What Is Hormone Replacement Therapy and should you consider It?

October 18 is World Menopause Day and imagine finally reaching a stage of life where you feel confident and established, only to be sidelined by unpredictable symptoms that disrupt your sleep, mood, and daily routine. Far too many women in perimenopause live this reality. For too long, healthcare professionals (and others) dismissed the discomfort of this transition as something to simply “power through.”

Explore: October 18 is World Menopause Day: Let’s bust some myths

Read: Understanding perimenopause and menopause

A different conversation is changing that narrative, highlighting how hormone replacement therapy (HRT) can provide significant relief and empower women to reclaim control over their bodies and their lives.

Has HRT been around for long?

HRT first gained popularity in the 1960s with the publication of Dr. Robert Wilson’s book, Feminine Forever, which promoted HRT as a cure for “hormone deficiency disease,” leading to its widespread use. By the 1990s, researchers discovered that combining lower doses of estrogen and adding progesterone to the HRT therapy could prevent chronic diseases like osteoporosis and cardiovascular issues.

But then, a 2002 study released by the Women’s Health Initiative (WHI) fundamentally changed the conversation. The WHI found that a specific type of combined HRT carried an increased risk of heart disease and breast cancer in postmenopausal women. The media publicized these negative findings widely, causing a sudden and dramatic drop in HRT use. In the following years, researchers analyzed the WHI data and uncovered an important limitation in the original study: most of its participants were older and well past menopause.

Subsequent studies showed that HRT can benefit younger women (ages 50-59) or those who start treatment within 10 years of menopause. In these groups, HRT reduced coronary disease and overall mortality.  Yet despite this newer evidence and the concept of a “window of opportunity” for safe use, public and medical opinion has been slow to change, and the fear surrounding HRT has largely persisted.

What is HRT, and what benefits does it offer?

HRT is the medical use of hormones (most often estrogen and progesterone for women) to restore levels that naturally decline with age. This therapy helps ease menopause symptoms like hot flashes, night sweats, and disrupted sleep. It can also support long-term health by protecting bone density, brain function, and cardiovascular health, said Dr. Andrea Matsumura, MD, MS, FACP, FAASM and sleep expert at Sleep Goddess MD.

It helps with mood swings, irritability, and anxiety related to hormone changes. It also improves vaginal dryness, discomfort with sex, and urinary issues. HRT can also help maintain bone density, reducing the risk of osteoporosis and fractures. For some women, it can also help with heart and blood vessel health, skin elasticity, and joint stiffness. There is also some evidence suggesting it may lower the risk of memory decline or dementia, said Dr. Elizabeth Rubin, clinical advisor at Embers Recovery.

Who is a good candidate for HRT?

Candidates for HRT include women experiencing moderate to severe perimenopause symptoms that interfere with their daily life. “It’s also indicated for women with early menopause (before age 40) or premature ovarian insufficiency,” said Matsumura.

Patients with surgical menopause, those with a high risk of osteoporosis or fractures, and those with good overall health and no major risk for blood clots, stroke, or hormone-sensitive cancers are all good candidates for HRT, said Rubin.

HRT isn’t recommended for everyone, especially those with unexplained vaginal bleeding, certain active cancers, clotting disorders, or recent heart attacks or strokes, said Dr. Jobby John, PharmD and founder of Nimbus Healthcare. “For years, doctors considered any history of breast cancer an absolute barrier to HRT. However, the thinking on this philosophy is evolving,” he said. “Some specialists now use advanced risk-assessment tools to carefully weigh the benefits of symptom relief against the potential risks, even for some women with a past breast cancer diagnosis.”

Are there side effects or risks associated with HRT?

Dr. Andrea Caamano, head of medical at the HRT Club, said, “Like any other treatment, there’s always a possibility of risks and side effects. HRT is no different.” Common side effects include:

• Breast tenderness
• Headaches
• Breakthrough bleeding
• Belly bloating
• Nausea or indigestion
• Mood changes

She said that women with active breast or endometrial cancer, undiagnosed vaginal bleeding, liver disease, or who are currently experiencing a stroke, heart attack, embolism or other bleeding disorder should not use HRT.

“Any woman with a uterus (has not had a complete hysterectomy) must use progesterone if she is using estrogen therapy,” said Caamano. “If you still have a uterus and only use estrogen, you increase your risk of contracting endometrial cancer. Progesterone, which is uterine protective, helps to reduce that risk.”

Oral estrogen carries some greater risks, like increased risk for gallbladder issues, deep vein thrombosis, and blood clots, than transdermal options. Patches, gels, and sprays have a lower clot risk than pills. Women who start HRT later in life (after age 60 or more than 10 years after the start of menopause) have an increased risk of dementia.

Other potential long-term risks include breast cancer if someone is on combined HRT (estrogen + progestogen) for more than 5 years, said Rubin. Starting HRT late can raise the risk of heart attack and stroke. The earlier a woman starts HRT (under 60 or within 10 years of the start of menopause), the safer an option it is.

The moral of this story? Find a provider with a thorough understanding of HRT who will listen to your symptoms and carefully review your medical history, including any current health conditions and your family history, too.

What type of doctor should I consult if I’m considering HRT?

If you want to know more about HRT and whether it’s right for you, talking to a healthcare professional is your first step. Caamano recommends these specialists:

• Primary care physician (PCP) or OB-GYN
  Start with your PCP or OB-GYN. They’re usually your first point of contact because they have a comprehensive understanding of your overall health history. They can help you coordinate your care and monitor any long-term risks associated with HRT.
• Menopause specialist
  If your symptoms are complex or you have other metabolic concerns, a menopause specialist might be your best choice. These doctors have extensive training and focus specifically on the nuances of perimenopause and menopause, making them experts in crafting a personalized treatment plan.
• If you have other healthcare issues, you may want or need to consult with other doctors.
  • Endocrinologists may be part of your healthcare team if you have other hormonal issues, such as thyroid problems or diabetes, that require careful consideration when prescribing HRT.
  • Urologists can offer guidance if you’re experiencing chronic urinary or vaginal issues that are linked to hormonal changes.
  • Sleep medicine physicians may be helpful, as hormone shifts can profoundly impact sleep, which is often one of the first and most disruptive symptoms women experience during menopause.

As always, your first stop before deciding on any treatment is your doctor. 

Correction on October 21: Dr. Andrea Caamano’s name was misspelled in the first version of this story. Dr. Caamano is the head of medical at the HRT Club,