menopause symptoms

Anyone who gets a period will likely go through menopause too. But just because it’s a natural process, doesn’t mean it doesn’t suck. Just when you reach the life stage where you should be throwing yourself a little party—no more riding the crimson wave, overpriced period products, or birth control, for that matter—you might be hit with hot flashes, painful sex, and other unpleasant symptoms.

The good news? There are treatments, like hormone therapy (HT)—which is also known as hormone replacement therapy (HRT) or menopausal hormone therapy—that are perfectly appropriate for a lot of people. The bad news? There’s so much confusion and misinformation about who can take HT and what type is the best—there are pills, gels, creams, vaginal suppositories, and even a topical spray, to name a few—that your doctor might shrug their shoulders and leave you to white-knuckle (or google) your way through your Golden Girls years. “We still have this sense of confusion,” Lauren Streicher, MD, a professor of obstetrics and gynecology at Northwestern University Feinberg School of Medicine, in Chicago, tells SELF. “And that’s not only on the part of women, but of medical professionals, who are often very uncomfortable with hormone therapy.”

If you count yourself among the confused or simply the curious, read on for some hormone therapy basics.

What is HT and why is it controversial?

Hormone therapy is basically estrogen, the hormone that declines at menopause, taken with or without another one, called progestogen. If you’ve had a hysterectomy, you can take estrogen-only HT. If you have a uterus, the estrogen needs to be balanced with a progestogen—usually a type called progestin—since using estrogen alone can raise the risk of uterine cancer.

Decades ago, HT was seen not just as a way to fix hot flashes but as a possible remedy for other health problems—heart disease, cancer, even Alzheimer’s disease—despite the fact that the research was decidedly murky as to whether it really did all that. At the height of its use, about 15 million women were on HT, or roughly 40% of women aged 50 to 74 in the US. That’s a lot of people.

So the federal government launched a huge clinical trial called the Women’s Health Initiative (WHI) to really nail down all those supposed health benefits. But surprise! The trial was halted early, in 2002, when it became apparent that women using the most commonly prescribed type, a combination of an estrogen and progestin, actually had a slightly increased chance of having a heart attack, stroke, or breast cancer. (Oh, and dementia too.) Even though the risks were relatively small, the fact that millions of people were taking them meant that added up to more than 14,000 people in the US who developed potentially life-threatening health problems every year from taking oral estrogen combined with progestin.

Practically overnight, women dumped their pills, and doctors stopped prescribing them. (And for many of them, this was entirely the right thing to do—the breast cancer rates dropped sharply at the same time, with a 6.7% decline between 2002 and 2003.)

The problem with that reaction, Dr. Streicher tells SELF, is that the WHI had some nuances that were lost in the shock of it all. The biggest one, she says, is that most participants were older than 60. That means they started hormones when they were most likely past the age of having hot flashes—which is the biggest benefit of HT—and at a baseline greater risk of the serious side effects, like heart disease and cancer, than younger women.

Those initial findings, Dr. Streicher says, got tons of media coverage and became ingrained in the collective psyche. But what came next did not get the same attention: First, Dr. Streicher says, another analysis of the WHI found that for younger participants—those who started HT in their 50s—“the data were actually very reassuring.” A raft of studies published since have also suggested as much. (More on that below.)

Today, Dr. Christmas says, the evidence suggests that for many people younger than 60 and within 10 years of menopause, the potential benefits of HT outweigh the risks.

What are the benefits of HT?

Hot flashes and night sweats are the number one menopause complaint. And for those symptoms, HT is “hands down” the most effective treatment option, says Samantha Dunham, MD, co-irector of the Center for Midlife Health and Menopause at NYU Langone Health, in New York City. (That said, there are other treatment options—more on that in a bit.)

HT is approved by the Food and Drug Administration for four menopause-related uses, says Monica Christmas, MD, director of the Center for Women’s Integrated Health at University of Chicago Medicine:

Treating moderate-to-severe hot flashes and night sweats (what doctors call “vasomotor” symptoms)
Managing premature menopause (before age 45)
Slowing bone-density loss (although it’s not the gold standard of treatment and there are a lot of other options, like bisphosphonate drugs, which are better for this)
Treating moderate-to-severe genitourinary symptoms—which include vaginal dryness and irritation, pain during sex, and urinary problems like having difficulty peeing or feeling like you need to go all the time

What defines “moderate-to-severe” symptoms? That’s up to you, based on how much they’re disturbing your well-being and daily functioning. “I don’t pick what’s ‘moderate’ or ‘severe’ for people,” Dr. Christmas tells SELF. “I let them tell me.”

What type of HT should you take?

On average, systemic HT (which exposes more of the body to estrogen) can be taken in a pill, foam, spray, gel, or patch and cuts the frequency of hot flashes and night sweats by 75% and the severity by even more, according to a 2022 review by the North American Menopause Society (NAMS). However, if you want to take it for other reasons—painful sex for example—there are other options that may be even safer because they limit exposure to one part of the body—the vagina—and avoid sensitive areas, like breast tissue. (If you do use systemic HT for hot flashes, experts generally recommend you take the lowest dose possible for the shortest amount of time.)

So if you have vaginal dryness and irritation, an OTC vaginal moisturizer without hormones would generally be the first go-to, Dr. Dunham tells SELF. If that doesn’t do the job—or you don’t like using one—vaginal estrogen would be the next step. (You can get this type in a ring, cream, or a pill that’s inserted into the vagina.) As one of the experts we talked to put it, “vaginal estrogen stays in the vagina,” so it’s not considered a good option for hot flashes.

How long should you use HT?

That depends on why you’re using it. If you’re taking a vaginal product, Dr. Christmas says, there’s no time limit. It’s a different story if you’re on systemic HT for hot flashes. Those symptoms, Dr. Christmas says, almost always go away at some point—plus the risk/benefit picture changes as you get older. So she recommends having a “thoughtful conversation” with your provider about whether it’s time for a hormone holiday to see whether your symptoms flare—and if so, possibly switch to a non-hormone alternative.

While there’s no specific recommendation, you might end up taking HT for hot flashes for two to five years, and it’s wise to check in with your doctor once a year or so to discuss how it’s going.

What about the risks?

Hormones are generally safe, but there are risks and downsides, and it’s important to be aware of them. Here are some important things to keep in mind:

Blood clots

Blood clots in the veins—called venous thromboembolisms—are the main risk of HT, Dr. Streicher says. (But, she adds, that seems to be the case only with oral HT, not forms that are absorbed through the skin.) One research review found that for every 1,000 people who used oral HT before age 60, eleven developed a blood clot, compared with six in every 1,000 who took a placebo. Despite that risk, some people may still prefer a pill over a patch or gel, both Drs. Streicher and Dunham say: You might get skin irritation from those products, or you may not absorb transdermal estrogen that well. And other times, Dr. Streicher notes, the choice comes down to insurance coverage.

Heart disease and stroke

In the WHI, women who started HT when they were younger than 60 did not have heightened risks of heart attack or stroke. There’s even evidence, from the WHI and other studies, that those HT users are less likely to develop or die from heart disease than their peers who don’t use HT. (Hormones are not approved for preventing heart trouble, though.)

Breast cancer

Looking to the WHI again, women who used estrogen-only HT had a reduced risk of breast cancer over the next 20 years. In contrast, those who took estrogen-progestin pills had a slightly heightened risk of breast cancer: It would amount to less than one additional case of breast cancer for every 1,000 users per year—a little higher than the risk linked to drinking a glass of wine every day, to give it some context. Dr. Streicher says that extra risk is believed to be due to the progestin used in the WHI. There’s evidence, Dr. Dunham says, that the progestins used today may be less likely to contribute to breast cancer risk—but that’s not yet proven.

Last but not least, menopausal HT can cause less serious but still annoying side effects, including breast soreness, spotting or bleeding, bloating, and headaches.

Who should avoid using HT?

Some people really shouldn’t use menopausal HT. Per the American College of Obstetricians and Gynecologists, this includes anyone who has ever had:

Breast or endometrial cancer
A heart attack or stroke
Blood clots
Liver disease

Those contraindications are specific to systemic hormone therapy, Dr. Dunham says. Local estrogen therapy delivered to the vagina “really stays in the vagina when used as prescribed,” she tells SELF.

How do I know if I should take HT?

First, Dr. Christmas says, it can be helpful to know that hot flashes and night sweats have an expiration date. “For the vast majority of people, they persist for about 4.5 years after the last menstrual period,” she says—though research shows that Black women tend to deal with them longer (even up to 10 to 11 years).

For someone with only occasional hot flashes, Dr. Christmas says, the prospect of having them for a few years might seem manageable without any particular treatment. (Here are some cooling products that might help.)

If that is not you, or you have other symptoms, talk to your doctor about the options—which do include non-hormonal therapies. Dr. Christmas points to several: Certain antidepressants, cognitive behavioral therapy, the anti-seizure medication gabapentin, and the overactive-bladder drug oxybutynin have all been shown to reduce hot flashes and night sweats. There’s also a new oral medication called Veozah that treats vasomotor symptoms by targeting certain brain receptors that help regulate body temperature.

Ultimately, everyone’s experience of menopause is different, Dr. Christmas says, and there’s no one magic pill for addressing symptoms.

A final word

It’s not always easy to find a health care provider who listens to you and will discuss your concerns about menopause—let alone go in depth on hormone therapy. “It’s like they don’t think it’s their job to meet you where you are, and say, ‘Okay, this is troubling you, let’s look into this,’” Jennifer McCarthy, a 52-year-old New Yorker, tells SELF. She went through something of a medical odyssey for her debilitating hot flashes and other symptoms. “They were like, ‘Just drink less wine, and stop with the coffee, and work out more, and meditate,’” McCarthy says.

Eventually, she found a physician who specializes in menopause and took the time to ask her “tons of questions.” McCarthy ultimately opted for an estrogen/progestin skin patch. “I’ve never had another hot flash…. And it’s slowed down my bone loss,” she says.

Unfortunately, Dr. Streicher says, many doctors lack education and training in menopause. She notes that NAMS has a search feature that helps you find a local person who is either a member of NAMS and/or a “certified menopause practitioner”—which means that they have taken a menopause exam, so that at least tells you the provider is interested in the topic and has basic knowledge.

“It’s not a guarantee they’ll be an expert,” Dr. Streicher says. “But it’s a good place to start.”