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6 Things You Need to Know About Hormone Therapy

6 Things You Need to Know About Hormone Therapy

Relief from hot flashes may be around the corner, but it’s important to find the treatment that fits your health profile.

If you’re going through menopause or perimenopause, you may be experiencing symptoms such as hot flashes, sleep problems, vaginal dryness or changes in your menstrual cycles. These are all normal parts of the transition, but they can still be unpleasant.

You don’t have to suffer in silence, says Erin Mateer, MD, an attending physician at Oak Hill Hospital in Brooksville, Florida. There are a number of options available, including menopausal hormone therapy (MHT), sometimes called hormone replacement therapy (HRT) or hormone therapy (HT).

The MHT formula generally consists of two hormones, estrogen and progestogen. Estrogen is the hormone that relieves menopausal symptoms, explains Dr. Mateer. But it can also cause cells in your uterine lining to overgrow (a condition known as endometrial hyperplasia), which may lead to uterine cancer. So, if you have a uterus, you’ll also need to take a progestogen to counteract that uterine overgrowth. If you don’t have a uterus because you’ve had a hysterectomy, you’re typically just given estrogen.

Is hormone therapy safe?
You may have heard about how MHT fell out of favor in years past. The Women’s Health Initiative (WHI)—a trial funded by the National Institutes of Health—found in 2002 that women who took MHT had an increased risk of heart attack, breast cancer, blood clots and stroke. A follow-up to that study in 2019 found that the elevated risk of breast cancer, though small, still persisted with estrogen plus progestin treatments. (Estrogen-only treatments were linked to a lower chance of breast cancer in the same study.)

But the thinking on therapy has changed over the years, despite these findings. This change was partly due to a reconsideration of the 2002 WHI study’s limitations. For example, the study looked only at orally administered MHT and included only a limited number of women younger than 60 years old, the population best-suited to receive and benefit from MHT.

Considering all the available research together, experts now typically recommend short-term use of MHT for certain groups of women who experience moderate-to-severe hot flashes and haven’t responded to behavioral interventions.

“The pendulum has swung back in the opposite direction,” notes Mateer. “We’re now advising it for younger women because they may actually get some protective side benefits when it comes to their heart and bone health,” in addition to symptom relief.

The primary recommended uses for MHT are to address:

  • Hot flashes, which can often lead to sleep disturbances
  • Genitourinary syndrome of menopause (GSM), which can lead to painful sex, vaginal dryness and itching, vaginal discharge, urinary burning, increased urinary frequency and urgency, and more urinary tract infections

MHT may also offer relief for achy joints and—when used alone or in tandem with an anti-depressant—low mood or depression during menopause.

If you’re considering MHT, here’s what you need to know.

It’s recommended for women under 60
The optimal candidate is a woman younger than age 60 who is either going through perimenopause or menopause, has no cardiovascular risk factors and is a non-smoker. More broadly, MHT is considered a safe option for most who are within 10 years of menopause or those younger than 60 who don’t have a history of breast cancer, heart disease, previous blood clots or stroke or liver disease, among other conditions. Discuss therapy with your healthcare provider (HCP) to be sure you understand the possible risks and benefits.

Take it for the shortest time possible
If you do decide to take MHT, it should involve the lowest effective dose for the shortest time needed to provide relief from symptoms. How long is “shortest time”? Talk to your HCP about the dose and duration that makes the most sense for your health profile.

Most women don’t have trouble stopping MHT once they’ve started. When you do discontinue MHT, some experts recommend tapering off your dose rather than stopping cold turkey.

There are different forms of MHT
The most common form is an oral pill, but there are also skin patches, rings and tablets that are placed in your vagina, and even creams and sprays you apply to the skin. If a woman has an increased risk of blood clots, the patch is preferred over a pill. That’s because the hormones in the patch are absorbed directly into the blood through the skin—bypassing the digestive system and the liver where clotting factors can be affected, which may reduce the risk for blood clots.

If you have only vaginal symptoms such as dryness, the estradiol vaginal ring (Estring) or a tablet placed in the vagina may be good options. “It’s broken down by the vaginal cells and stimulates receptors to help relieve dryness and pain,” Mateer adds. There are also vaginal creams that you insert via an applicator.

To know: If you are using vaginal estrogen to address GSM, you do not need progestogen, even if you still have your uterus.

Non-hormonal medications may also offer relief
If you and your HCP decide that hormone therapy—in any form—just isn’t right for you, there are other medication options, stresses Mateer. While they generally aren’t as effective as MHT, anti-depressants including paroxetine, venlafaxine, desvenlafaxine, citalopram and escitalopram have all been shown to improve hot flashes. An anti-seizure medication, like gabapentin or pregabalin, usually given at bedtime, could offer relief as well.

