Is HRT Safe for Menopause? New Guidelines Say Yes

February 13, 2023

For over two decades, healthcare providers have been reluctant to prescribe hormone replacement therapy (HRT) to help women manage symptoms of menopause such as hot flashes, vaginal dryness, weight gain and joint pain. Fortunately, new guidelines are offering women much-needed relief.

Benefits of Menopausal Hormone Therapy

For many women, menopause symptoms can greatly affect their quality of life. In addition to the symptoms mentioned above, women often experience mood changes, insomnia, inability to concentrate (brain fog) and a dwindling sex drive.

HRT, also called menopausal hormone therapy (MHT), can manage all of these symptoms as well as:

Protect against osteoporosis (bone loss) and fractures
Lower the risk of diabetes and heart disease
Prevent or reduce urinary tract infections (vaginal estrogen only)
Relieve dry skin, nails and eyes

In general, when MHT is started in women before age 60 or within 10 years of menopause without any medical contraindications, the benefits typically outweigh the risks.

Why Were Women Advised Against HRT?

A study in 2002 by the Women’s Health Initiative found a link between hormone therapy and an increased risk of blood clots and breast cancer. Fear took hold and, since that study, countless women endured the often debilitating symptoms of menopause and perimenopause (the years leading up to menopause) without relief.

Dozens of studies since 2002 have provided evidence that MHT may be safer than previously believed. The women in the 2002 study were older and prescribed MHT for a much shorter period of time. “The risks, while still worthy of discussion with your provider, are actually quite minimal,” says Jean Marino, CNP, women’s health nurse practitioner and certified menopause practitioner at University Hospitals.

A Shared Decision between Each Woman and Their Provider

In 2022, the North American Menopause Society (NAMS) published a new statement on menopausal hormone therapy. Instead of issuing broad restrictions for the use of MHT, the new recommendations state that the risks and benefits of hormone therapy should be discussed with each individual patient.

“These shared decision-making conversations should consider the woman’s age, medical history, existing medical conditions and medications, and the severity of her symptoms,” says Marino.

“A woman and her provider should decide if MHT is right for her and work together to find the correct dose to effectively manage her symptoms. Determining the duration of MHT should also be a shared decision with no mandatory cut-off age.”

What Are the Different Types of MHT?

MHT delivers estrogen and/or progesterone in different strengths and formulations. The best dosage, formulation and delivery method to manage menopause symptoms is different for every woman.

Estrogen

Considered the gold standard for the treatment of hot flashes, estrogen is also helpful for mood changes, brain fog/difficulty concentrating, joint pain, dry hair/eyes and difficulty sleeping. It is available in several formulas, including:

Oral: Usually less expensive and may help with acne and chin or chest hair growth.
Transdermal Patch, Gel or Spray: Transdermal estrogen may be safer for women at higher risk of blood clots and those with heart disease or high triglycerides.
Vaginal Cream or Suppository: A very safe option, vaginal estrogen can effectively treat the symptoms of genitourinary syndrome of menopause (GSM), which include vaginal dryness and inflammation, urinary frequency/urgency, urinary tract infections, lowered sexual arousal and difficulty reaching orgasm.
Vaginal Ring: Another type of transdermal estrogen, vaginal rings are placed in the vagina and remain in place for up to 90 days. There are two well-known brands: Femring (delivers a high enough dose to treat hot flashes and other menopause symptoms) and Estring (delivers a lower dose and is only used to treat GSM).

“Vaginal estrogen can be started at any age and should be continued indefinitely or the symptoms will return. This therapy should be thought of as a menopausal woman’s new vaginal care routine,” says Marino. “It is important to note, however, that vaginal estrogen cream and suppositories are not systemic therapy and are only used to treat GSM – they won’t treat hot flashes, difficulty sleeping and other menopause symptoms,” she adds.

Progesterone

The main benefit of progesterone therapy is to reduce the risk of uterine cancer. If a woman has had a hysterectomy, progesterone is not necessary. Progesterone also helps some people sleep better. It comes in several formats, including:

Oral: This is often the preferred method for women.
Patch: Some brands combine progesterone and estrogen in a patch to treat moderate to severe symptoms of menopause.
Intrauterine Device (IUD): If a woman can’t tolerate oral progesterone (some women have mood changes), a progesterone-releasing IUD can be effective and safe. It can also be helpful in managing abnormal uterine bleeding that may occur during perimenopause.

Potential Risks of MHT

As with all medical therapies, hormone therapy has some risks. This is why each woman and her provider must have an in-depth conversation before beginning therapy. Possible risks include:

Slightly increased risk of breast cancer. Research shows that less than one additional case of breast cancer occurs per 1,000 women per year of MHT use, and three additional cases occur per 1,000 women when MHT is used for five years. Women who have had a hysterectomy and take estrogen only don't have an increased risk of breast cancer.
Blood clots. Women older than 60 or who begin MHT more than 10 years after the onset of menopause have a greater risk of blood clots, which can be fatal. However, the risk is reduced with lower doses and the use of transdermal delivery methods (patch, gel, spray or vaginal ring) instead of oral pills.

“The overall risk of MHT is significantly greater in women with a history of liver disease, heart disease, stroke, heart attack, blood clots in the chest or legs, inherited history of increased risk for blood clots or a personal history of estrogen-sensitive cancer, including breast cancer. For these women, the risks of MHT may be too great and alternate treatment methods may be recommended,” says Marino.

Are Over-the-Counter Menopause Treatments Effective?

There is limited research about the safety and effectiveness of over-the-counter (OTC) menopause remedies such as Estroven and herbal supplements like black cohosh and St. John’s Wort. In addition, OTC supplements are not standardized in their formulas and are not regulated by the FDA so it is difficult to compare different brands and make any generalized findings as to their effectiveness.

“I am hesitant to recommend OTC products to my patients because there are no large research studies to support their claims. In addition, it should not be assumed that just because a product is available without a prescription that it is always safer than a prescribed medication,” says Marino. “We have much more research on the safety and effectiveness of hormone therapy. The bottom line is, women don’t have to suffer with bothersome menopausal symptoms – they should talk to their provider about their best treatment option.”