What Is Hormone Therapy?
Hormone therapy (HT) replaces the estrogen (and sometimes progesterone) your ovaries stop making during menopause. It's the most effective treatment for hot flashes, night sweats, and vaginal dryness. ✓✓✓ Well-Established
Hormone therapy is not one-size-fits-all. There are many types, doses, and delivery methods. What works for your friend may not be right for you—and that's okay.
Types of Hormone Therapy
Estrogen-Only Therapy (ET)
- Who it's for: Women who've had a hysterectomy (uterus removed)
- Why: Without a uterus, you don't need progesterone to protect against uterine cancer
- Forms: Pills, patches, gel, spray, vaginal ring, or cream
Combined Estrogen + Progestogen Therapy (EPT)
- Who it's for: Women who still have their uterus
- Why: Estrogen alone can thicken the uterine lining and increase cancer risk; adding progestogen (progesterone or a synthetic version called progestin) protects your uterus
- Forms: Combined pills, separate pills, patch, or hormonal IUD (Mirena) for the progestogen part
Local (Vaginal) Estrogen
- Who it's for: Women who only have vaginal symptoms (dryness, painful sex, urinary issues) and don't need treatment for hot flashes
- Why: Very low doses stay mostly in the vaginal area, minimal absorption into bloodstream
- Forms: Vaginal cream, tablet, or ring
- Note: Can be used safely even by women who can't take systemic HT
What Hormone Therapy Treats
Proven Benefits ✓✓✓
Vasomotor Symptoms (Hot Flashes & Night Sweats)
Hormone therapy reduces hot flashes by 75-90% and is far more effective than any non-hormonal option. If hot flashes are disrupting your life, HT is the gold standard.
Vaginal/Urinary Symptoms
HT effectively treats:
- Vaginal dryness, itching, burning
- Painful intercourse
- Urinary urgency and recurrent UTIs
- Vaginal atrophy (thinning of vaginal tissues)
Bone Protection
Estrogen therapy prevents bone loss and reduces fracture risk by 30-40%. However, it's not recommended solely for osteoporosis prevention—we have other effective medications for that.
Possible Benefits ✓✓
- Mood improvements: Some women report better mood, less anxiety, improved sleep quality
- Cognitive function: Mixed evidence; may help if started early in menopause, but not proven to prevent dementia
- Joint pain relief: Some women notice improvement in joint aches
- Skin elasticity: May slow skin thinning and collagen loss
Important: Don't take HT primarily for these "possible benefits." Take it for symptoms that are significantly affecting your quality of life—hot flashes, vaginal dryness, or sleep disruption from night sweats.
Understanding the Risks
The WHI (Women's Health Initiative) study in 2002 made headlines about HT risks—and terrified millions of women. But the full picture is more nuanced.
Timing matters enormously.✓✓✓
Starting HT early (under age 60 or within 10 years of menopause) has a favorable risk-benefit profile. Starting late (over 60 or 10+ years past menopause) increases risks without the same benefits.
Breast Cancer ✓✓✓
What we know:
- Estrogen-only therapy (for women without a uterus): No increased risk for up to 7 years; some studies suggest possible slight decrease in risk
- Combined estrogen + progestogen: Small increased risk—about 1 additional case per 1,000 women per year of use
- Context: This is similar to the increased risk from being overweight, drinking 1-2 alcoholic drinks daily, or not exercising
- Risk decreases after stopping HT
Blood Clots ✓✓✓
What we know:
- Oral estrogen (pills) increases risk of blood clots 2-3x (but base risk is still low—about 2-4 per 1,000 women per year)
- Transdermal estrogen (patches, gel) does NOT increase clot risk significantly
- Higher risk if you: Smoke, are very overweight, have history of clots, have certain clotting disorders
Key takeaway: If you have risk factors for blood clots, use patches or gel instead of pills. If you have strong personal or family history of clots, HT may not be appropriate.
