The Benefits and Risks of HRT

Alex Fulton

Written by Alex Fulton

Alex Fulton

Written by Alex Fulton

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%.3Subsequent 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. 

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/ 

    Comments

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    I did not want to do HRT because of the risk of cancer. I was prescribed Effexor for mood swings and hot flashes. I have been taking this for almost 10 years. Unfortunately my sex drive suffered and also had severe vaginal dryness. I’ve tried creams, prescription medications for vaginal dryness which in turn increased my hot flashes. Nothing had helped with my sex drive and it was effecting my marriage. My husband didn’t believe it was out of my control. Fortunately during my last well woman appointment my doctor gave me a sample of Bonafide. I was apprehensive but figured I’d give it a try. I read the pamphlet and decided I would order a 3 month supply a long with the vaginal inserts to relieve dryness. I have been taking them now for 2 months and oh my goodness, I did not think I’d ever have desire for sex again. I had pretty much came to a conclusion it was over and sex was just a chore to keep my husband happy and from straying. Can I tell you, now he is the one saying, slow down, we don’t have to do it everyday. What a change this product has made in my life! Thank you, Thank you Bonafide!

    Michelle Cossey on

    My main menopause symptom is severe vaginal dryness and UTIs. I am in my 50s. This started during Covid lockdown when it was impossible to see doctors in person. Once I finally got a doctor to look and listen to me, it was bad. I have been on HRT and I also use Bonafide too. This combo finally got me relief and the desire for intercourse again. It also stopped the frequent UTI situation I also had since the tissue down there was finally working normally again.

    Nancy on

    I, too, had many debilitating menopausal symptoms and felt HRT was very helpful in regulating those symptoms, particularly my sensitivity to heat. I had in situ ducal carcinoma and laid off the hormones but miss them every day due to the return of menopausal side effects. I realize it is not recommended in my situation, but i have considered returning to that therapy if I could regardless because I felt that much better on HRT.

    Lisa on

    I’m 64. Recently started ERT due to urinary urgency, chronic UTIs, and painful sex. I had mastectomy in 2017- hormone related cancer- lumpectomy but not radiation or chemotherapy. It came down to quality of life for me. Peeing all over the place, not being able to enjoy sex with my husband and chronic UTIs convinced me to use estrogen- 1/2 g twice a week. Enjoying life is important.

    Amy Wheeler MacLeod on

    I started HRT at age 42 and continued for 15 years when I got DCIS, ductile carcinoma insitu. Had a lympectomy but no chemo or radiation. Dr. immediately stopped HRT but I continue to have severe hot flashes day and night. I’m 69 years old

    Lydia Crano on

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