Hormone Replacement Therapy (HRT)

Hormone therapy is the most effective treatment for hot flashes and night sweats related to menopause. It can also improve sleep, mood symptoms, and overall quality of life for many people. Systemic HRT may improve vaginal dryness and other genitourinary symptoms, although low-dose vaginal estrogen may be preferred when these are the only symptoms present.

HRT may also have important effects on long-term health:

• Bone health: HRT helps prevent the bone loss that occurs around menopause and reduces the risk of osteoporosis-related fractures. 

• Heart and metabolic health: The effects of HRT depend partly on when treatment is started. Starting HRT near the time of menopause may have favorable cardiovascular and metabolic effects in appropriately selected patients, but HRT is not currently recommended solely to prevent heart disease. 

• Colorectal cancer: Some studies have found a lower risk of colorectal cancer with combined estrogen and progestogen therapy, although HRT is not prescribed specifically for cancer prevention. 

• Brain health: The relationship between estrogen, menopause, and brain health is complex and continues to be studied. HRT should not currently be started solely to prevent dementia.
  
  

HRT is not a medication that everyone needs to take simply because they have reached menopause. The decision to use it should be based on your symptoms, health history, age and timing of menopause, and individual balance of benefits and risks.

• • HRT & Heart Health (Heather Hirsch, MD, video)

  • HRT & Weight Gain (Heather Hirsch, MD, video)

There are many different ways to take hormone replacement therapy. Treatment can be individualized based on your symptoms, medical history, personal preferences, and whether you still have a uterus. Many products are available as both brand-name and generic medications, and insurance coverage may help determine which specific product you receive.

Systemic Estrogen

Systemic estrogen circulates throughout the body and is commonly used to treat hot flashes, night sweats, and other menopausal symptoms.

• Estradiol tablets (Estrace)

• Estradiol patches (Climara, Vivelle-Dot, Minivelle)

• Estradiol gels (Divigel)

• Estradiol spray (Evamist)

• Femring, a vaginal ring that provides systemic estrogen
  
  

• Estrogen Gel vs Patch for HRT (Heather Hirsch, MD, video)

Progesterone

If you still have a uterus, progesterone or another progestogen is typically used with systemic estrogen to protect the uterine lining.

• Micronized progesterone (Prometrium)

• Synthetic progestins (Provera, Aygestin) 

• Mirena IUD

• • Progesterone Replacement: Part 1 (Heather Hirsch, MD, video)

  • Progesterone Replacement: Part 2 (Heather Hirsch, MD, video)

  • The Best Progesterone for HRT (Heather Hirsch, MD, video)

Combined Hormone Therapy

Some medications provide estrogen and a progestogen together in a single product.

• CombiPatch (estradiol + norethindrone patch)

• Climara Pro (estradiol + levonorgestrel patch)

• Bijuva (estradiol + micronized progesterone capsule)

• Other combination pills are also available

Vaginal Estrogen

Low-dose vaginal estrogen primarily treats vaginal dryness, discomfort with intercourse, urinary symptoms, and other symptoms of genitourinary syndrome of menopause (GSM). Unlike systemic estrogen, these products are intended primarily to treat tissues in and around the vagina and urinary tract.

• Vaginal Estrogen creams (Estrace or Premarin)

• Vaginal estradiol tablets (Vagifem, Yuvafem)

• Vaginal Estradiol suppositories (Imvexxy)

• Estring, a low-dose vaginal estradiol ring

→ Learn more information at: Vaginal Dryness & GSM 

Testosterone

Testosterone therapy may be appropriate in select patients, particularly for hypoactive sexual desire disorder (HSDD) after appropriate evaluation. It is not routinely needed as part of menopausal hormone therapy.

→ Learn more information at:  Testosterone Therapy for Women 

• • Menopausal Testosterone Replacement (Heather Hirsch, MD, video)

For many healthy women who are experiencing bothersome menopause symptoms, hormone therapy can be a safe and effective treatment option. For most women who begin HRT before age 60 or within 10 years of menopause, the benefits generally outweigh the risks when there are no significant contraindications.

The safety of hormone therapy is not the same for everyone. Your individual risk depends on factors such as your age, how long it has been since menopause, your personal and family medical history, and the type, dose, and route of hormone therapy used.

Breast Cancer

The relationship between HRT and breast cancer is more nuanced than is often portrayed. Risk differs depending on the type of hormone therapy and how long it is used.  Combined estrogen and progestogen therapy is associated with a small increase in breast cancer risk with longer-term use. Estrogen-only therapy in women who have had a hysterectomy has a different risk profile and has not shown the same increase in breast cancer risk in major clinical trials. Your personal and family history should be considered when deciding whether hormone therapy is appropriate.

Blood Clots & Stroke

Oral estrogen can slightly increase the risk of blood clots and stroke, particularly as age and other risk factors increase. The absolute risk is low for many healthy women who begin treatment near menopause. Transdermal estrogen, such as an estrogen patch, does not appear to carry the same degree of blood-clot risk as oral estrogen and may be preferred when minimizing this risk is particularly important.

Heart Health

Timing matters when considering HRT and cardiovascular health. For healthy women who begin hormone therapy before age 60 or within about 10 years of menopause, cardiovascular risks are generally low. Hormone therapy is not currently recommended solely for the purpose of preventing heart disease, and starting systemic HRT later in life or many years after menopause may carry a different balance of benefits and risks.

The decision to use HRT should be individualized rather than based on a single risk or family-history factor. We can review your medical history, symptoms, and treatment goals together to determine whether hormone therapy is an appropriate option for you.

Why Have I Heard That Hormone Therapy Is Dangerous?

Much of the concern surrounding hormone therapy began after results from the Women's Health Initiative (WHI) were published in the early 2000s. The study provided important information about HRT, but its results were initially applied very broadly to women of all ages and to different types of hormone therapy.

Subsequent research has helped clarify that age, timing of treatment, type of hormone therapy, and route of administration all matter. Our understanding of the benefits and risks of HRT has therefore evolved considerably.

• Misinformation Surrounding Hormone Therapy (Menopause Society)

• Menopausal HRT & Cancer (National Cancer Institute)

• Estrogen & Breast Cancer Risk (Heather Hirsch, MD, video)

• The WHI Study Explained (Heather Hirsch, MD, video)

• Understanding Family History & Hormone Therapy (Heather Hirsch, MD, video)

Systemic hormone therapy is not appropriate for everyone. HRT may not be recommended, or may require additional evaluation, if you have a history of certain medical conditions, including:

• Breast cancer or another estrogen-sensitive cancer

• Unexplained vaginal bleeding

• Blood clots, such as deep vein thrombosis (DVT) or pulmonary embolism (PE), or certain conditions that significantly increase the risk of blood clots

• Stroke or heart attack

• Significant liver disease

• Certain other medical conditions that may make systemic hormone therapy higher risk

Having one of these conditions does not necessarily mean that all treatments for menopausal symptoms are off limits. Nonhormonal treatments may be appropriate, and some people may still be candidates for low-dose vaginal estrogen for vaginal or urinary symptoms even when systemic HRT is not recommended.

If you are unsure whether your medical or family history affects your ability to use HRT, please talk with your healthcare provider so that your individual risks and treatment options can be reviewed.

Many women are interested in "bioidentical" hormone therapy. The term bioidentical refers to hormones that have the same chemical structure as hormones naturally produced by the body.

It is important to understand that many FDA-approved hormone therapy products contain bioidentical hormones, including estradiol and micronized progesterone. These products are manufactured under strict quality and safety standards and have been studied extensively.

Some bioidentical hormone products are prepared by compounding pharmacies. While compounded hormones may be appropriate in select situations, they are generally not recommended over FDA-approved products when an approved option is available, because compounded products are not subject to the same FDA oversight for consistency, purity, effectiveness, and safety.

• Bioidentical Hormone Therapy (ASRM)

• Bioidentical Hormone Therapy: Compounded vs Government Approved (Menopause Society)

• What are Bioidentical Hormones?  (Heather Hirsch, MD, video)
  
  

What About Hormone Pellets?

Hormone pellets are small implants placed under the skin that slowly release hormones, most commonly testosterone and/or estrogen, over several months. They are often marketed as a more "natural" or individualized form of bioidentical hormone therapy.

However, pellet therapy is generally not recommended when FDA-approved hormone therapy options are available. Once a pellet is inserted, the dose cannot easily be adjusted or removed, and hormone levels may remain elevated for months. Some pellet regimens may also produce hormone levels that are higher than normal physiologic levels.

For these reasons, I generally recommend FDA-approved hormone therapy that can be more easily adjusted based on your symptoms and response to treatment.

• Hormone Pellet Injections (Heather Hirsch, MD, video)

• Why to Avoid Testosterone Pellets (Heather Hirsch, MD, video)

Do I Need Hormone Testing?

Compounded hormone therapy is sometimes marketed as being customized based on blood, urine, or saliva hormone testing. Because estrogen and other hormone levels can fluctuate significantly, and there is not a specific hormone level that treatment needs to target for most menopausal symptoms, routine hormone testing is generally not needed to determine or adjust HRT dosing. Treatment is usually adjusted based on symptoms, side effects, and clinical response.

Testosterone therapy is an exception. When testosterone is prescribed, blood levels may be monitored before and during treatment to help guide safe dosing and ensure levels do not become higher than the normal physiologic range.

• The Hormone Balancing Hoax (Mama Doctor Jones, video)

Finding the right hormone therapy can sometimes take a little time and adjustment. The dose, formulation, and route of treatment can be individualized, and your treatment may change over time based on your symptoms, side effects, and response.

When Will I Notice Improvement?

Some symptoms, particularly hot flashes and night sweats, may begin improving within the first few weeks. Other symptoms, including sleep, mood, and overall well-being, may improve more gradually.

We typically recommend giving a new HRT regimen about 2–3 months to assess its full effect before making a dose adjustment, unless you are experiencing significant side effects or another concern.

Not every symptom experienced during perimenopause or menopause is caused by hormones, so some symptoms may persist even when HRT is working well.

