Deciding About Hormone Therapy Use

Many women experience hot flashes, vaginal dryness, and other physical changes with menopause. For
some women, the symptoms are mild and do not require any treatment. For others, symptoms are moderate
or severe and interfere with daily activities. Hot flashes improve with time, but some women have bothersome
hot flashes for many years. Menopause symptoms often improve with lifestyle changes and nonprescription
remedies, but prescription therapies also are available, if needed. Government-approved treatments for
bothersome hot flashes include hormone therapy (HT) containing estrogen, as well as two nonhormone
medications (paroxetine and fezolinetant).

Hormone therapy involves taking estrogen in doses high enough to raise the level of estrogen in your blood in
order to treat hot flashes and other symptoms. Because estrogen stimulates the lining of the uterus, women
with a uterus need to take an additional hormone, progestogen, or a tissue-selective estrogen complex
(TSEC) to protect the uterus. Women without a uterus just take estrogen. If you are bothered only by vaginal
dryness, you can use very low doses of estrogen placed directly into the vagina. These low doses generally
do not raise blood estrogen levels above postmenopause levels and do not treat hot flashes. You do not need
to take a progestogen when using only low doses of estrogen in the vagina. (The MenoNote “Vaginal
Dryness” covers this topic in detail.)

Every woman is different, and you will decide about whether to use HT based on the severity of your
symptoms, your personal and family health history, and your own beliefs about menopause treatments. Your
healthcare professional will be able to help you with your decision.

Potential benefits
Hormone therapy is one of the most effective treatments available for bothersome hot flashes and night
sweats. If hot flashes and night sweats are disrupting your daily activities and sleep, HT may improve sleep
and fatigue, mood, ability to concentrate, and overall quality of life. Treatment of bothersome hot flashes and
night sweats is the principal reason women use HT. Hormone therapy also treats vaginal dryness and painful
sex associated with menopause, as well as some urinary symptoms such as increased urinary frequency,
urgency. Hormone therapy keeps your bones strong by preserving bone density and decreasing your risk of
osteoporosis and fractures. If preserving bone density is your only concern, and you do not have bothersome
hot flashes, other treatments may be recommended instead of HT.

Potential risks
As with all medications, HT is associated with some potential risks. For healthy women with bothersome hot
flashes aged younger than 60 years or within 10 years of menopause, the benefits of HT generally outweigh
the risks. Hormone therapy might slightly increase your risk of stroke or blood clots in the legs or lungs
(especially if taken in pill form). If started in women aged older than 65 years, HT might increase the risk of
dementia. If you have a uterus and take estrogen with progestogen, there is no increased risk of cancer of the
uterus. Hormone therapy (combined estrogen and progestogen) might slightly increase your risk of breast
cancer if used for more than 4 to 5 years. Using estrogen alone (for women without a uterus) does not appear
to carry the same risk.

Some studies suggest that HT might be good for your heart if you start before age 60 or within 10 years of
menopause. However, if you start HT further from menopause or after age 60, HT might slightly increase your
risk of heart disease. Although there are risks associated with taking HT, they are not common, and most go
away after you stop treatment.
Potential adverse effects
Hormone therapy can cause breast tenderness, nausea, and irregular bleeding or spotting. These adverse
effects are not serious but can be bothersome. Reducing your dose of HT or switching the form of HT you use
often can decrease adverse effects. Weight gain is a common problem for midlife women, associated with
both aging and hormone changes. Hormone therapy is not associated with weight gain and may lower the
chance of developing diabetes.

Hormone therapy options

Each woman must make her own decision about HT with the help of a healthcare professional. If you decide
to take HT, the next step is to choose between the many HT options available to find the best dose and route
for you. With guidance from your healthcare professional, you can try different forms of HT until you find the
type and dose that treats your symptoms with few adverse effects.

Pill or non-pill
Hormone therapy is available as a daily pill, but it also may be taken as a skin patch, gel, cream, spray, or
vaginal ring. Non-pill forms may be more convenient. Hormone therapy pills need to be taken every day, but
skin patches are changed only once or twice weekly, and the HT vaginal ring is changed only every 3 months.
Hormone therapy taken in non-pill form enters your blood stream more directly, with less effect on the liver.
Studies suggest that this may lower the risk of blood clots in the legs and lungs compared with HT taken as a
pill.

Estrogen alone or estrogen plus progestogen

If you have a uterus, you will need to take progestogen or a TSEC with your estrogen. Many pills and some
patches contain both hormones together. Otherwise, you will need to take two separate hormones (eg,
estrogen pill with progestogen pill or estrogen patch with progestogen pill). Taking both hormones every day
usually results in no bleeding. Women who prefer regular periods can take estrogen every day and
progestogen for about 2 weeks each month. Another option is to take estrogen combined with a nonhormone
medication (bazedoxifene) to protect the uterus. If you do not have a uterus, you can take estrogen alone,
without a progestogen.

Dose of estrogen
As with all medications, you should take the lowest dose of estrogen that relieves your hot flashes. You can
work with your healthcare professional to find the right dose for you. It typically takes about 8 to 12 weeks for
HT to have its full effect, so doses should be adjusted slowly. Even low doses of estrogen will preserve your
bone density and reduce your risk of a fracture.

Stopping hormone therapy

There is no “right” time to stop HT. Women may choose lower doses or change to non-pill forms of HT. You
and your healthcare professional will work together to decide how long you should remain on HT. Reasons to
consider longer-term HT use include recurrent, persistent hot flashes or night sweats, prevention of
osteoporosis, or for perceived enhanced quality of life. Because there may be greater risks with longer
duration of use and as you age, you and your healthcare professional should work together to decide what is
the best option for you.

This MenoNote provides current general information but not specific medical advice. It is not intended to
substitute for the judgment of a person’s healthcare professional. Additional information can be found at
www.menopause.org. The Menopause Society is committed to leading the conversation about improving
women’s health and healthcare experiences during the menopause transition and beyond. The Society develops
evidence-based position statements and consensus recommendations to ensure that healthcare professionals
and the public have access to the most up-to-date information.

Copyright 2025 The Menopause Society. All rights reserved. The Menopause Society grants permission to
healthcare professionals to reproduce this MenoNote for distribution to women in their quest for good health.

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2/2025