Stroke ✓✓✓
What we know:
- Small increased risk with oral HT (about 1 additional stroke per 1,000 women per year)
- Risk is primarily in women who start HT after age 60
- If you have uncontrolled high blood pressure, history of stroke, or smoke—HT is not recommended
Heart Disease—The Timing Hypothesis ✓✓✓
What we know:
- Starting early (under 60, within 10 years of menopause): Neutral to possibly beneficial for heart health
- Starting late (over 60, 10+ years past menopause): Increased risk because atherosclerosis (plaque buildup) has already developed
- Bottom line: Don't start HT primarily for heart protection, but if you need it for symptoms and start early, it won't harm your heart
Who Should NOT Take Hormone Therapy
⚠ Hormone therapy is NOT appropriate if you have:
- Current or past breast cancer
- Estrogen-dependent cancers (some uterine, ovarian)
- Unexplained vaginal bleeding (must be evaluated first)
- History of blood clots or stroke
- Severe liver disease
- Known clotting disorders (Factor V Leiden, antiphospholipid syndrome)
- Uncontrolled high blood pressure
- Heart attack in the past year
Use Caution or Consider Alternatives If You Have:
- ☐ Migraine with aura (estrogen can worsen or trigger strokes)
- ☐ Gallbladder disease
- ☐ History of endometriosis or fibroids (may worsen with HT)
- ☐ High triglycerides
- ☐ Strong family history of breast cancer
- ☐ Smoke (significantly increases risks)
Choosing the Right Type & Dose
Delivery Methods
| Method |
Pros |
Cons |
| Pills |
Convenient; familiar; good for hot flashes and bone |
Increased clot risk; must remember daily; processed by liver |
| Patches |
Steady hormone levels; lower clot risk; change 1-2x/week |
Visible; can cause skin irritation; may not stick well if sweaty |
| Gel/Spray |
Low clot risk; flexible dosing; invisible |
Must dry before dressing; daily application; transfer risk to others |
| Vaginal Ring |
Low dose; change every 3 months; good for vaginal symptoms |
Some women uncomfortable with insertion; not for systemic symptoms |
| Vaginal Cream/Tablet |
Very low dose; treats local symptoms only; safe long-term |
Messy; doesn't treat hot flashes; requires applicator |
If you have risk factors for blood clots: Always request transdermal (patch/gel) instead of pills. Tell your doctor: "I understand transdermal estrogen has lower clot risk. I'd like to start with that."
Start Low, Go Slow
Your doctor should prescribe the lowest effective dose that controls your symptoms. You can always increase if needed, but starting high increases side effects.
Typical starting doses:
- Estradiol patches: 0.025-0.05 mg twice weekly
- Estradiol gel: 0.75-1 mg daily
- Oral estradiol: 0.5-1 mg daily
How Long Should You Take It?
The old "use for the shortest time possible" advice has evolved. Current thinking:
You can stay on HT as long as benefits outweigh risks for YOU. ✓✓
There's no arbitrary cutoff age or duration. Many women use it through their 50s and into their 60s if symptoms persist.
Reassessment Schedule
- Every 6-12 months: Discuss symptoms, benefits you're getting, any side effects
- Every 1-2 years: Consider trying lower dose or stopping to see if symptoms return
- No automatic stop: If you're doing well and understand your risks, continuing is reasonable
Stopping Hormone Therapy
When you decide to stop:
- Gradual taper (reducing dose over weeks-months) may reduce symptom rebound, though evidence is mixed
- Immediate stop is also fine and won't harm you
- Expect: 50% of women have return of hot flashes when stopping, but they're usually milder and resolve within months
- Vaginal symptoms often return and worsen over time—consider continuing local vaginal estrogen even if you stop systemic HT
Non-Hormonal Alternatives
If hormone therapy isn't right for you, or you want to try other options first:
For Hot Flashes ✓✓
Medications That Help (Not FDA-Approved for Hot Flashes but Effective)
- SSRIs/SNRIs: Low-dose paroxetine, venlafaxine, or escitalopram reduce hot flashes 40-60% (less than HT's 75-90% but still significant)
- Gabapentin: Reduces hot flashes ~45%; especially helpful for nighttime symptoms
- Fezolinetant (Veozah): New non-hormonal prescription; blocks brain receptors that trigger hot flashes; reduces frequency ~60%
Lifestyle Measures
- Layer clothing; keep bedroom cool
- Regular exercise (reduces frequency/severity 20-30%)
- Avoid triggers: spicy food, caffeine, alcohol, hot drinks, stress
- Mind-body practices: hypnotherapy, cognitive behavioral therapy (modest benefit)
For Vaginal Dryness
- Vaginal moisturizers: Use 2-3x/week (not just before sex)
- Lubricants: Use during sex (water-based or silicone-based)
- DHEA vaginal suppositories (Prasterone): Non-estrogen option that works locally
- Vaginal laser therapy: Emerging option; expensive; results variable
Herbal supplements: Black cohosh, red clover, soy—evidence is weak and inconsistent. They're generally safe but unlikely to provide significant relief. Save your money.
