Hormone Therapy: An Overview | The Rosewoman Library

What Hormone Therapy Is

Hormone therapy (HT) for menopause—sometimes called hormone replacement therapy (HRT)—involves taking hormones to supplement or replace what the body no longer produces in the same quantities.

The primary hormone involved is estrogen. For women who still have a uterus, progesterone or a progestin is added to protect the uterine lining from the effects of estrogen.

Hormone therapy comes in many forms:

Pills taken orally
Patches applied to skin
Gels or sprays applied to skin
Vaginal rings, tablets, or creams (for local symptoms)

The type, dose, and delivery method can be tailored to individual needs.

The Complicated History

Hormone therapy has had a turbulent history in medical opinion.

In the 1990s, HRT was widely prescribed, thought to protect against heart disease and other conditions of aging. Then came the Women’s Health Initiative (WHI) study in 2002, which found increased risks of breast cancer, heart disease, stroke, and blood clots in certain groups of women on HRT.

The headlines were alarming. Millions of women stopped HRT overnight. Doctors became reluctant to prescribe it. A generation of women suffered through severe symptoms without support.

In the years since, reanalysis of the WHI data and additional research have nuanced the picture considerably:

The women in the WHI were older (average age 63)—not women starting HRT at menopause onset
The formulation studied was oral conjugated equine estrogen plus synthetic progestin—not the bioidentical hormones now more commonly used
For women who start HRT within 10 years of menopause and before age 60, the risk profile is much more favorable
Transdermal estrogen (patches, gels) appears to have fewer risks than oral

The pendulum has swung again. Major medical organizations now recognize HRT as appropriate for many women with menopausal symptoms.

What HRT Treats

Hormone therapy is most effective for:

Vasomotor symptoms: Hot flashes and night sweats—often dramatically reduced or eliminated

Sleep disruption: When related to night sweats or hormonal insomnia

Vaginal and vulvar atrophy: Dryness, discomfort, painful sex (local estrogen is particularly effective here)

Mood changes: Some women find HRT improves mood and reduces anxiety

Bone health: Estrogen helps maintain bone density, reducing osteoporosis risk

It may also help with:

Brain fog and cognitive symptoms
Joint pain
Skin changes
Overall quality of life

The Risk Considerations

Hormone therapy is not risk-free. The risks depend on:

Your age and how far you are from menopause
The type, dose, and delivery method of hormones
Your personal medical history
Your family history

Potential risks include:

Breast cancer: Combined estrogen-progestin therapy is associated with a small increased risk of breast cancer with long-term use (more than 5 years). Estrogen-only therapy (for women without a uterus) may have little to no increased risk.

Blood clots: Oral estrogen increases clot risk. Transdermal estrogen does not appear to carry this risk.

Stroke: There may be a small increased risk, particularly with oral estrogen.

Heart disease: The timing hypothesis suggests that starting HRT early in menopause may actually be cardioprotective, while starting later may increase risk.

Endometrial cancer: Unopposed estrogen (without progesterone) significantly increases risk for women with a uterus. Adding progesterone prevents this.

Who Might Consider HRT

HRT may be particularly worth considering if you:

Have moderate to severe hot flashes or night sweats
Have significant sleep disruption from vasomotor symptoms
Have vaginal atrophy affecting quality of life
Are within 10 years of menopause onset and under 60
Don’t have contraindications

Who Should Not Take HRT

HRT is generally not recommended for women with:

History of breast cancer
History of blood clots or stroke
Active liver disease
Unexplained vaginal bleeding
History of heart disease (timing dependent)

Even with these conditions, low-dose vaginal estrogen may be appropriate—this has minimal systemic absorption.

Types of Hormone Therapy

Systemic estrogen: Treats whole-body symptoms. Available as pills, patches, gels, sprays, or injections.

Local/vaginal estrogen: Treats vaginal and urinary symptoms specifically. Minimal systemic absorption. Available as creams, tablets, rings.

Estrogen + progesterone/progestin: Required for women with a uterus to protect the uterine lining.

Bioidentical vs. synthetic: Bioidentical hormones are molecularly identical to what the body produces. Some women prefer them, though both can be effective.

Compounded hormones: Custom-mixed by compounding pharmacies. Less regulated and studied than FDA-approved options.

How to Decide

The decision about HRT is personal and should be made with a knowledgeable healthcare provider who can:

Assess your symptoms and their severity
Review your personal and family medical history
Discuss your risk factors
Explain the options and their risk-benefit profiles
Help you weigh quality of life against potential risks

Questions to consider:

How severely are symptoms affecting my life?
What are my specific risk factors?
Am I within the window where benefits likely outweigh risks?
What are my options if I don’t take HRT?
Can I start low and adjust based on response?

It’s Not All or Nothing

Hormone therapy isn’t a binary choice. Options include:

Starting with the lowest effective dose
Using transdermal rather than oral for lower clot risk
Using local vaginal estrogen for specific symptoms
Trying it and reassessing after 3-6 months
Using it for a defined period rather than indefinitely
Combining with lifestyle approaches

Many women use HRT for the most intense years of symptom transition, then taper off. Others continue long-term. The approach can be individualized.

Finding the Right Provider

Not all providers are equally knowledgeable about menopause and hormone therapy. Look for:

A provider who takes menopause symptoms seriously
Someone current on the research (not stuck in 2002 fear)
Willingness to discuss options rather than just saying no
Ability to tailor treatment to your individual situation

The North American Menopause Society maintains a list of certified menopause practitioners.

Go Deeper

These are the original writings this entry draws from: