What to Know About Hormone Replacement Therapy for Menopause

During menopause, significant hormone decline can create numerous uncomfortable or downright miserable symptoms. Throughout this transition, estrogen is usually the first hormone to nosedive. Other hormones, including progesterone and testosterone, quickly follow. The repercussions include mood swings, brain fog, sleep disturbances, hot flashes, vaginal dryness and discomfort, and an increased risk of osteoporosis.

What if there were a way to manage those symptoms and improve your quality of life? That’s the promise of hormone-replacement therapy (HRT).¹

What Is HRT?

HRT involves supplementing declining estrogen and progesterone levels with synthetic or bioidentical hormones to alleviate menopausal symptoms. Replacing these hormones can also help manage complications around menopause, including:

Supporting bone health and reducing the likelihood of fractures
Decreasing vaginal dryness, discomfort during sex, and the risk of urinary tract infections
Reducing the risk of heart disease
Alleviating mood disturbances, potentially enhancing overall well-being

There are two types of HRT that your healthcare practitioner may prescribe:

Estrogen alone (for those who have had a hysterectomy). The type and formulation of estrogen depends on your health needs, preferences, and any existing health conditions.
Estrogen and progesterone (for those who have not had a hysterectomy). Progesterone is added here to protect the uterine lining from excessive growth and hyperplasia, reducing the risk of endometrial cancer. This usually involves synthetic forms of progesterone, called progestins.

HRT comes in various forms, such as pills, patches, gels, creams, and injections. If you opt to use it, your healthcare practitioner will monitor your progress regularly to ensure effectiveness and safety, adjusting the form and dosage if necessary. It is crucial to never modify or discontinue HRT without the guidance of your doctor. Symptoms can recur if you abruptly stop, and there may also be other health implications.

What’s the Difference Between HRT and BHRT?

HRT typically involves the use of synthetic hormones, often sourced from animal origins or created in a laboratory setting. While some HRT utilizes hormones that differ in molecular structure from those our bodies produce, bioidentical hormone-replacement therapy (BHRT) specifically utilizes hormones that are molecularly identical to those in the human body, and are often derived from plant sources.

Traditional HRT usually comes as standard prescription medications in specific doses and forms such as pills, patches, and creams. BHRT is often customized based on your unique hormone levels, measured through saliva or blood testing. While there are FDA-approved BHRT medications, some formulations of BHRT, called compounded bioidentical hormones, are custom-made by a pharmacy according to a doctor’s orders.

Research shows that BHRT can help restore hormone balance and improve moderate to severe menopause symptoms, including hot flashes, night sweats, mood swings, memory issues, sleep problems, and weight gain.²

Proponents claim that bioidentical hormones are safer than HRT, including lower risks for breast cancer and cardiovascular disease. However, both types carry risks.³ Whether you opt for HRT or BHRT, you’ll want to carefully consider those potential benefits and risks with your doctor.

Is HRT Safe?

HRT is generally recommended for short-term use (typically about three to five years) to manage menopausal symptoms. Longer-term use may increase risks of cardiovascular disease, blood clots, stroke, and certain cancers.

One study that made headlines was the Women’s Health Initiative (WHI) trial. Started in 1991 by the US National Institutes of Health (NIH), the long-term WHI trial looked at various health concerns affecting postmenopausal women, including hormone-replacement therapy. Until 2002, HRT was the standard approach for managing menopause. That changed following the release of initial results from this trial, which emphasized the risks of HRT (including breast cancer and heart attacks).

Critics noted the report incited unnecessary fears based on flawed research. Among them was the age researchers looked at in the trial. Most women initiate HRT close to the onset of menopause. In the WHI trial, however, the average age of participants was about 63, often years after menopause had begun, which could impact the therapy’s safety profile. Despite these and other purported flaws, HRT use declined after the report came out.⁴

An unintended positive outcome of the trial was a broader exploration of alternative approaches to managing menopausal symptoms. This opened discussions on non-hormonal interventions, including exercise, supplements, diet, and other complementary therapies, leading to a more holistic approach to women’s health.

Benefits of Hormone-Replacement Therapy

Replenishing declining hormone levels with HRT or BHRT can alleviate menopausal symptoms, but that’s just the tip of the iceberg to improve overall well-being and quality of life.

Other potential benefits of HRT include:

Bone health. Estrogen plays a crucial role in maintaining strong bones. HRT can reduce bone loss created by estrogen deficiencies, reducing the risks of osteoporosis and fractures.⁵
Heart health. Estrogen can improve your lipid profile. Declining levels of this hormone during menopause can adversely impact cholesterol, triglycerides, and other lipid levels. HRT may help restore estrogen levels and reduce the risk of cardiovascular disease in some women.⁶
Skin health. HRT may help maintain skin elasticity and moisture.⁷ Declining estrogen levels can affect skin health, and restoring these levels might mitigate some of these effects, such as dryness.
Better mood. In some women, HRT might help alleviate mood swings, irritability, depression, and anxiety that hormonal fluctuations can create.⁸
Better sleep. HRT can address night sweats and hot flashes, common disruptors of sleep during menopause. Estrogen may also improve sleep quality, reduce the time to fall asleep, increase REM sleep time, and reduce the number of times you wake up at night.⁹
Brain health. Some research shows that HRT may reduce cognitive decline and the risk of dementia.¹⁰
Urinary health. HRT may alleviate urinary symptoms that arise from declining estrogen levels, which can affect the strength and elasticity of pelvic tissues. These symptoms include urgency, frequency, and urinary incontinence.¹¹

