If you’re a woman of a certain age, you’ve likely heard about hormone replacement therapy (HRT) for menopause, which is also sometimes referred to as menopause hormone therapy or MHT. HRT is a prescription treatment for menopausal women designed to address common symptoms like hot flashes, night sweats, and vaginal dryness, and in some cases, it 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 HRT pros and cons. 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 — during and after menopause, could help women prevent chronic disease, specifically coronary heart disease and invasive breast cancer.2
In 2002, results of the WHI study were released, suggesting HRT could increase a woman’s risk of developing breast cancer and/or heart disease. Following the release of these findings, use of hormone replacement therapy for menopause dropped by nearly 80%.3 A subsequent review of the data from the WHI, and others, have shown that hormone replacement therapy benefits 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 may simply wish to avoid hormones in favor of a more natural approach to addressing their menopause symptoms.
Knowing how difficult it can be to understand HRT pros and cons, we reached out to Dr. Alyssa Dweck, Bonafide Chief Medical Officer, with some questions about this complex topic. Read on to review her advice regarding HRT for menopause symptoms, as well as some treatment alternatives to consider.
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What is HRT for Menopause?
“HRT typically refers to the replacement of estrogen, the production of which declines during menopause, and progesterone, which is 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.
Hear more from Dr. Dweck on HRT in our quick clip, below:
Hormone Replacement Therapy Benefits and Risks
Prescription hormone replacement therapy is very effective for the treatment of certain menopause symptoms, according to Dr. Dweck. “Systemic estrogen, be it in the form of a pill, patch, vaginal ring or topical gel form, works quickly to alleviate symptoms, but could pose potential risks for women, including breast cancer, blood clots, cardiovascular events, and uterine cancer; in women with a uterus. In some cases, the benefits of hormone therapy outweigh the risks, in others, not so much. Similar concerns exist for compounded bio-identical hormone products,” she adds.
What Are Hormone Replacement Therapy Benefits During Menopause?
While there are clear benefits to HRT, there are also potential risks. “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.
Additionally, clinical studies suggest that there is no increased risk of cardiovascular disease when HRT is initiated before age 60 and/or within 10 years of onset of menopause.6
What Are the Risks of Hormone Replacement Therapy for Menopause?
The most notable risks of using hormone replacement therapy for menopause symptoms are breast cancer, uterine cancer, and cardiovascular events, like stroke and heart attack.7 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 2002.8
Are Certain Women More at Risk than Others When it Comes to Using HRT for Menopause?
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 for menopause in women who have migraine headaches with an aura because these women may have a slightly increased risk of stroke when on estrogen-containing medication.9
Who is Most Often Prescribed Hormone Replacement Therapy for Menopause?
“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 in my office complaining of distressing hot flashes and night sweats, along with other common menopause symptoms, it seems some clearly want a non-hormonal option and others who will do whatever it takes to feel better. So, it's up to us as healthcare providers to present all the options — including lifestyle modification, supplements, antidepressants, non-hormonal medications, and hormone therapy of different varieties — and then 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 for menopause, with an emphasis on using the lowest dose for the shortest amount of time that is appropriate to manage symptoms. A common regimen is to consider discontinuing HRT around age 60, because that's when cardiovascular risk may increase.10 But it’s important to note there is no one size fits all approach.
Are There Alternatives to Hormone Replacement Therapy?
Because there are HRT pros and cons, some women may prefer to look for alternative treatment options. As mentioned, 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, can be very 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 weight management has also been shown to provide benefits for vasomotor symptoms.” She concludes by stating; "I’ve also seen notable benefits and relief in my patients when using well-studied, non-drug, plant-based products, as well."
Is HRT for Menopause 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.