Making Your Decision
Questions to Ask Yourself
- ☐ How much are my symptoms affecting my quality of life? (Sleep? Work? Relationships? Mental health?)
- ☐ Have I tried non-hormonal approaches first?
- ☐ Do I have any conditions that make HT too risky for me?
- ☐ Am I under 60 or within 10 years of menopause? (Better risk-benefit profile)
- ☐ What scares me most about HT? Are my concerns based on accurate, current information?
- ☐ What's my risk tolerance? (Some women prioritize symptom relief; others prioritize minimizing any cancer risk)
Questions to Ask Your Doctor
- ☐ "Given my personal and family health history, do you think HT is appropriate for me?"
- ☐ "What's my breast cancer risk with and without HT?"
- ☐ "Which type of HT do you recommend for me—pills, patch, gel? Why?"
- ☐ "If I have risk factors for blood clots, can I use transdermal estrogen instead of pills?"
- ☐ "What's the lowest effective dose we can try?"
- ☐ "How often should we reassess whether I still need HT?"
- ☐ "What are my non-hormonal options if HT doesn't work or I can't take it?"
Advocate for Yourself
Red Flags—When to Push Back or Get a Second Opinion
- Your doctor refuses to discuss HT because "it's too dangerous" without considering your individual situation
- You're told HT is only for "the first 5 years" as a blanket rule (this is outdated)
- Your doctor won't prescribe transdermal estrogen even though you have clot risk factors
- You're prescribed HT but never reassessed or asked about benefits/side effects
- You're told to stop HT immediately when you turn 60 or reach year 5, regardless of how well you're doing
- Your vaginal symptoms are dismissed as "just part of aging" without offering treatment options
- You're prescribed "bioidentical" hormones from a compounding pharmacy without discussion of FDA-approved options
Remember: Menopause is not a disease, but severe symptoms don't have to be endured. You deserve treatment that allows you to function well and maintain your quality of life. If your provider isn't helping you achieve that, find a menopause specialist (NAMS-certified practitioners at menopause.org).
Key Takeaways
- Hormone therapy is the most effective treatment for hot flashes (75-90% reduction) and vaginal dryness.
- Timing is everything: Starting HT before age 60 or within 10 years of menopause has favorable risk-benefit. Starting late increases risks.
- Transdermal (patches/gel) is safer than pills for blood clot risk. Always request this if you have risk factors.
- Combined estrogen + progestogen has small increased breast cancer risk (~1 per 1,000 women per year); estrogen-only does not.
- Use the lowest effective dose that controls your symptoms. You can always adjust.
- There's no mandatory stop date. You can continue as long as benefits outweigh risks for YOU.
- Vaginal estrogen is very safe and can be used even by women who can't take systemic HT.
- Non-hormonal options exist (SSRIs, gabapentin, fezolinetant) but are less effective than HT for hot flashes.
- Herbal supplements have weak evidence. Don't waste money expecting significant relief.
- This is YOUR decision based on YOUR symptoms, YOUR health history, and YOUR priorities. There's no one right answer for everyone.