Hormone-Replacement Therapy Side Effects

While HRT during menopause can provide benefits, it isn’t a one-size-fits-all solution. For some folks, the risks may outweigh benefits. Among the potential drawbacks and risks of using HRT:

Breast cancer. Studies indicate a potential increased risk of breast cancer with HRT use. The risk appears to be influenced by the duration of HRT and its type. Importantly, this increased risk seems to decline once women stop HRT.¹²
Blood clots. HRT may increase the risk of blood clots, creating deep vein thrombosis (the formation of a blood clot within a deep vein, usually in your legs or pelvis) or pulmonary embolism (a blockage in one of the pulmonary arteries in your lungs).¹³
Cardiovascular issues. The effects of HRT on heart health can vary based on your individual health factors. If you have a history of heart attacks, high blood pressure, or other heart-related issues, you may want to avoid HRT.¹⁴ Discuss your potential risks with your doctor.
Stroke. While some research suggests an increased risk of stroke with certain HRT types, particularly those containing both estrogen and progestin, it’s essential to consider individual factors when evaluating this risk.¹⁵
Gallbladder issues. The reasons are not fully understood, but HRT might increase the risk of gallstones and other gallbladder complications.¹⁶
Dementia and cognitive changes. Some studies suggest a slight increased risk of dementia and cognitive decline with long-term HRT use. Factors such as age and the specific type of HRT could influence this risk.¹⁷
Bone health. While HRT can help maintain bone density, discontinuing HRT after a prolonged period can lead to a rapid decrease in bone density, increasing the risk of osteoporosis.¹⁸
Mood swings. HRT might impact mood and emotional well-being, leading to symptoms like mood swings and irritability.¹⁹
Other side effects. HRT can also lead to other side effects such as breast tenderness, bloating, headaches, and vaginal bleeding.²⁰

What to Discuss With Your Doctor About HRT

The same benefits one person experiences can become risks for another, highlighting the importance of understanding the pros and cons before making an informed decision about HRT.

“Discussion about hormone therapy for perimenopause and menopause is complex,” says Sara Gottfried, MD. “Questions about safety, timing, and duration typically require a nuanced conversation about a person’s history, diet, lifestyle, risk factors, genetics, blood tests, and cognitive function.”²¹

You don’t need to make informed decisions alone. Talk with a healthcare professional about these and other factors that can impact your decision to use HRT:

Risks vs. benefits. The potential benefits of HRT, such as symptom relief, bone health, and cardiovascular protection, need to be weighed against the potential risks, including increased breast cancer risk, cardiovascular events, and blood clotting.
Severity of symptoms. Women with severe menopausal symptoms, like intense hot flashes and night sweats, may benefit more from HRT, while those with milder symptoms might find the potential risks outweigh the benefits.
Your medical history. Women with a history of certain medical conditions, such as breast cancer, cardiovascular disease, blood-clotting disorders, or liver disease, may choose not to use HRT because of potential risks.
Age and timing. The age you enter menopause, along with when you start HRT, can influence its efficacy. Starting HRT within a few years of menopause onset might offer more benefits, particularly for bone and heart health.
Type of menopause. Women who experience natural menopause or early menopause might respond differently to HRT compared to those who undergo surgical menopause (due to procedures like the removal of ovaries).
Your hormone levels. Some women may experience more dramatic hormonal changes during menopause than others. HRT can help normalize hormone levels in those with significant imbalances.
Duration of treatment. Short-term HRT for managing severe menopausal symptoms might be more acceptable for some women, while long-term use could raise concerns about cumulative risks.
Combination vs. estrogen-only therapy. Some people benefit more from a combination of estrogen and progestin therapy, while others (especially those who have had a hysterectomy) might only need estrogen-only therapy.

Work With a Functional Medicine Doctor to Weigh Your Options

Both functional medicine doctors and conventional physicians offer unique approaches to HRT. It’s essential to choose a practitioner who aligns with your healthcare philosophy and needs.

If you’re considering HRT, a functional medicine doctor can provide a comprehensive, personalized approach to menopausal symptoms. They will evaluate your medical history, current health status, and any existing conditions. They may also recommend a range of tests to assess hormone levels, nutrient deficiencies, inflammation markers, and other relevant biomarkers.

Based on the results of your assessments and tests, your functional medicine doctor will create a personalized treatment plan. Unlike some conventional physicians who may be time-crunched, functional practitioners take the time to explain the benefits and risks of different HRT options based on your individual health profile.

They also help implement changes in diet, exercise routine, stress management, sleep quality, and other lifestyle factors that can complement the effects of HRT. Search for a functional medicine doctor in your area. Two excellent databases are The Institute for Functional Medicine and The American Academy of Anti-Aging Medicine.

