Medical Treatment Options for Menopause: Complete Guide to Hormone Therapy, Medications & Relief

What Is Hormone Therapy?

Hormone therapy (HT), previously called hormone replacement therapy (HRT), involves taking medications that replace the hormones, primarily estrogen and progesterone, that your ovaries produced before menopause but no longer make in significant quantities.

Why It’s Called the Gold Standard

According to the North American Menopause Society, hormone therapy remains the most effective treatment for vasomotor symptoms (hot flashes and night sweats), reducing them by 75-90% in most women. No other treatment comes close to this level of effectiveness.

Beyond hot flashes, HT is highly effective for:

• Night sweats and sleep disruption caused by them
• Vaginal dryness and genitourinary symptoms
• Prevention of bone loss and osteoporosis
• Potentially mood symptoms (when related to hormonal changes)
• Overall quality of life improvement in symptomatic women

The Components of Hormone Therapy

Estrogen: The primary active component that addresses most menopause symptoms. Estrogen therapy alone (called ET) is used for women who’ve had a hysterectomy.

Progestogen (Progesterone or Progestins): Added to protect the uterine lining in women who still have a uterus. Without it, estrogen alone increases risk of uterine cancer. The combination is called EPT (estrogen-progestogen therapy).

Testosterone: Sometimes added off-label for women with persistent low libido, though this remains controversial and is not FDA-approved for this use in women.

Routes of Administration

Hormones can be delivered through various routes, each with different characteristics:

Oral (Pills):

• Taken daily by mouth
• Convenient and familiar
• Undergoes “first-pass” metabolism through liver
• May have different risk profile than transdermal

Transdermal (Patches, Gels, Sprays):

• Absorbed through skin
• Bypasses first-pass liver metabolism
• May have more favorable risk profile
• Patches changed once or twice weekly; gels/sprays applied daily
• Generally preferred by many experts

Vaginal (Rings, Creams, Tablets):

• High-dose rings provide systemic effects
• Low-dose preparations treat local genitourinary symptoms only
• Creams and tablets primarily for local symptoms

Intrauterine (IUD):

• Certain IUDs release progestogen
• Can provide the uterine protection component of HT
• Combined with estrogen (patch, gel, etc.)

Types of Estrogen and Progestogen

Estrogen Types:

• Estradiol: The primary estrogen your ovaries produced; most commonly prescribed
• Conjugated estrogens: Mixture of estrogens from natural sources
• Estrone: Another form of estrogen

Progestogen Types:

• Micronized progesterone: Bioidentical to body’s progesterone
• Synthetic progestins: Various synthetic forms with different properties
• Each type has slightly different effects, benefits, and side effect profiles

Bioidentical vs. Non-Bioidentical Hormones

Bioidentical hormones are chemically identical to the hormones your body produces naturally. Many FDA-approved hormone therapies are bioidentical, including:

• Estradiol patches, gels, and tablets
• Micronized progesterone capsules

Important distinction: FDA-approved bioidentical hormones are safe, regulated, and well-studied. “Compounded bioidentical hormones” from compounding pharmacies are not FDA-regulated, lack quality control, and have inconsistent dosing. They should be approached with extreme caution despite marketing claims.

Who Is a Candidate for Hormone Therapy?

According to the North American Menopause Society’s 2022 position statement, for most healthy women under age 60 or within 10 years of menopause, the benefits of HT outweigh the risks when used for bothersome vasomotor symptoms.

Good candidates typically have:

• Moderate to severe hot flashes and/or night sweats
• Symptoms significantly affecting quality of life
• No contraindications
• Within the “window of opportunity” (within 10 years of menopause or under age 60)
• After informed discussion of individual benefits and risks

HT may also benefit women with:

• Genitourinary syndrome of menopause
• Low bone density or osteoporosis risk
• Premature or early menopause (before age 45)

Contraindications: Who Should NOT Use Hormone Therapy

Absolute contraindications:

• Known or suspected breast cancer (with rare exceptions)
• Known or suspected estrogen-dependent cancer
• Undiagnosed vaginal bleeding
• Active or recent blood clots (DVT, pulmonary embolism)
• Active or recent arterial thromboembolic disease (stroke, MI)
• Active liver disease
• Known thrombophilic disorders (clotting disorders)
• Known allergy to ingredients
• Pregnancy

Relative contraindications (may be considered with careful evaluation):

• History of breast cancer (years after treatment, individualized decision)
• Elevated triglycerides
• Gallbladder disease
• History of blood clots
• Certain cardiovascular conditions

Your healthcare provider will assess your individual situation.

