If you’re reading about hormone replacement therapy, chances are you’ve already heard two very different versions of the story. Perhaps you have a friend who says her new prescription has changed her life–she has better sleep, more energy, and her sense of herself back. And then there’s the other story—the one many of us have carried around for more than 20 years—that hormones are dangerous, cause cancer, and menopause is simply something women should learn to tolerate.
You may have even been offered hormones already, after a brief telehealth visit or an online questionnaire, and found yourself wondering: Is this really all there is to deciding whether I should take hormones? In truth, the answer is no; it likely isn’t enough. The question isn’t whether hormone replacement therapy is universally good or bad. It’s whether it makes sense for you.
I’d like to delve into what HRT actually is, what it does well, what the risks really are, and how I decide with a patient whether it makes sense for her.
What Hormone Therapy Actually Is
Hormone replacement therapy, or HRT, replaces some of the hormones that decline during the menopause transition—primarily estrogen and, when needed, progesterone, and sometimes testosterone.
The more current medical term is menopausal hormone therapy (MHT), because we aren’t necessarily trying to “replace” hormones to the levels you had when you were younger. We’re using prescription hormones to treat specific symptoms and health concerns associated with the menopause transition. I’ll use both terms throughout this article, since many women still know it as HRT.
Hormone therapy can be systemic (meaning absorbed in the blood stream and circulated throughout the body)—a patch, gel, spray, or pill—or local, such as low-dose vaginal estrogen used primarily for vaginal and urinary symptoms. There are also excellent non-hormonal treatments for menopause symptoms. I cover those in my guide to menopause treatment options, so I’m going to keep this discussion focused specifically on systemic HRT.
Estrogen is the hormone doing most of the work when we’re treating classic menopausal symptoms such as hot flashes and night sweats. Since estrogen is the hormone that tells the endometrium of the uterus to grow (and progesterone is the hormone that tells it to stop growing), women who still have a uterus require some form of progesterone to protect their endometrium from overgrowth while on estrogen therapy. Women who have had a hysterectomy can typically take estrogen alone to manage menopausal symptoms.
At Femme, when I prescribe menopausal hormone therapy, I generally use FDA-approved bioidentical estradiol and micronized progesterone. We’ll come back to what “bioidentical” actually means, because that word causes a remarkable amount of confusion.
What Menopausal Hormone Therapy Does Well
Let’s start with what we know hormone therapy (also called HRT) does very well.
Hot flashes and night sweats: Systemic estrogen is the most effective treatment available for menopausal hot flashes and night sweats. For women whose lives are being disrupted by these symptoms, the difference can be dramatic.
Sleep: Hormone therapy can also improve sleep when hot flashes and night sweats are what keep waking you. That distinction matters. If your insomnia is being driven by anxiety, sleep apnea, alcohol, medication, chronic stress, or something else entirely, estrogen may not solve it.
Bone: Estrogen prevents the accelerated bone loss that occurs around menopause and reduces fracture risk while it is being used.
Vaginal and urinary symptoms: Estrogen is also highly effective for the genitourinary syndrome of menopause—vaginal dryness, painful intercourse, and some urinary symptoms. If those are your only symptoms, however, low-dose vaginal estrogen may be all you need rather than systemic hormone therapy.
Just as important is what hormone therapy isn’t proven to do. Although there are many symptoms related to the perimenopause transition, there is not enough evidence to confirm that hormone therapy will necessarily improve fatigue, brain fog, and weight gain. There is a call from the community of female physicians and patients alike to fund more research into women’s health, so these unanswered questions can be discussed with the weight of quality research behind them. Whether or not treating women with estrogen during perimenopause reduces rates of dementia and cardiovascular disease remains unknown.
Symptoms matter, but so does understanding what is causing them. If you’re wondering whether what you’re experiencing might be related to the menopause transition, I’ve written more about signs of hormone imbalance and when they deserve an evaluation. Good menopause care isn’t about assuming all symptoms women are experiencing is due to hormonal changes. It’s about figuring out what actually is due to hormones and what might need to be addressed in other ways.
Is Menopausal Hormone Therapy Safe?
This is usually the question underneath all the others.
And the answer is more reassuring—and more nuanced—than the message many women received 20 years ago.
Much of our collective fear of hormone therapy traces back to the initial results of the Women’s Health Initiative in 2002. The headlines were frightening: breast cancer, heart attacks, strokes, blood clots. Physicians quickly stopped writing prescriptions for hormones in menopause, and an entire generation of women and physicians became wary of HRT. Like many mid-career physicians, I received little instruction on hormone therapy–outside of “don’t do it; it’s not safe for women.”
The story that emerged with longer follow-up and closer analysis of women on hormone therapy during the menopause transition was much more complicated than those early headlines suggested. Once the data was analyzed based on age at the start of hormone therapy, a new picture emerged to suggest that the earlier warnings about risk were off base.
Today, major menopause organizations generally agree that for healthy women who have bothersome menopausal symptoms and are younger than 60 or within approximately 10 years of menopause, the benefits of hormone therapy generally outweigh the risks when there are no contraindications.
The enthusiasm for getting women the help they need and addressing symptoms that can be debilitating at mid-life is a wonderful thing. But I worry that it has led women to believe hormone therapy is risk free. It isn’t.
