Hormone Therapy

Estrogen is the primary hormone used in hormone therapy.

Progesterone (or another progestogen) is added if you have a uterus and are taking systemic estrogen. This protects the uterine lining from overgrowth and reduces the risk of endometrial cancer. If you've had a hysterectomy, estrogen alone may be appropriate. Low-dose vaginal estrogen generally does not require added progesterone.

Testosterone may be considered for select postmenopausal women experiencing low sexual desire that causes distress, following an appropriate evaluation.

Whenever appropriate, we use estradiol and micronized progesterone, which are chemically identical to the hormones your body makes. (In medicine, these are called "bio-identical" or "body-identical" hormones.)

Hormone therapy can significantly improve quality of life during perimenopause and menopause. Benefits may include:

• Relief from hot flashes and night sweats. Hormone therapy is often the most effective treatment for these symptoms.

• Better sleep and quality of life. Especially when sleep is disrupted by night sweats and other menopause symptoms.

• Relief from vaginal and urinary symptoms. Including vaginal dryness, discomfort with sex, and certain urinary symptoms, particularly with local vaginal estrogen.

• Bone protection. Helps prevent bone loss and reduces the risk of osteoporosis-related fractures.

• Potential long-term health benefits. Research suggests hormone therapy may also lower the risk of cardiovascular disease, type 2 diabetes, and colorectal cancer, though findings vary and more research is needed.

The benefits and risks of hormone therapy depend on your age, time since menopause, medical history, and the type and route of hormones used. Your provider will help you weigh what makes sense for you.

Like any medication, hormone therapy can cause side effects, and its potential risks vary with the type of hormones, the dose, how they're taken, and your individual health history.

Common side effects are usually mild and often improve as your body adjusts:

• Breast tenderness or swelling

• Bloating or fluid retention

• Headaches

• Nausea

• Irregular spotting or bleeding, particularly during perimenopause or the first months of treatment

If side effects stick around or become bothersome, we can often adjust your dose or change your treatment plan.

Potential health risks are important to consider and discuss. Depending on the type of therapy, they may include:

• Blood clots and stroke. Systemic hormone therapy can increase the risk of blood clots and stroke. The risk of blood clots is generally higher with oral estrogen than with estrogen absorbed through the skin, such as patches or gels.

• Breast cancer. Combined estrogen-progestogen therapy has been associated with an increased risk of breast cancer, particularly with longer use. The risk differs between combined therapy and estrogen-only therapy.

• Uterine (endometrial) cancer. Systemic estrogen taken without adequate progesterone or another progestogen can thicken the uterine lining and increase endometrial cancer risk in people who have a uterus.

• Gallbladder disease. Estrogen therapy, especially oral estrogen, can increase the risk of gallbladder problems.

• Cardiovascular events. The effect of systemic hormone therapy on heart health depends on age, time since menopause, existing health conditions, and the type of therapy. Starting treatment later in life, or more than 10 years after menopause, generally carries greater cardiovascular risk.

Much of the fear around HRT comes from the Women's Health Initiative (WHI) study, published in the early 2000s. It reported increased risks of breast cancer, stroke, and blood clots, and concluded that the risks of HRT outweighed the benefits.

Later analyses found important limitations in applying those findings to all women. The study participants were older on average (63 years), and the study used specific hormone formulations (conjugated equine estrogen and medroxyprogesterone acetate) that differ from many of the options available today.

Here's what we know now:

• For many healthy women under 60, or within 10 years of menopause, the benefits of hormone therapy generally outweigh the risks.

• Better treatment options exist, including estradiol and micronized progesterone, which are body-identical and generally have lower risk profiles.

The bottom line: HRT is not inherently dangerous. Like any medication, it has benefits and risks that should be weighed and discussed, and treatment should always be individualized to your health history and needs.

There's no single "right" time to stop. Hormone therapy can generally be used throughout the menopause transition for as long as you need symptom relief. Deciding whether to continue is an ongoing conversation with your provider, weighing the benefits you're still getting against potential risks as your health changes.

With combined estrogen-progestogen therapy, breast cancer risk may rise slightly with longer use, becoming more apparent after roughly 3–5 years. The absolute increase in risk is generally small, and it doesn't mean everyone needs to stop at that point. Regular follow-ups help us decide together whether continuing is still the right choice for you.