Benefits of Hormone Therapy

Well-Established Benefits:

Vasomotor Symptoms:

• 75-90% reduction in hot flashes and night sweats
• Most dramatic improvement occurs with HT
• Significantly improves sleep quality when night sweats are disrupting rest

Genitourinary Health:

• Prevents and treats vaginal atrophy
• Improves vaginal dryness and lubrication
• Reduces painful intercourse
• May reduce urinary frequency and urgency
• Decreases recurrent urinary tract infections

Bone Health:

• Prevents bone loss during menopause transition
• Reduces fracture risk (hip, spine, other bones)
• Effect lasts as long as therapy continues
• One of the most effective osteoporosis prevention strategies

Quality of Life:

• Overall improvement in quality of life for symptomatic women
• Better sleep (when night sweats resolve)
• May improve mood when symptoms are hormone-related
• Enhanced sexual function when vaginal symptoms improve

Potential Additional Benefits:

Cognitive Function:

• The timing hypothesis suggests that HT started early may support cognitive function
• May reduce dementia risk when started in early menopause
• More research needed

Cardiovascular Health:

• When started early (within 10 years of menopause), it may have favorable cardiovascular effects
• May improve cholesterol profile
• Potential reduction in coronary artery disease
• NOT recommended solely for cardiovascular protection

Metabolic Health:

• May help prevent visceral fat accumulation
• Can improve insulin sensitivity
• May reduce diabetes risk

Risks and Side Effects of Hormone Therapy

Important Context: Risks are generally small for appropriate candidates and vary significantly based on:

• Type of hormone therapy
• Route of administration
• Timing of initiation
• Duration of use
• Individual health factors
• Age at initiation

Potential Risks:

Breast Cancer:

• Combined estrogen-progestogen therapy shows a small increased risk with prolonged use
• Risk appears after 3-5 years of use
• Absolute risk increase is small (about 1-2 additional cases per 1,000 women per year)
• Estrogen-only therapy (for women without a uterus) does NOT increase risk and may slightly decrease it
• Transdermal estrogen may have a lower risk than oral

Research from the Women’s Health Initiative and subsequent re-analyses have provided a nuanced understanding of breast cancer risk with HT.

Cardiovascular Risks:

• Risk varies dramatically by age at initiation
• Women starting HT within 10 years of menopause: favorable or neutral cardiovascular effects
• Women starting HT more than 10 years after menopause or over age 60: increased risk
• Transdermal estrogen has a more favorable profile than oral
• This illustrates the timing hypothesis or window of opportunity.

Blood Clots (Venous Thromboembolism):

• Small increased risk, particularly with oral estrogen
• Absolute risk is low (about 1-3 additional cases per 1,000 women per year)
• Transdermal estrogen carries much lower or no increased risk
• Higher risk in the first year of use
• Risk factors include obesity, smoking, and immobility

Stroke:

• Small increased risk in older women (over 60)
• Very low absolute risk in younger women within the window of opportunity
• Route of administration may affect risk

Gallbladder Disease:

• Increased risk of gallstones and gallbladder disease
• Transdermal estrogen may have a lower risk

Common Side Effects (Usually Temporary):

• Breast tenderness
• Bloating
• Headaches
• Mood changes
• Nausea
• Breakthrough bleeding or spotting

Most side effects resolve within the first few months as the body adjusts.

The Timing Hypothesis or Window of Opportunity

This critical concept explains much about HT safety:

The hypothesis: Hormone therapy provides maximum benefit with minimal risk when started:

• Within 10 years of the final menstrual period
• Before age 60
• In otherwise healthy women

Starting HT during this window appears to:

• Maximize benefits (symptom relief, bone protection, possible cardiovascular benefit)
• Minimize risks
• Potentially provide cognitive benefits

Starting HT many years after menopause (late post-menopause) has a less favorable risk-benefit profile.

This is why the Women’s Health Initiative findings (which studied primarily older women, average age 63, many starting HT more than 10 years after menopause) don’t apply to women considering HT soon after menopause onset.

Duration of Hormone Therapy Use

The Approach: Lowest effective dose for the shortest necessary duration with regular reassessment.

However, the shortest necessary duration is individualized:

• Some women need HT for just a few years
• Others benefit from longer-term use
• Women with early menopause may use until the average menopause age (51)
• Some women choose continued use for quality of life and bone protection

Reassessment includes:

• Annual or more frequent discussions with the provider
• Evaluation of continued benefits vs. risks
• Individual health changes
• Personal preferences
• Latest evidence

There’s no arbitrary cutoff age or duration. Decisions should be individualized based on ongoing risk-benefit assessment.

Monitoring While on Hormone Therapy

Regular monitoring includes:

• Annual pelvic exams (or per provider recommendation)
• Breast exams and mammograms per screening guidelines
• Blood pressure checks
• Assessment of symptoms and side effects
• Evaluation of continued need
• Discussion of any health changes

Some providers may check blood work, though routine hormone level monitoring is generally not necessary once an appropriate dose is established.