The Benefits and Risks of HRT

If you’re a woman of a certain age, you’ve likely heard about hormone replacement therapy (HRT). HRT is a prescription treatment for menopausal women designed to address common symptoms like hot flashes, night sweats, mood swings and vaginal dryness, and in some cases, may also provide protection against osteoporosis.¹ 

While many women have found HRT to be immensely helpful for relieving menopause symptoms, others are unsure of how to weigh the risks of hormone replacement therapy. Some of the hesitation and confusion around HRT may be related to a landmark study called the Women’s Health Initiative (WHI). This was a large randomized controlled clinical trial in women ages 50 to 79 designed to study whether taking estrogen — either alone or with progestin — after menopause could help women prevent chronic disease including heart disease, stroke, breast and colorectal cancer and osteoporosis.² 

In 2002, results of the WHI study were released suggesting HRT could increase a woman’s risk of developing breast cancer or heart disease. Following the release of these findings, use of HRT dropped by nearly 80%.³ Subsequent studies from the WHI and others have shown that the benefits of hormone replacement therapy for menopause can certainly outweigh the risks for some,⁴ and that estrogen-only HRT can actually lower breast cancer risk.⁵ However, many women are still reluctant to try hormone therapy because of the 2002 findings. Some may worry about side effects associated with HRT, while others simply wish to avoid hormones in favor of a more natural approach to address their menopause symptoms. 

Knowing how difficult it can be to understand the pros and cons of HRT, we reached out to Dr. Alyssa Dweck, Bonafide Chief Medical Officer, with some questions about this complex topic. Read on to review her HRT advice for menopause symptoms, as well as some treatment alternatives to consider. 

What is Hormone Replacement Therapy for Menopause? 

“HRT typically refers to the replacement of estrogen, the production of which declines during menopause, and progesterone, added to protect the uterus from uterine cancer or precancer,” says Dr. Dweck. In other words, HRT usually means estrogen and progesterone replacement. 

“Some women, including those who have had a hysterectomy, don’t need to worry about uterine cancer prevention, and may use estrogen alone. This is known as estrogen replacement therapy (ERT),” she adds. 

What Are the Risks of Hormone Replacement Therapy for Menopause? 

The most notable risks of hormone replacement therapy are for breast cancer, uterine cancer, and cardiovascular events, like stroke and heart attack.⁶ In 2003, the Food and Drug Administration ordered all companies making drugs that contain estrogen or estrogen combined with progestin (a synthetic form of progesterone) for menopausal women to include a black box warning, the strongest warning level a medication can receive, based on these risks. These changes were prompted by the findings of the WHI study released in 2002.⁷ 

Are Certain Women More at Risk than Others When it Comes to HRT? 

According to Dr. Dweck, HRT is not recommended for women with a history of a hormone-dependent cancer, like breast or uterine cancer. “HRT is usually contraindicated in women who have a genetic propensity towards blood clots due to the increased risk of cardiovascular disease and stroke. There is a relative contraindication for use of HRT during menopause for women who have migraine headaches with an aura because these women may have a slightly increased risk of stroke on estrogen-containing medication.⁸ 

What Are the Benefits of Hormone Replacement Therapy for Menopause? 

While there are certain risks associated with hormone replacement therapy, there are also clear benefits of HRT. “HRT is an excellent treatment option for some women since it provides significant relief of menopausal symptoms, while also offering protection against osteoporosis,” says Dr Dweck. 

Another benefit of HRT is that it may also protect against heart disease in certain age groups: research indicates a reduction in cardiovascular events and deaths in women taking either estrogen-only or combined HRT within 10 years of menopause, or under 60 years of age.⁹ 

Who is Most Often Prescribed HRT? 

“Among my patients, those who are interested in HRT are usually quite symptomatic with the iconic symptoms of menopause. This means they’re having significant and debilitating hot flashes and night sweats with really notable interruption of sleep, and severe vaginal dryness,” Dr. Dweck says. 

She continues, “With that said, when women present to my office complaining of distressing hot flashes and night sweats, it seems that one camp clearly wants a non-hormonal option and another who will do whatever it takes to feel better. So, it's up to me and other healthcare providers to present all the options — including lifestyle modification, supplements, antidepressants, non-hormonal medications, and hormone therapy of different varieties — and discuss what might be best for that particular person.” 

Can HRT Be Used Indefinitely? 

According to Dr. Dweck, the recommendation is to individualize treatment with HRT during menopause, with an emphasis on using the lowest dose for the shortest amount of time possible. A common regimen is to consider discontinuing HRT around age 60, because that's when cardiovascular risk may increase.¹⁰ 

Are There Alternatives to Hormone Replacement Therapy? 

Because there are HRT pros and cons, some women may prefer to look for an alternative treatment option. Certain antidepressants can be very helpful for relieving hot flashes and other menopause symptoms, although they can come with their own baggage, in terms of sexual side effects like low libido (which may already be a problem for some women during menopause).¹¹ Gabapentin, a prescription medication often used for seizure control or chronic pain, is actually quite helpful for hot flashes.¹² “The at bedtime dosing of gabapentin is especially helpful for those with vasomotor symptoms which interfere with sleep since it makes one drowsy,” says Dr. Dweck. 

She goes on to state, “Without question, lifestyle matters when it comes to managing menopause symptoms. I always recommend the Mediterranean diet because it's a naturally low-glycemic and cardioprotective diet. I also recommend regular exercise, as well as stress reduction through meditation, yoga, or mindfulness. Paced breathing exercises can often help with hot flashes.” 

“Last but not least, non-prescription natural products can be a wonderful option for women who can’t or don’t want to use hormones to treat their menopause symptoms,” says Dr. Dweck. 

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Is HRT Right for Me? 

If you’re interested in learning more about HRT pros and cons, you and your healthcare provider should talk over your symptoms and health history and decide whether it’s right for you. If you prefer a more natural approach to managing menopause symptoms, there are plenty of effective and clinically studied options available. 

Resources 

1. https://medlineplus.gov/hormonereplacementtherapy.html#summary 
2. https://jamanetwork.com/journals/jama/fullarticle/195120 
3. https://pubmed.ncbi.nlm.nih.gov/24625303/ 
4. https://academic.oup.com/jcem/article/98/5/1771/2536695 
5. https://www.breastcancer.org/research-news/hrt-and-its-effect-on-bc-risk 
6. https://www.womenshealth.gov/30-achievements/25 
7. https://www.medscape.com/viewarticle/785840 
8. https://medlineplus.gov/hormonereplacementtherapy.html#summary 
9. https://www.womens-health-concern.org/help-and-advice/factsheets/hrt-know-benefits-risks/ 
10. https://www.womens-health-concern.org/help-and-advice/factsheets/hrt-know-benefits-risks/
11. https://pubmed.ncbi.nlm.nih.gov/23888328/ 
12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4076904/