The risk depends on the woman, the hormones we use, how we deliver them, and when treatment is started. Oral estrogen increases the risk of venous blood clots more than estrogen delivered through the skin, which is one reason I often favor transdermal estradiol—a patch or gel—when appropriate.
Breast cancer deserves an equally honest discussion. Combined estrogen-progestogen therapy is associated with an increased risk of breast cancer with longer use. The absolute increase for an individual woman is small, but “small” is not the same as “zero,” and I think women deserve to have that distinction explained clearly.
There are also women for whom systemic hormone therapy may not be appropriate, or for whom the decision requires additional expertise. A personal history of certain hormone-sensitive cancers, unexplained vaginal bleeding, previous blood clots or stroke, significant cardiovascular disease, or active liver disease can substantially change the conversation.
This is why I don’t think the useful question is simply, “Is hormone therapy safe?” The better question is: “What are my risks without treatment, what are my risks with treatment, and what benefit am I likely to gain?” That is a much more meaningful conversation.
What Does “Bioidentical Hormone Replacement Therapy” Mean?
Women ask me about bioidentical hormones all the time, and the terminology has become unnecessarily confusing.
“Bioidentical” simply means that a hormone has the same molecular structure as the hormone your body naturally produces.
Estradiol is bioidentical estrogen. Micronized progesterone is bioidentical progesterone. Bioidentical does not mean compounded. There are FDA-approved bioidentical hormones manufactured in standardized doses and tested for purity, potency, and consistency. These are what I generally prescribe.
Compounded bioidentical hormones are individually prepared by compounding pharmacies. There are circumstances in which compounding is useful—for example, when a patient cannot tolerate an ingredient in an FDA-approved formulation or needs a dose outside what is available in standard FDA approved formulations. Compounded preparations have not been shown to be safer or more effective than FDA-approved hormone therapy, and consistency of dose and purity is not regulated in the same way.
Long story short, you can absolutely use bioidentical hormones without using compounded hormones.
How I Decide Whether Hrt Is Right For A Patient
A prescription should be the end of the evaluation, not the beginning.
Before I prescribe hormone therapy, I want to understand what has changed and what is actually bothering you. Your periods. Your sleep. Hot flashes. Sexual health. Mood. Worry about bone health. Medications. Personal medical history. Family history. Breast cancer risk. Cardiovascular risk.
And then I want to know something that can easily get lost in a medical visit:
What is your personal goal or hope for hormone therapy to address?
We shouldn’t start a medication without knowing what we’re asking it to accomplish.
From there, we decide together whether hormone therapy makes sense and, if it does, which formulation and dose best fit your particular risk profile and goals.
I often favor transdermal estradiol, and when a woman with a uterus needs progesterone, micronized progesterone is frequently my choice. But there isn’t one “perfect” hormone regimen that every woman should be taking.
Once hormone therapy has been started, it’s important to follow up. Did your symptoms improve? Are there side effects? Does the dose need to change? Has anything about your health or risk profile changed? Does continuing treatment still make sense?
There is also no arbitrary birthday when every woman must stop HRT. Duration is individualized and reassessed over time.
I am a Menopause Society Certified Practitioner (MSCP), but the credential matters less to me than what it represents: menopause care deserves the same thoughtful risk assessment, evidence-based prescribing, and follow-up that we expect in every other area of medicine. It shouldn’t be reduced to a questionnaire and a prescription.
The Bottom Line On Hormone Replacement Therapy
Hormone therapy is neither a miracle nor a menace. For the right woman, it can be extraordinarily effective. For another woman, the expected benefit may not justify the risk—or her symptoms may have very little to do with estrogen in the first place. That distinction is exactly why personalized care matters.
At Femme, hormone therapy starts with time: time to understand your symptoms, your health history, your risks, and what matters most to you. Then we build a plan together—hormonal or not—that makes sense for you as an individual.
You can learn more about Femme memberships, or if you’re simply trying to decide whether this approach is right for you, start with a complimentary Welcome Visit. You can also call 225-532-2300 to schedule your welcome visit.
Frequently Asked Questions
-
Bioidentical hormones have the same molecular structure as hormones your body naturally produces. FDA-approved estradiol and micronized progesterone are both bioidentical. “Bioidentical” and “compounded” are not interchangeable terms.
-
For many healthy women younger than 60 or within about 10 years of menopause who are experiencing bothersome symptoms, hormone therapy has a favorable benefit-risk profile. Your personal history, family history, cardiovascular and breast cancer risks, symptoms, and priorities all matter, so candidacy should be assessed individually.
-
Some women notice improvement in hot flashes and night sweats within several weeks. It may take a few months—and sometimes an adjustment in dose or formulation—to know how well a regimen is working for you.
-
There is no universal cutoff or age at which every woman must stop HRT. The decision to continue should be revisited periodically based on your symptoms, health, risks, and preferences.
-
Usually not. During perimenopause, hormone levels can fluctuate considerably, so a single estrogen or FSH level often tells us less than women expect. For most women over 45 with a typical menopause transition, symptoms, menstrual history, and medical history are more useful than routine hormone testing. I order laboratory testing when there is a specific question I am trying to answer or when the result would change what we do.