Is hormone replacement therapy (HRT) safe?

Oct 15, 2023
Key Takeaways
  • Hormone Replacement Therapy (HRT) can relieve menopause symptoms, including hot flashes and bone loss, improving overall quality of life.
  • Despite past controversy, recent studies suggest HRT, especially combined hormone therapy, may offer cardiovascular benefits for women under 60.
  • Deciding on HRT requires collaboration with your healthcare professional, considering individual health, lifestyle, and potential alternatives for managing menopause symptoms.

Hormone replacement therapy (HRT) is a medical treatment that can help relieve the symptoms of menopause and perimenopause, such as hot flashes and night sweats. As you approach menopause and your ovaries run out of eggs, When your body stops making much estrogen on its own. Medication with estrogen can be used to control and lessen menopause symptoms. 

HRT and its risks and benefits is an important topic of conversation for women navigating menopause. Is the therapy safe? Is it worth it? Is it worth talking to your doctor about? Could it reduce your risk of heart disease and bone fractures? Let’s get to the core of HRT and whether this treatment is right for you.  

What is HRT?

Hormone replacement therapy is delivered in two forms: systemic estrogen therapy and local estrogen therapy. In systemic estrogen therapy, estrogen is delivered directly into the bloodstream and travels to the organs and tissues where it is needed (Examples: pills, skin patches, gels and sprays). In local estrogen therapy, estrogen is delivered directly into the vaginal tissue to help relieve dryness (Examples: vaginal ring or vaginal cream).

Depending on whether you have a uterus, estrogen might not be the only hormone included in treatment. There are two main types of hormone replacement therapy: estrogen only, and estrogen plus progesterone. Estrogen only therapy is used for people who do not have a uterus.  Estrogen plus progesterone (sometimes called combined hormone therapy) therapy is used for people who still have a uterus. Progesterone is used because it lowers the risk of developing uterine cancer, which can occur when estrogen is used alone. It may also improve hot flash symptoms and sleep problems.  

Estrogen comes in pills or tablets, nasal spray, skin gels, skin patches, applied to the buttocks or belly, vaginal creams or vaginal tablets to help with dryness and pain during sex, and vaginal rings. Progestin comes in pills or intrauterine device.

Your doctor can help you determine which delivery method may be right for you depending on your symptoms, where you are in your menopause journey, your medical history, and lifestyle. For example, pills can ward off night sweats while vaginal rings or cream can help with vaginal dryness and pain during sex. [1]

How HRT can relieve symptoms of menopause

Menopause symptoms is a woman's signal that her estrogen is on the decline. It’s those sometimes life-altering symptoms that drive women to tap into the benefits of hormone replacement therapy. The benefits include: 

  • Reducing hot flashes and night sweats (systemic estrogen therapy with or without progesterone)
  • Relieving vaginal dryness (systemic and local estrogen therapy) 
  • Protecting against bone loss during early menopause, and as a result, preventing osteoporosis
  • Lowering the frequency of recurrent urinary tract infections 
  • Reducing the risk of colon cancer (combined hormone therapy)

Controversy around HRT

Hormone replacement therapy has a controversial history due to a single study called the Women’s Health Initiative (WHI) that was stopped prematurely in 2002. When researchers presented statistics to international media, scary information was accompanied without much context. The message was that HRT increases the risk of heart disease, breast cancer, and stroke. [2] The reality is that the increase in risk was less than a tenth of one percent per year for each individual. 

Keep in mind that the small increased risk of heart attack with combined hormone therapy is only associated with: older women; a specific hormone preparation that is not commonly prescribed anymore; and could be related to other existing medical conditions. 

Additionally, the average age of the women in the study was about 63 years old, a prime time for heart disease to exist already. Many had other health conditions, were a decade or more beyond their final period, and most didn’t even have menopause symptoms. In the snap of a finger, however, women and healthcare providers were spooked, and steered away from HRT as a viable option for those in actual menopause to reduce symptoms. 

Setting the record straight around HRT

There have been several follow-up studies showing that combined hormone therapy may protect against heart disease in women who start the therapy within 10 years of menopause and who are younger than 60 years old. This benefit could be even stronger for women taking estrogen alone. 

In terms of cancer, studies have shown that combined hormone therapy may reduce the risk of colon cancer. Combined hormone therapy using synthetic progestins, not progesterone – the one we currently prescribe - is associated with a small increased risk of breast cancer, and women with a history of breast cancer should use non-hormonal therapies to alleviate menopause symptoms. 

Overall, the benefits of hormone therapy reducing all-cause mortality and easing hard-to-live-with menopause symptoms likely outweigh the risks for healthy women who are younger than 60. [3]

Determining whether hormone replacement therapy is right for you is a team effort. You can collaborate with your healthcare professional to talk through the severity of your symptoms, your medical history, your lifestyle, and whether you are pregnant (women who are pregnant cannot take HRT). Typically, women with a history of breast or endometrial cancer, stroke, heart attack, blood clots, and liver disease won’t be recommended systemic hormone therapy: [4]

Options beyond HRT 

If hormone replacement therapy isn’t an option for you to manage menopause symptoms, there are other possibilities you can explore with your healthcare professional. There include: 

  • Over-the-counter vaginal moisturizers and lubricants to help with dryness
  • Non-hormonal medications, such as 
    • Antidepressants - to calm hot flashes
    • Selective estrogen modulators (SERMs) – for improvement in pain during sex
    • A daily vaginal insert called dehydroepiandrosterone (DHEA) - to ease pain during sex
    • A seizure medication called gabapentin and a blood pressure medication called clonidine - to reduce hot flashes and minimize sleep problems
    • A new medication called fezolinetant (Veozah) which helps with hot flashes 
  • Plant and herbal supplements have not been shown to improve menopausal symptoms in rigorous scientific studies. Read our blog Managing hot flashes without hormones for more information on non-hormonal treatment options.
  • Non-hormonal treatments like cognitive behavioral therapy, breathing and meditation

Get expert guidance with Visana

Like with most medical treatments, the benefits and risks of hormone replacement therapy are not black or white. If your doctor says they are against hormone replacement therapy and won’t consider it for anyone, think about getting a second opinion with someone who is more up-to-date on the current research, like Visana clinicians who are specially trained in the diagnosis and treatment of menopause. You deserve options.

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