Your Dose May Change Over Time

The first dose you try may not ultimately be the dose that works best for you. If symptoms are not adequately controlled, the dose can often be increased. If you are experiencing side effects, decreasing the dose or changing the type or route of hormone therapy may help.

This can be particularly common during perimenopause, when your ovaries are still producing hormones and your natural hormone levels continue to fluctuate. A regimen that works well at one point in the transition may need to be adjusted later.

The goal is to find the lowest effective dose that adequately manages your symptoms while minimizing side effects.

Common Side Effects

Some people experience temporary side effects when starting or adjusting hormone therapy. These may include:

• Breast tenderness

• Bloating or fluid retention

• Headaches

• Nausea

• Mood changes

• Spotting or irregular vaginal bleeding

Many of these improve as your body adjusts. If side effects are persistent or bothersome, please contact us. Changing the dose, formulation, or route of treatment may help.

• • • Common Side Effects While on HRT (Heather Hirsch, MD, video)

    • Progesterone Side Effects (Heather Hirsch, MD, video)
      
      

What About Bleeding?

Spotting or irregular bleeding can occur after starting HRT, particularly during the first several months and during perimenopause. The expected bleeding pattern also depends on the specific HRT regimen you are using. However, heavy, persistent, or unexpected bleeding should not simply be assumed to be caused by HRT. Please contact us if you are concerned about your bleeding.

If you had already gone 12 months without a period before starting HRT, new vaginal bleeding or spotting may require additional evaluation, even if you are using hormone therapy.

• Bleeding on HRT (Heather Hirsch, MD, video)

Follow-Up & Adjustments

Hormone therapy is not always “one and done.” We can reassess how you are feeling after you have had enough time to evaluate your response and make adjustments when needed. Once you are doing well on a stable regimen, your hormone therapy can be reviewed periodically as part of your routine care. There is no single dose or regimen that is right for everyone.

• • • What is a Normal Hormone Therapy Journey (Heather Hirsch, MD, video)

    • Why Your HRT May Not Be Working (Heather Hirsch, MD, video)

    • Transitioning From Birth Control Pills to Hormone Therapy (Heather Hirsch, MD, video)

How you use hormone therapy depends on the medication and formulation you have been prescribed. Always follow the instructions on your prescription, since dosing schedules can vary between products.

Estrogen Patches

• Apply the patch to clean, dry skin on the lower abdomen or buttocks, depending on the specific product.

• Do not apply it to the breasts, irritated skin, or areas where tight clothing may rub against it.

• Rotate application sites to help prevent skin irritation.

• Patches are typically changed once or twice weekly, depending on the product.

• You can usually shower, swim, and exercise while wearing the patch.

• If a patch falls off, try to reapply it. If it will not stick, replace it with a new patch and continue your usual schedule.
  
  
  

Estrogen Gel or Spray

• Apply to clean, dry skin according to the instructions for your specific product. Recommended application sites vary.

• Allow the medication to dry completely before dressing.

• Wash your hands after applying a gel.

• Avoid allowing another person to touch the application area until it is dry, and follow your product's instructions about when the area can be washed or exposed to water.

• Do not apply estrogen gel or spray to the breasts or genital area unless specifically instructed.
  
  
  

Oral Estrogen

Take your estrogen once daily as prescribed, preferably around the same time each day. It can generally be taken with or without food.

Progesterone

If you are prescribed oral micronized progesterone, it is usually taken at bedtime because it can cause drowsiness or dizziness.

Progesterone may be prescribed every day or for a certain number of days each month, depending on your treatment plan. Follow the schedule on your prescription carefully.

Testosterone

Testosterone may be prescribed for select patients, most commonly for low sexual desire (HSDD). Because testosterone products used for women are typically prescribed in much smaller doses than those used for men, it is important to follow your specific dosing instructions carefully.

→ Learn More About Testosterone Therapy

Vaginal Estrogen

Vaginal estrogen comes in several forms, including creams, tablets or inserts, and vaginal rings. How often it is used varies by product.

→ Learn More About Vaginal Estrogen & GSM

Not sure when to change your patch or take your progesterone? Your pharmacy label contains the dosing schedule prescribed specifically for you. If those instructions are unclear or do not match what you remember discussing with us, please contact the office.

There is no specific age or number of years when hormone therapy must automatically be stopped. Some people use HRT for a few years, while others continue treatment longer because symptoms persist or they continue to benefit from therapy.

HRT does not need to be routinely discontinued at age 60 or 65. The decision to continue should be individualized based on your symptoms, health history, and how the benefits and risks of treatment may change over time. Your dose or type of hormone therapy can also be adjusted as your needs change.

If you decide to stop HRT, symptoms may return. Hormone therapy can be stopped gradually or more directly, depending on your preferences and treatment plan.

If you experience early menopause or premature ovarian insufficiency (POI), recommendations are different. In the absence of a contraindication, hormone therapy is generally recommended until approximately the usual age of natural menopause to help protect long-term health.

• • How Long to Take HRT (Heather Hirsch, MD, video)