Hormone therapy: Is it right for you?

Hormone therapy was once routinely used to treat menopausal symptoms and protect long-term health. Then large clinical trials showed health risks. What does this mean for you?

By Mayo Clinic Staff

Hormone replacement therapy — medications containing female hormones to replace the ones the body no longer makes after menopause — is sometimes used to treat common menopausal symptoms, including hot flashes and vaginal discomfort.

Hormone therapy has also been proved to prevent bone loss and reduce fracture in postmenopausal women.

Along with the benefits, there are risks associated with using hormone therapy. These risks depend on a few factors, including the type of hormone therapy, the dose and how long the medication is taken. For best results, hormone therapy should be tailored to each person and re-evaluated every so often to be sure its benefits still outweigh the risks.

What are the benefits of hormone therapy?

The benefits of hormone therapy depend, in part, on whether you take systemic hormone therapy or low-dose vaginal preparations of estrogen.

  • Systemic hormone therapy. Systemic estrogen — which comes in pill, skin patch, gel, cream or spray form — remains the most effective treatment for the relief of troublesome menopausal hot flashes and night sweats. Estrogen can also ease vaginal symptoms of menopause, such as dryness, itching, burning and discomfort with intercourse.

    Combined estrogen and progesterone therapy may reduce the risk of colon cancer. Some data also suggest that estrogen can decrease the risk of heart disease when taken early in the postmenopausal years. Systemic estrogen helps protect against the bone-thinning disease called osteoporosis. However, doctors usually recommend medications called bisphosphonates to treat osteoporosis.

  • Low-dose vaginal products. Low-dose vaginal preparations of estrogen — which come in cream, tablet or ring form — can effectively treat vaginal symptoms and some urinary symptoms while minimizing absorption into the body. Low-dose vaginal preparations do not help with hot flashes, night sweats or protection against osteoporosis.

If you haven’t had your uterus removed, your doctor will typically prescribe estrogen along with progesterone or progestin (progesterone-like medication). This is because estrogen alone, when not balanced by progesterone, can stimulate growth of the lining of the uterus, increasing the risk of uterine cancer. If you have had your uterus removed (hysterectomy), you don’t need to take progestin.

What are the risks of hormone therapy?

In the largest clinical trial to date, a combination estrogen-progestin pill (Prempro) increased the risk of certain serious conditions, including:

  • Heart disease
  • Stroke
  • Blood clots
  • Breast cancer

Subsequent studies have suggested that these risks vary, depending on age. For example, women who begin hormone therapy more than 10 or 20 years from the onset of menopause or at age 60 or older are at greater risk of the above conditions. But if hormone therapy is started before the age of 60 or within 10 years of menopause, the benefits appear to outweigh the risks.

The risks of hormone therapy may also vary depending on whether estrogen is given alone or with progestin, the dose and type of estrogen, and other health factors such as your risks of heart and blood vessel (cardiovascular) disease, cancer risks, and family medical history.

All of these risks should be considered in deciding whether hormone therapy might be an option for you.

Who should consider hormone therapy?

Despite its health risks, systemic estrogen is still the most effective treatment for menopausal symptoms. The benefits of hormone therapy may outweigh the risks if you’re healthy and you:

  • Experience moderate to severe hot flashes or other menopausal symptoms
  • Have lost bone mass and either can’t tolerate or aren’t benefiting from other treatments
  • Stopped having periods before age 40 (premature menopause) or lost normal function of your ovaries before age 40 (premature ovarian insufficiency)

Women who experience early menopause, particularly those who had their ovaries removed and don’t take estrogen therapy until at least age 45, have a higher risk of:

  • Osteoporosis
  • Heart disease
  • Earlier death
  • Parkinson’s-like symptoms (parkinsonism)
  • Anxiety or depression

For women who reach menopause prematurely, the protective benefits of hormone therapy usually outweigh the risks.

Your age, type of menopause and time since menopause play significant roles in the risks associated with hormone therapy. Talk with your doctor about your personal risks.

Who should avoid hormone therapy?

Women who have or previously had breast cancer, ovarian cancer, endometrial cancer, blood clots in the legs or lungs, stroke, liver disease, or unexplained vaginal bleeding should usually not take hormone therapy.

If you aren’t bothered by menopausal symptoms and started menopause after age 45, you do not need hormone therapy to stay healthy. Instead, talk to your doctor about strategies to reduce the risk of conditions such as osteoporosis and heart disease. These strategies might include lifestyle changes and medications other than hormone therapy for long-term protection.

If you take hormone therapy, how can you reduce risk?

Talk to your doctor about these strategies:

  • Find the best product and delivery method for you. You can take estrogen in the form of a pill, patch, gel, vaginal cream, or slow-releasing suppository or ring that you place in your vagina. If you experience only vaginal symptoms related to menopause, estrogen in a low-dose vaginal cream, tablet or ring is usually a better choice than an oral pill or a skin patch.
  • Minimize the amount of medication you take. Use the lowest effective dose for the shortest amount of time needed to treat symptoms, unless you’re younger than age 45, in which case you need enough estrogen to provide protection against the long-term health effects of estrogen deficiency. If you have lasting menopausal symptoms that significantly impair your quality of life, your doctor may recommend longer term treatment.
  • Seek regular follow-up care. See your doctor regularly to ensure that the benefits of hormone therapy continue to outweigh the risks, and for screenings such as mammograms and pelvic exams.
  • Make healthy-lifestyle choices. Include physical activity and exercise in your daily routine, eat a healthy diet, maintain a healthy weight, don’t smoke, limit alcohol, manage stress, and manage chronic health conditions, such as high cholesterol or high blood pressure.

If you haven’t had a hysterectomy and are using systemic estrogen therapy, you’ll also need progestin. Your doctor can help you find the delivery method that offers the most benefits and convenience with the least risks and cost.

What can you do if you can’t take hormone therapy?

You may be able to manage menopausal hot flashes with healthy-lifestyle approaches, such as keeping cool, limiting caffeinated beverages and alcohol, and practicing paced relaxed breathing or other relaxation techniques. For vaginal concerns, such as dryness or painful intercourse, a vaginal moisturizer or lubricant may provide relief. You might also ask your doctor about the prescription medication ospemifene (Osphena), which may help with episodes of painful intercourse.

The bottom line: Hormone therapy isn’t all good or all bad

To determine if hormone therapy is a good treatment option for you, talk to your doctor about your individual symptoms and health risks. Be sure to keep the conversation going throughout your menopausal years.

As researchers learn more about hormone therapy and other menopausal treatments, recommendations may change. If you continue to have bothersome menopausal symptoms, review treatment options with your doctor on a regular basis.