Black cohosh, an herbal product, is often touted to help with hot flashes, as are plant-derived estrogens called phytoestrogens. But studies haven’t consistently shown that these so-called natural treatments help. It’s best to steer clear of over-the-counter remedies unless you’ve gotten the green light from your HCP.

Stay away from compounded hormones
While exploring MHT, you and your HCP may want to consider bioidentical hormone treatments. They have the same molecular makeup as hormones you produce in your body, but are made in a lab. There are multiple pills, creams and other preparations approved by the U.S. Food and Drug Administration (FDA). 

Some women turn to “compounded” hormonal replacement products—customized medications mixed at a pharmacy to meet your individual needs—believing they’re safer than conventional hormones. But these treatments are not regulated by the FDA, so there’s no guarantee of quality control.

In short, there’s no good evidence that compounded hormones either work or are safe for long-term use. The American College of Obstetricians and Gynecologists recommends FDA-approved hormone therapy instead. Compounded products should be used only when someone has an allergy to an inert ingredient in an approved product, or the necessary dose is not available.

Medically reviewed in December 2020.

Sources:

Cleveland Clinic. “Hormone Therapy.” January 16, 2017. Accessed November 19, 2020.
Writing Group for the Women's Health Initiative Investigators. “Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women: Principal Results From the Women's Health Initiative Randomized Controlled Trial.” JAMA. 2002;288(3):321–333.
WomenHealth.gov. “Largest women’s health prevention study ever—Women’s Health Initiative.” May 17, 2019. Accessed December 2, 2020.
RT Chlebowski, GL Anderson, et al. “Association of Menopausal Hormone Therapy With Breast Cancer Incidence and Mortality During Long-term Follow-up of the Women's Health Initiative Randomized Clinical Trials.” JAMA. 2020 Jul 28;324(4):369-380.
JE Manson, RT Chlebowski RT, et al. “Menopausal Hormone Therapy and Health Outcomes During the Intervention and Extended Poststopping Phases of the Women’s Health Initiative Randomized Trials.” JAMA. 2013;310(13):1353–1368.
North American Menopause Society. “The Experts Do Agree About Hormone Therapy.” 2020. Accessed December 2, 2020.
Pinkerton JV, Sánchez Aguirre F, et al. “The 2017 hormone therapy position statement of The North American Menopause Society.” Menopause. 2017 Jul;24(7):728-753.
UpToDate.com. “Treatment of menopausal symptoms with hormone therapy,” “Patient education: Vaginal dryness (Beyond the Basics),” “Patient education: Non-estrogen treatments for menopausal symptoms (Beyond the Basics).”
American College of Obstetricians and Gynecologists. “ACOG committee opinion no. 556: Postmenopausal estrogen therapy: route of administration and risk of venous thromboembolism.” Obstet Gynecol. 2013 Apr;121(4):887-90.
Bailey TG, Cable NT, et al. “Exercise training reduces the frequency of menopausal hot flushes by improving thermoregulatory control.” Menopause. 2016 Jul;23(7):708-18.
Mayo Clinic. “Vaginal atrophy.” May 2, 2019. Accessed November 18, 2020.
J Gandhi, A Chen, et al. “Genitourinary syndrome of menopause; an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management.” American Journal of Obstetrics & Gynecology. 2016 Dec;215(6):704-711.
The American College of Obstetricians and Gynecologists—Committee Opinion. “Postmenopausal Estrogen Therapy: Route of Administration and Risk of Venous Thromboembolism.” Number 566. April 2013. Accessed December 2, 2020.
SH Lindahl. “Reviewing the options for local estrogen treatment of vaginal atrophy.” International Journal of Women's Health. 2014; 6: 307–312.
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U.S. Food & Drug Administration. “Compounding and the FDA: Questions and Answers.” June 21, 2018. Accessed November 18, 2020.
Estring.com. “Estring: 1 Ring for 90 Days.” 2020. Accessed December 2, 2020.
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NIH National Center for Complementary and Integrative Health. “Menopausal Symptoms: In Depth.” May 2017. Accessed December 2, 2020.
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N Santoro, GD Braunstein, et al. “Compounded Bioidentical Hormones in Endocrinology Practice: An Endocrine Society Scientific Statement.” The Journal of Clinical Endocrinology & Metabolism. Volume 101, Issue 4, 1 April 2016, pages 1318-1343.
Ronilee Shye. “What Are Compounded Medications?” GoodRx. October 4, 2019.
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The National Academies of Sciences, Engineering, and Medicine. “Clinical Utility of Treating Patients with Compounded ‘Bioidentical Hormone Replacement Therapy.’” 2020.

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