When is menopausal hormone therapy the right choice?

I enjoy educating people about their options to help make menopause more comfortable. It’s one of the most rewarding aspects of my job because this time of transition can be the best in a menopausal person’s life, if managed properly.

Postmenopausal hormone therapy was once thought to be the Holy Grail method for treating menopausal symptoms. The Women's Health Initiative, however, challenged physicians’ way of thinking. We learned that hormone therapy not only doesn’t prevent chronic diseases, such as stroke and breast cancer, but it might increase the risk for cardiovascular disease in older postmenopausal people.

Let’s look at some of the most pertinent topics concerning hormone therapy to help you evaluate whether it might be the right choice for you.

Why consider postmenopausal hormone therapy?

The postmenopausal time of life is often busy, active and often a career peak. We need to feel good. These days can be the best in someone’s life — it’s a time many can do what’s fun for them. They’re no longer trying to climb the ladder of success; they don't have periods; and the days of rearing young children are likely in the past. For many, it’s time to refocus on their lives.

There’s a transition between menopause and the time just before, which is referred to as perimenopause. It’s this period that starts changes in monthly menstrual cycles, hot flashes, fatigue, weight gain or breast tenderness.

The transition usually takes place between the ages of 45 and 55, ranging from seven to 10 years or more. The two main hormones that decline are estrogen and progesterone, both produced by ovaries. Surgical removal of both ovaries could initiate menopause more abruptly.

What is hormone therapy for menopause?

I think hormone therapy is a good, underused treatment option that could benefit far more people. Hormone therapy replaces natural hormones and works in an area of the brain that helps reduce hot flashes. The therapy can also prevent osteoporosis by slowing down bone loss, which often happens during menopause.

It’s controversial whether hormone therapy is helpful for other menopause symptoms, including difficulty sleeping, concentrating, incontinence and vaginal dryness. There are other treatment options for these symptoms.

How long is hormone therapy typically needed for menopause?

I still readily prescribe hormone therapy as a short-term option for treating hot flashes in menopause — five to seven years, depending on the duration of the hot flashes — and to prevent osteoporosis. After the hot flashes go away, I reevaluate hormone therapy as a treatment option and offer other first-line treatment for osteoporosis if needed.

What are the risks of hormone therapy?

Taking hormone therapy short-term immediately after the last menstrual period seems to be safe for most women. In the 10 years immediately after the last menstrual period, the risks are primarily a slight increased risk of deep vein thrombosis (“DVT” — blood clots in the leg), and a slight increased risk of breast cancer after five years of use. Long-term use, however, especially in older women, seems to cause an increased risk of cardiovascular disease and stroke in addition to the elevated risks of DVT and breast cancer.

When is hormone therapy not suitable?

The use of hormone therapy is a very individual decision based on the risks and benefits to an individual person. Hormone therapy is probably not a first-line treatment for menopausal symptoms in people with breast cancer or other hormone-dependent cancers, a history of blood clots, a history of liver disease, or people at high risk of cardiovascular disease.

What types of hormone therapy are available?

If someone chooses to use hormone therapy for menopausal symptoms, it’s important to use FDA-approved products. There are providers who prescribe compounded products, drugs that are specifically mixed and prepared based on a provider’s prescription. Unfortunately, compounded products are usually unreliable in their preparation and dosing and therefore pose potential risks that aren’t present in FDA-approved products.

There are multiple FDA-approved options for hormone therapy, including bioidentical products. The FDA-approved products are preferred because the dosing and preparation are reliable, and the approved products have been studied for safety.

What are alternatives to hormone therapy?

For those who choose not to take hormone therapy, or are unable to take it, other good medication options exist to help with the symptoms of menopause. Low doses of antidepressant medications (SSRIs and SNRIs including brand names Brisdelle, Paxil and Effexor) can be helpful. Gabapentin, sold under the brand name Neurontin (often used as an alternative for pain management because it is non-addictive) also helps with hot flashes at low doses. There is a new product, fezolinetant, approved in 2023 that is not a hormone, works directly in the area of the brain causing hot flashes and is an excellent alternative for many who cannot or choose not to take hormone therapy.

What self-care is recommended during and following menopause?

Postmenopausal women have a higher risk of dementia, cardiovascular disease and osteoporosis. Thus, it’s vital that they eat well, exercise and increase calcium intake to promote strong bones.