If you opt for HRT, many women notice a difference within 30 days. However, individual experiences can vary. Remember, too, that some forms of HRT kick in faster than others.

Because I want to help you make the most informed decision about HRT, I’ve compiled some helpful blogs and episodes of Well Beyond 40:

How Do You Know if You Need Hormone-Replacement Therapy?
Debunking the Biggest Myths of Hormone Replacement (with Deb Matthew, The Happy Hormones Doctor)
Bioidentical Hormone-Replacement Therapy During Menopause: Yes or No?
Redefining Menopause: Why We Need a New Narrative (with Suzanne Gilberg-Lenz, a conventional board-certified OB-GYN who also practices integrative, holistic, and Ayurvedic medicine)
6 Ways to Master Menopause
7 Tips to Help You Feel Your Best During Menopause
The Best Foods for Menopause Symptoms
Which Supplements Are Best for Menopause?

References:

Dr. Jolene Brighten: Perimenopause Symptoms and Treatment

Healthline: Bioidentical Hormone Replacement Therapy

Holtorf K. The bioidentical hormone debate: are bioidentical hormones (estradiol, estriol, and progesterone) safer or more efficacious than commonly used synthetic versions in hormone replacement therapy? Postgrad Med. 2009 Jan;121(1):73-85. doi: 10.3810/pgm.2009.01.1949. PMID: 19179815.

Langer RD, Hodis HN, Lobo RA, Allison MA. Hormone replacement therapy – where are we now? Climacteric. 2021 Feb;24(1):3-10. doi: 10.1080/13697137.2020.1851183. Epub 2021 Jan 6. PMID: 33403881.

Barlow DH. HRT and osteoporosis. Baillieres Clin Rheumatol. 1993 Oct;7(3):535-48. doi: 10.1016/s0950-3579(05)80077-9. PMID: 8293488.

Yang XP, Reckelhoff JF. Estrogen, hormonal replacement therapy and cardiovascular disease. Curr Opin Nephrol Hypertens. 2011 Mar;20(2):133-8. doi: 10.1097/MNH.0b013e3283431921. PMID: 21178615; PMCID: PMC3123884.

Stevenson S, Thornton J. Effect of estrogens on skin aging and the potential role of SERMs. Clin Interv Aging. 2007;2(3):283-97. doi: 10.2147/cia.s798. PMID: 18044179; PMCID: PMC2685269.

Zweifel JE, O’Brien WH. A meta-analysis of the effect of hormone replacement therapy upon depressed mood. Psychoneuroendocrinology. 1997 Apr;22(3):189-212. doi: 10.1016/s0306-4530(96)00034-0. Erratum in: Psychoneuroendocrinology 1997 Nov;22(8):655. PMID: 9203229.

Blum, Esther. See ya later, Ovulator!: Mastering Menopause with Nutrition, Hormones, and Self-Advocacy (p. 132). Hybrid Global Publishing. Kindle Edition.

Leblanc E, Chan B, Nelson HD. Hormone Replacement Therapy and Cognition [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2002 Aug. PMID: 20722108.

Medical News Today: Perimenopause and overactive bladder: Link and treatment

Vinogradova Y, Coupland C, Hippisley-Cox J. Use of hormone replacement therapy and risk of breast cancer: nested case-control studies using the QResearch and CPRD databases. BMJ. 2020 Oct 28;371:m3873. doi: 10.1136/bmj.m3873. PMID: 33115755; PMCID: PMC7592147.

Waheed SM, Kudaravalli P, Hotwagner DT. Deep Vein Thrombosis. [Updated 2023 Jan 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507708/

Cedars-Sinai: Hormone Replacement Therapy (HRT) & Heart Health

Henderson VW, Lobo RA. Hormone therapy and the risk of stroke: perspectives 10 years after the Women’s Health Initiative trials. Climacteric. 2012 Jun;15(3):229-34. doi: 10.3109/13697137.2012.656254. PMID: 22612608; PMCID: PMC3675220.

Karger Publishers: Hormone Replacement Therapy and Symptomatic Gallstones

Alzheimer’s Research UK: Potential link between hormone replacement therapy and increased risk of dementia in later life.

Royal Osteoporosis Society: HRT for osteoporosis and bone health

Fischer B, Gleason C, Asthana S. Effects of hormone therapy on cognition and mood. Fertil Steril. 2014 Apr;101(4):898-904. doi: 10.1016/j.fertnstert.2014.02.025. PMID: 24680649; PMCID: PMC4330961.

Evans MP, Fleming KC, Evans JM. Hormone replacement therapy: management of common problems. Mayo Clin Proc. 1995 Aug;70(8):800-5. doi: 10.4065/70.8.800. PMID: 7630222.

Sara Gottfried MD: Hormone Therapy for Women: What Are the Known Risks?

*These statements have not been evaluated by the Food & Drug Administration. Products mentioned are not intended to diagnose, treat, cure, or prevent any disease. The views in this blog by JJ Virgin should never be used as a substitute for professional medical advice. Please work with a healthcare practitioner concerning any medical problem or concern.