Is Hormone Replacement Therapy (HRT) Right for You?

As women transition through perimenopause and into post menopause, they begin to produce less, and eventually none, of their primary ovarian hormones. This decrease and subsequent cessation causes significant changes in the body, many of which may negatively impact a woman’s health and well-being.

For women at average risk (based on health history, lifestyle habits and pre-existing conditions), hormone replacement therapy (HRT) is a highly effective and appropriate treatment for the management of most common perimenopausal and menopausal symptoms, while also providing system-wide benefits such as bone, brain and heart health support.

What Is Hormone Replacement Therapy (HRT)?

Hormone replacement therapy (HRT) involves administering physiologic doses of hormones such as estrogen, progesterone and testosterone to supplement and eventually replace a woman’s ovarian hormone production.

Hormone supplementation and replacement work by supporting the hormone dependent functions in a woman’s body, thus relieving symptoms of hormone instability or deficiency. For many women, this allows them to not only feel better, but to also experience better health spans.

Estradiol is typically the primary hormone supplemented in HRT, though other forms of estrogen are often also helpful. Estrogen replacement therapy is available in safe and effective, FDA-approved patches, pills, gels, sprays, creams or vaginal rings.

Systemic estradiol therapies are those that are absorbed into the bloodstream after being taken orally or absorbed through the skin or vagina. These treat symptoms that impact widespread areas, like hot flashes, night sweats and difficulty with sleep or mood. Estradiol also supports important functions in the woman’s body such as primary prevention of bone loss or Osteoporosis.

Locally acting, lower-dose hormone therapies are those administered directly to the vagina and vulva, to treat issues occurring in the vagina, vulva or urinary tract, such as the Genitourinary Syndrome of Menopause (GSM).

Progesterone is often replaced along with estradiol, especially if a woman still has her uterus. It can be administered systemically by mouth, or locally within the uterus by a progesterone containing intrauterine device (IUD). These can be especially useful for women in perimenopause when contraception and bothersome bleeding may still be concerns.

Testosterone supplementation may be useful for some women who experience hypoactive sexual desire disorder. It is typically administered by topical gels or creams in very small amounts. Testosterone supplementation in women needs to be closely monitored as small excesses in dosing may result in significant side effects, some of which may become permanent.

Benefits of Hormone Replacement Therapy (HRT)

For many women, HRT can greatly improve their quality of life during a time when symptoms might otherwise be overwhelming. Estrogen and progesterone supplementation can effectively alleviate common symptoms of menopause, such as hot flashes, night sweats, vaginal dryness, sleep and mood changes while also reducing the risk of bone loss and fractures. Effective treatment of vasomotor symptoms such as hot flashes and night sweats (VMS) may reduce a woman’s lifetime risk of cardiovascular disease.

Some recent studies also suggest that HRT can potentially lower the risk of dementia and colon cancer, as well as improve cardiovascular health if taken early into the onset of perimenopause.

The FDA has advised that in 2020, about 41 million U.S. women were between the ages of 45–64, yet only about 2 million women ages 46–65 received a hormone-therapy prescription. That means that there are a lot of women who could benefit from HRT who are not receiving it.

Potential Risks of Hormone Replacement Therapy (HRT)

While hormone replacement therapy offers significant benefits, it also comes with certain risks that must be evaluated on an individual basis. 

There may be an increased risk of blood clots (VTE), especially in women with other risk factors such as obesity, smoking, or a personal or family history of clotting disorders. Transdermal estradiol appears to have a lower risk of VTE than oral estradiol.

Combined estrogen-progestogen therapy is associated with a small increased risk of breast cancer. Estrogen-only therapy does not show the same association.

Unopposed estrogen stimulates the uterine lining and may cause endometrial cancer. It is important that any woman with an intact uterus who is taking estrogen, also take a progestogen for endometrial protection. Gallbladder disease may occur with the use of oral estrogen.

Factors to Consider Before Starting Hormone Replacement Therapy

The American College of Obstetricians and Gynecologists (ACOG) recommends HRT as the most effective treatment for menopausal symptoms such as hot flashes, night sweats and vaginal symptoms, when initiated for women under 60 and within 10 years of menopause.

The Menopause Society concurs that systemic menopausal hormone therapy is considered safe for many symptomatic women when started before age 60 or within 10 years of menopause if there are no contraindications. Safety is less favorable when started later because the absolute risks of CHD, stroke, VTE and dementia rise with age and time since menopause.

When initiated after the age of 60 or more than 10 years past the final menstrual period, HRT may increase the risk of coronary events and dementia.

Additionally, systemic HRT is typically not recommended for women who have had hormone sensitive cancer, stroke, heart attack, blood clots or liver disease, according to ACOG. Lower-dose local options such as vaginal estrogen have lower risks in these women and are recommended in circumstances where symptoms and medical history indicate use.

Earlier this year, the FDA approved label changes to six menopausal HRT products to remove “black box” warnings about breast cancer, cardiovascular disease and dementia from labeling. This change was accompanied by a recommendation to ensure that women receive evidence-based information about HRT to make more informed decisions.

Alternatives to Hormone Replacement Therapy

For women who are not able to take HRT due to their medical history, there are treatment options available for many common menopause symptoms.

Over-the-counter vaginal lubricants can help reduce vaginal dryness and related discomfort during sex. Antidepressants and other prescription medications can also be used to treat hot flashes, painful sex, insomnia and urinary tract issues.

Pelvic floor muscle therapy has been shown to help reduce the pelvic pain and urine leakage that can sometimes accompany menopause. Other lifestyle changes such as regular exercise, a healthy diet, quitting smoking and reducing caffeine and alcohol consumption, can also help you control your symptoms and provide additional health benefits.

As with any medication or alternative therapy, you should talk to your healthcare provider about potential risks and your personal health history before starting.

When to Talk to Your Doctor About HRT

Perimenopausal or menopausal symptoms can easily be mistaken for other conditions and can start at a different age for every woman. If you are experiencing irregular periods, mood changes, difficulty sleeping, changes in your libido or painful sex, hot flashes, night sweats, needing to urinate more often or other common symptoms, you should schedule a visit with your provider or a menopause specialist. Even if your quality of life has not yet been impacted, early intervention can benefit long-term well-being.

Final Thoughts: Weighing the Benefits and Risks of HRT

The most appropriate HRT for an individual depends on where they are in their perimenopause or menopause journey, lifestyle and health goals, the symptoms they’re experiencing, what pre-existing conditions they may have and their personal and family history of conditions like cancer, stroke and heart disease. It is important that a person talks to an experienced healthcare provider about all of these considerations before selecting HRT therapy or alternate solutions. What may work best for you may be different than what friends or family find effective for a host of reasons.

Book An Appointment with Advantia Health!

Advantia Health offers menopause consultations in-person or via telehealth. We believe that telehealth can be a convenient and effective way to provide some patient consultations, follow-up discussions and ongoing medication management that do not require physical exams. Menopause consultations, especially initial ones to understand health history and symptoms, can easily occur this way.

Many Advantia providers hold The Menopause Society Certified Practitioner Credential (MSCP) or similar certifications, and bring a deeper background in topics like HRT to your consultations. You can find them through the sites of the credentialing organizations such as The Menopause Society or on the biography pages of each provider.