Deciding about hormone therapy
HRT - deciding; Estrogen replacement therapy - deciding; ERT- deciding; Hormone replacement therapy - deciding; Menopause - deciding; HT - deciding; Menopausal hormone therapy - deciding; MHT - deciding
Hormone therapy (HT) uses one or more hormones to treat symptoms of menopause.
Menopause and Hormones
During menopause:
- A woman's ovaries stop making eggs. They also produce less estrogen and progesterone.
- Menstrual periods slowly stop over time.
- Periods may become more closely or more widely spaced. This pattern may last for 1 to 3 years once you start skipping periods.
Menstrual flow may come to a sudden halt after surgery to remove the ovaries, chemotherapy, or certain hormone treatments for breast cancer.
Menopause symptoms may last 5 or more years, including:
- Hot flashes and sweats, usually at their worst for the first 1 to 2 years after your last period
- Vaginal dryness
- Mood swings
- Sleep problems
- Less interest in sex
HT can be used to treat menopause symptoms. HT uses the hormones estrogen and progestin, a type of progesterone. Sometimes testosterone is also added. In women who've had a hysterectomy, estrogen alone is often used.
Some symptoms of menopause can be managed without HT. Low-dose vaginal estrogen and vaginal lubricants may help vaginal dryness.
HT comes in the form of a pill, patch, injection, vaginal cream or tablet, or ring.
Taking hormones can have some risks. When considering HT, learn about how it can help you.
You're a woman nearing middle age. It's that time in your life when your periods are starting to stop and your body is going through changes. You may be starting to have hot flashes that you've heard about before. Could menopause be around the corner? So, what is menopause? Menopause typically happens to women somewhere around the ages of 45 to 55. During menopause, your ovaries stop making eggs and produce less estrogen and progesterone, hormones that play a vital role in pregnancy and how your body uses calcium and maintains healthy cholesterol levels, among other things. Changes in these hormones cause menopause symptoms. You will often begin having fewer periods, and eventually they stop. Menopause is complete when you have not had a period for over a year. Women who are post-menopausal can no longer get pregnant without a donor egg. Symptoms can vary from woman to woman. And these symptoms may last 5 or more years. Also, some women have worse symptoms than others. The first thing you may notice is that your periods start to change. They might occur more often or less often. Some women get their period every 3 weeks during menopause. These changes may last several years before periods completely stop. Other common symptoms include your heart pounding or racing, hot flashes, night sweats, skin flushing, and problems sleeping. You may have a decreased interest in sex, develop forgetfulness, have headaches, and suffer from mood swings, and have vaginal dryness and painful sexual intercourse. Treatment for menopause depends on many things, including how bad your symptoms are, your overall health, and your preference. It may include lifestyle changes or hormone therapy. Hormone therapy may help if you have severe hot flashes, night sweats, mood problems, or vaginal dryness. Hormone therapy is treatment with estrogen and, sometimes, progesterone. Talk to your doctor about the benefits and risks of hormone therapy. Hormone therapy may increase your risk of developing breast cancer, heart attacks, strokes, and blood clots. Topical hormone therapy has some of the benefits and fewer of the risks. Your doctor can tell you about other options besides taking hormones, including antidepressants, a blood pressure medicine called clonidine, and Gabapentin, a seizure drug that can help reduce hot flashes. Lifestyle changes may help in reducing your menopause symptoms, though it's not been proven. You might consider trying to avoid caffeine, alcohol, and certain spicy foods. Or to try eating soy foods and other legumes, because they contain phytoestrogens. You'll want to remember to get plenty of calcium and vitamin D in your food or supplements, and plenty of exercise especially during this time. Consider Kegel exercises every day to strengthen the muscles of the vagina and pelvis. Practice slow, deep breathing if you feel a hot flash coming on. Yoga, tai chi, or meditation may also helpful. After menopause, you may be at risk for bone loss, higher cholesterol, and heart disease, so make sure you work with your doctor to manage or even prevent these problems.
Benefits of Hormone Therapy
When taking hormones, hot flashes and night sweats tend to occur less often and can even go away over time. Slowly reducing HT may make these symptoms less bothersome.
Hormone therapy can also be very helpful in relieving:
- Problems sleeping
- Vaginal dryness
- Anxiety
- Moodiness and irritability
At one time, HT was used to help prevent thinning bones (osteoporosis). That is no longer the case. Your doctor can prescribe other medicines to treat osteoporosis.
Studies show that HT does not help treat:
- Heart disease
- Urinary incontinence
- Alzheimer disease
- Dementia
Research indicates that while taking estrogen appear to reduce the risk of heart attack and death among women in their 50s, it increases these risks for women in their 70s.
Risks of Hormone Therapy
Be sure to talk with your doctor about the risks for HT. These risks may be different depending on your age, medical history, and other factors.
BLOOD CLOTS
Taking HT may increase your risk for blood clots. Your risk for blood clots is also higher if you are obese or if you smoke.
Your risk for blood clots may be lower if you use estrogen skin patches instead of pills.
Your risk is lower if you use vaginal creams and tablets and the low-dose estrogen ring.
BREAST CANCER
- Most experts believe that taking HT for up to 5 years does not increase your risk for breast cancer.
- Taking estrogen and progestin together for longer than 3 to 5 years may increase your risk for breast cancer, depending on the type of progestin you are prescribed.
- Taking HT can make the mammogram image of your breasts look cloudy. This can make it hard to find breast cancer early.
- Taking estrogen alone is associated with a reduction in risk of breast cancer. However, if you take estrogen and progestin together, your risk of breast cancer may be higher, depending on the type of progesterone you take.
ENDOMETRIAL (UTERINE) CANCER
- Taking estrogen alone increases your risk for endometrial cancer.
- Taking progestin with estrogen protects against this cancer. If you have a uterus, you should take HT with both estrogen and progestin.
- You cannot get endometrial cancer if you do not have a uterus. It is safe and recommended to use estrogen alone in this case.
HEART DISEASE
HT is safest when taken before age 60 or within 10 years after starting menopause. If you decide to take estrogen, studies show that it's safest to begin the estrogen shortly after being diagnosed with menopause. Beginning estrogen more than 10 years after the onset of menopause does increase the risk of heart disease.
- HT may increase the risk of developing heart disease in older women.
- HT may increase the risk in women who began using estrogen more than 10 years after their last period.
STROKE
Women who take only estrogen and who take estrogen with progestin have an increased risk for stroke. Using the estrogen patch instead of an oral pill decreases this risk. However, risk may still be increased compared to not taking any hormones at all. Lower HT dosage also reduces the risk for stroke.
GALLSTONES
Taking HT may increase your risk of developing gallstones.
RISK OF DYING (MORTALITY)
Overall mortality is reduced in women who begin HT in their 50s. The protection lasts for about 10 years.
Making a Decision
Every woman is different. Some women aren't bothered by menopause symptoms. For others, symptoms are severe and affect their lives significantly.
If menopause symptoms bother you, talk to your doctor about the benefits and risks for HT. You and your doctor can decide if HT is right for you. Your doctor should know your medical history before prescribing HT.
You should not take HT if you:
- Have had a stroke or heart attack
- Have a history of blood clots in your veins or lungs
- Have had breast or endometrial cancer
- Have liver disease
Certain lifestyle changes can help you adjust to the changes of menopause without taking hormones. They can also help protect your bones, improve your heart health, and help you stay fit.
However, for many women, taking HT is a safe way to treat menopause symptoms.
Currently, experts are unclear on how long you should take HT. Some professional groups suggest that you can take HT for menopause symptoms for longer periods if there is no medical reason to discontinue the medicine. For many women, low doses of HT may be enough to control troublesome symptoms. Low doses of HT tend to have few side effects.
These are all issues to discuss with your health care provider.
When to Call the Doctor
If you have vaginal bleeding or other unusual symptoms during HT, call your doctor.
Be sure to continue seeing your doctor for regular checkups.
References
ACOG Committee Opinion No. 565: Hormone therapy and heart disease. Obstet Gynecol. 2013;121(6):1407-1410. PMID: 23812486
Cosman F, de Beur SJ, LeBoff MS, et al. Clinician's guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2014;25(10):2359-2381. PMID: 25182228
de Villiers TJ, Hall JE, Pinkerton JV, et al. Revised Global Consensus Statement on menopausal hormone therapy. Climacteric. 2016;19(4):313-315. PMID: 27322027
Lobo RA. Menopause and care of the mature woman: endocrinology, consequences of estrogen deficiency, effects of hormone therapy, and other treatment options. In: Gershenson DM, Lentz GM, Valea FA, Lobo RA, eds. Comprehensive Gynecology. 8th ed. Philadelphia, PA: Elsevier; 2022:chap 14.
Magowan BA, Owen P, Thomson A. The menopause and hormone replacement therapy. In: Magowan BA, Owen P, Thomson A, eds. Clinical Obstetrics and Gynaecology. 4th ed. Philadelphia, PA: Elsevier; 2019:chap 9.
National Cancer Institute. Menopausal estrogen therapy benefits and risk vary by age, WHI analysis suggests. May 20, 2011. Accessed May 5, 2022.
Stuenkel CA, Davis SR, Gompel A, et al. Treatment of symptoms of the menopause: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2015;100(11):3975-4011. PMID: 26444994
Version Info
Last reviewed on: 1/10/2022
Reviewed by: John D. Jacobson, MD, Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.
