Is Hormone Therapy Good for You During Menopause?
Menopause, defined as one full year without a period due to a decline in estrogen, usually starts between the ages of 44 and 55. As the body slowly decreases how much estrogen it produces, many women report uncomfortable symptoms like hot flashes, night sweats, mood changes, and menstrual fluctuations.
The solutions for menopause symptoms vary, and many women manage their symptoms without intervention or through dietary or exercise changes. But some choose hormone therapy (HT) as treatment to help alleviate symptoms or reduce the risk of certain complications associated with menopause.
What Is Hormone Therapy?
Previously commonly known as hormone replacement therapy, or HRT, this treatment focuses on the use of hormones as medication. HT provides low levels of the hormones your body stops making during menopause, to help relieve disruptive symptoms.
Recently, there’s been a shift toward dropping “replacement” from the term. “We no longer call it hormone replacement therapy, but rather just hormone therapy, because we are not actually trying to ‘replace’ what the ovaries used to make,” explains Stephanie Faubion, M.D., an internist based in Jacksonville, Florida, and the medical director for The North American Menopause Society (NAMS). “Instead, we aim to give the amount needed to manage symptoms.”
Potential Benefits of Hormone Therapy
Using hormone therapy may help relieve menopause symptoms caused by hormonal changes, such as:
- Hot flashes
- Night sweats
- Vaginal dryness
- Painful sex
- Mood changes
- Sleep disruptions
- Brain fog
- Joint aches
- Dry skin
- Overactive bladder
- Urinary tract infections
“The benefits are quite significant if you don't feel well—so if you're having any of those symptoms, particularly if it's a new onset, you're going to feel much better [if you start hormone therapy],” says Andrea Rapkin, M.D., an ob-gyn and department chair at the UCLA School of Medicine.
“[But] the other symptoms that women sometimes ask about—‘I've gained weight. Am I going to lose weight? Is my skin going to be better?’—that’s up in the air,” she says. “It's really not clear that that's going to ensue at all.”
HT may also help reduce your risk of other health conditions, such as:
- Colon cancer
- Heart disease (if HT is started within 10 years of menopause; see below)
“For a very long time, women didn't live very long beyond menopause, so it was not really an issue to have a lack of estrogen,” says Rachel Pope, M.D., an ob-gyn and chief of the Female Sexual Health Program at University Hospitals Cleveland Medical Center. “But nowadays, we're living decades beyond menopause. So not having estrogen, which is a very critical component for a lot of women, really starts to impact their health.”
What Are the Risks?
For some women, taking HT can increase the risk of certain conditions, including:
- Blood clots
- Heart attacks
- Breast cancer
- Uterine cancer
- Gallbladder disease
Because of findings from a large trial conducted by the Women’s Health Initiative in 2002, the FDA required hormone therapy to have a warning for these risks. As a result, some women backed away from HT altogether; others started seeking out alternatives like bioidenticals, which are produced in the laboratory from plants, but the hormones are identical to the ones made by the body.
“A lot of my patients come in thinking bioidentical hormone is less risky,” says Rapkin, who goes on to explain that “bioidentical just means it's chemically formulated from a plant-based product to look like estrogen or progesterone from the reproductive years.”
And that doesn’t mean it comes without risk, she adds. The majority of bioidentical hormone products are not FDA-approved and are therefore less regulated. It’s thought that the risks from these products are assumed to be similar to the risks of traditional hormone therapy.
Results from a follow-up trial conducted by the Women’s Health Initiative, published in JAMA in 2013, took a deeper dive and found that the risks vary from woman to woman. In particular, findings suggested that these risks tend to be lower in younger women (women ages 50-59) who take hormone therapy.
The type of HT that’s prescribed is also thought to affect these risks. For example, women who’ve had a hysterectomy and can take estrogen alone may have less of a risk than those who take estrogen plus progesterone. And while it was previously thought that the risks varied based on the type of estrogen therapy provided, a recent study published in the journal Menopause found that the risk of blood clots was similar across three different estrogen therapies.
Hormone Therapy Side Effects
With hormone therapy, side effects are relatively rare. “The estrogen that we're actually giving you [with HT] is lower than the amount of estrogen that your ovaries have been making throughout most of your life. So very few people have side effects,” explains Pope. It’s also possible for side effects to be temporary as your body is adjusting to the medication.
The following are potential side effects of HT:
- Breast soreness or enlargement
- Irregular bleeding
- Mood swings
- Skin irritation (with topical applications)
- Water retention
If you do experience side effects, talk to your doctor. “You can definitely tweak your dose so that you get the benefits of the estrogen replacement without the side effects,” Pope says.
Types of Hormone Therapy
There are a variety of different options for HT. Some of these medications contain estrogen only, others contain progesterone only, and some contain a combination of estrogen plus progesterone.
If you’ve had a hysterectomy, you may benefit from estrogen alone. A woman who still has her uterus typically needs estrogen plus progesterone, since the progesterone helps protect against an overgrowth of the lining of the uterus and lowers the risk of uterine cancer.
HT comes in a variety of options, depending on the type:
- Pill or tablet
- Nasal spray
- Skin gel or patch
- Vaginal applications, like cream, tablet, suppository, ring, or intrauterine device (IUD)
If you’re considering HT, work with your doctor to choose the right option or combination for you, as different types of HT provide relief for different menopause symptoms.
Your doctor will typically prescribe the lowest dose for the shortest time needed to manage menopause symptoms. “You’re not on it indefinitely,” emphasizes Pope.
Your doctor may follow up every three to six months to see whether you still need to take HT or whether your dose needs to be adjusted. Today, most women who take HT do so for about two to five years. “But that’s different for everyone,” Pope says. “Some women, as soon as they start to wean, their hot flashes get bad again, so it’s not that easy to taper off.”
Who Is a Good Candidate for Hormone Therapy?
HT may be a good option for you if you:
- Experience moderate or severe menopause symptoms that are disrupting your life
- Are within 10 years of the onset of perimenopause
- Are under age 60
“[For these individuals] the benefits typically outweigh the risks,” Faubion says.
Pope points out that starting HT within 10 years of the start of menopause is key. “All of the scary things we've seen about estrogen come from research that was looking at women who started replacement beyond 10 years after menopause,” she explains. “But if you are within 10 years, or you're perimenopausal or going through menopause, it is very safe to be on estrogen replacement, and the research on that is very robust.”
Who Shouldn’t Use Hormone Therapy?
HT isn’t a great option for those who:
- Are pregnant or think they’re pregnant
- Have issues with heavy or unpredictable vaginal bleeding that hasn’t been evaluated by a doctor
- Have a history of certain types of cancer, including breast or uterine cancers
- Have a history of heart attacks
- Have a history of strokes
- Have had blood clots
- Have dementia
- Have liver disease
“[There are] risks for cardiovascular disease, [especially if] someone is obese or has diabetes, hypertension, or hyperlipidemia,” adds Dr. Rapkin.
Alternatives to Hormone Therapy
If you’re not a good candidate for hormone therapy, or you’re just wondering what else is out there for helping to ease perimenopause and menopause symptoms, there are other options to consider. “Instead of going after the root of the problem [with HT], we tackle the symptoms [themselves],” Pope says of the alternate options.
Alternatives include varying lifestyle strategies and other drugs that don’t involve hormones.
Nonhormonal Drugs vs. Hormone Therapy
There are a few nonhormonal options that may be prescribed to help what’s known as vasomotor symptoms—that is, symptoms related to the opening or constricting of blood vessels, as controlled by nerves or nerve centers—such as hot flashes or night sweats. HT alternatives include:
- Paroxetine, an antidepressant medication (the only FDA-approved option)
- Gabapentin, an anti-seizure medication
- Clonidine, a blood pressure medication
- Oxybutynin, an overactive-bladder medication
The FDA has also approved a nonhormonal drug called ospemifene to treat pain with sex that’s related to changes from menopause.
There are also steps you can take in your day-to-day life to better manage uncomfortable menopause symptoms. Start with these strategies:
- Dress in loose, breathable layers of clothing that are easy to shed when a hot flash strikes.
- Eat a balanced diet and exercise regularly to fend off menopause-related weight gain.
- Keep your bedroom cool to help prevent night sweats that disrupt sleep.
- Practice Kegel exercises (tightening and releasing the muscles used to control the flow of urine) to strengthen the pelvic floor and help with urinary incontinence.
- Avoid hot showers, stay hydrated, and wear sunscreen to keep skin moisturized and protected.
- Use lubricants to help with vaginal dryness and prevent painful sex.
- Speak Up
Many women aren’t bothered by menopause symptoms and don’t need treatment. But if symptoms are disruptive to your life, be sure to talk to your doctor about the kinds of treatments and lifestyle interventions that may help.
Going through perimenopause and then menopause is a gradual process, says Pope. “I think a lot of women don't realize that. They think menopause is going to be like a date on the calendar or an event, but it is a slow transition,” she says. In fact, the transition to menopause typically lasts around seven years for most women—and can last as long as 14 years for some.
During this time, symptoms like hot flashes, sleep disturbances, mood changes, and vaginal dryness can take a toll on your quality of life. Although going through menopause is a normal part of aging, you don’t have to grin and bear it if it’s disrupting your day-to-day life.
“Please, do not suffer in silence,” Pope says. “This does not have to be your normal. . . . We have medications that can make this a much more tolerable transition for you.”
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