Hormone Replacement Therapy (HRT) for Menopause
Hormone replacement therapy (HRT) is the most common overall medical approach to treating menopause symptoms. And when clinicians say HRT, they’re typically referring specifically to estrogen replacement. HRT is most often prescribed for women with moderate to severe symptoms, and it’s also commonly recommended for women who experience premature or early menopause (before age 45) or who are at significant risk for bone loss/osteoporosis. Estrogen can be prescribed systemically to support the whole body (including the brain, bones, skin, vulva, and vagina) or as local therapy to target the vulva and vagina specifically. While there has historically been confusion and fear around HRT due to early interpretations of the 2002 Women’s Health Initiative (WHI), current guidance from the North American Menopause Society (NAMS) considers HRT safe and effective for most women when started before age 60 or within 10 years of the final menstrual period.
When medical practitioners talk about prescribing HRT, they are referring specifically to the replacement of estrogen. It is most often prescribed to women with moderate to severe symptoms of menopause, and it will also often be recommended to women who experience premature or early menopause (when periods stop before age 45) and those at significant risk for bone loss or osteoporosis. Estrogen can be prescribed systemically to reach and affect the whole body, or as “local treatment” to target one specific area or concern. Other hormones may also be prescribed to menopausal women, including progesterone, DHEA, testosterone, or oxytocin, although these are generally not referred to as HRT.
As you consider treatment, it’s important to understand the difference between systemic hormones (meant to support your entire body) and local hormones (meant only to affect the part of the body to which they are applied). Systemic estrogen is given at a high enough strength to impact the whole body, with the idea that estrogen will go to where it is most needed, such as the vulva, vagina, bones, skin, hair, or brain. Systemic estrogen can be delivered in many ways, including a patch, a pill, a capsule inserted into the vagina, or an ointment, but the key is that these are dosed to circulate throughout the body. In contrast, local estrogen therapies are meant to affect only the vulva and vagina and are not intended to circulate throughout the rest of the body. Local therapies can also come in various forms, including creams, gels, pellets, and rings. Because this distinction is easy to miss, if you are prescribed estrogen, it’s reasonable to ask whether it is local or systemic.
There is also a lot of confusion about bioidentical hormones. “Bioidentical” does not mean organic, natural, or “not really hormones.” Bioidentical hormones are products in which the chemical makeup of the hormones exactly matches the chemical makeup of the same hormones in your body. These products are usually man-made and created in a laboratory, but their molecular components are identical to your body’s hormones. If you tested blood for estrogen or testosterone, bioidentical versions compounded in a lab should not be discernible from the same compounds created in your body. Whether you are prescribed pills, topical creams, or pellets, we strongly encourage patients to use bioidentical products.
You may wonder why any pharmaceutical company would make hormones that don’t exactly match what your body creates. One reason is that products that match your biology can’t be patented, which is similar to how you can’t patent water unless you change it. Drug companies have historically been incentivized to alter chemical compounds so they can patent them, sometimes suggesting the difference is an improvement, though we haven’t found that to be the case. In recent years, since bioidentical hormones are often preferred, companies have developed unique delivery systems (e.g., creams, sprays, patches, or pellets) to patent the way the hormone is delivered rather than the hormone itself. As a result, many commonly used hormones are now available by prescription in FDA-approved bioidentical formulations.
Another common misconception is that anything made by a compounding pharmacy is automatically bioidentical. Compounding pharmacies make medications on the premises and can create both bioidentical and non-bioidentical hormones, depending on what the doctor orders. Some patients assume compounded products must be safer because they’re supposedly mixed for them, but that is not necessarily true. FDA-approved products have rigorous safety standards and are machine-made, making them less subject to human error. Where possible, we prefer FDA-approved bioidentical products that are commercially prepared rather than compounded. That said, compounding pharmacies can be extremely helpful when a medication isn’t available commercially, when a custom combination is needed, or when cost considerations make compounding a better option.
Many women have heard that HRT is “bad for you,” largely due to the 2002 Women’s Health Initiative (WHI) study, which initially reported increased risk of breast cancer, heart disease, and blood clots. However, many women in the study were older, had higher baseline health risks, and were often more than a decade past menopause, which skewed the results. Later analyses showed that a significant group of women had improved health outcomes on HRT, but the initial media response led many women and clinicians to abandon HRT and stigmas persist to this day. Today, NAMS considers HRT safe and effective for most women in perimenopause through menopause, especially when started prior to age 60 or within 10 years of the final menstrual period.
In terms of pros and cons, systemic estrogen therapy is extremely effective at reducing hot flashes and night sweats, and it can help vaginal dryness and support bone health by preventing bone loss. Women who still have a uterus typically need progestogen alongside estrogen to protect the uterine lining, while women without a uterus can often take estrogen alone. For vaginal dryness or discomfort with intercourse, low-dose local vaginal estrogen or laser treatment (such as MonaLisa Touch) is often preferred. The data on heart disease is mixed: estrogen can improve blood flow and cholesterol patterns, but oral estrogen can increase clotting risk, which is why route of delivery matters and long-term use beyond menopause is approached carefully. Breast cancer risk also varies by regimen; WHI data showed a slight increase with estrogen plus progesterone, while estrogen alone showed a slightly reduced incidence, and newer observational data suggests risks may differ depending on the type of progesterone used. Endometrial cancer risk is primarily a concern when estrogen is used without adequate uterine protection in women who still have a uterus. Blood clots and stroke risk applies almost exclusively to oral estrogen (processed through the liver) and generally does not apply to transdermal estrogen. Dementia risk may increase when HRT is started after age 60, while starting around the time of the final menstrual period may reduce risk for Alzheimer’s disease and dementia.