Hormone Replacement Therapy - The Complete Guide

In this article: Learn everything you need to know about the HRT Method. Uses, Pros, and Cons, Key considerations, Alternatives and Frequently asked questions and much more.

Table of Contents

What Is HRT?

Hormone replacement involves the giving of estrogen, progesterone, and sometimes testosterone to women suffering from hot flashes, night sweats, and other premenopausal and menopausal symptoms.

It is during menopause when ovaries begin to fail to produce these hormones on a regular basis. Some women have symptoms that are so severe that the only option is to take hormone replacement therapy to control the symptoms. Sometimes, hormone replacement therapy is called menopausal hormone therapy because it is given around the time of menopause.

As you will see, hormone replacement therapy or HRT is not without risks and side effects. This is a type of therapy that is not for every women, as women with an increased risk of breast cancer, stroke, or heart disease will have increased risks of these diseases if they take HRT.

You need to discuss these risks with your doctor to see if HRT is right for you. Sometimes hormone replacement therapy is taken for many years at a time. Other times, it is taken only during the time of menopause, when the symptoms are the greatest.

Usually the lowest effective dose is recommended to reduce the chances of risks and the use of HRT is reevaluated by the doctor every few months.

Administration Routes

Hormone replacement therapy can be given in several ways.

There are pill forms of estrogen and progesterone replacement therapy but these are synthetic hormones that are not identical to the hormones made by the body.
There are estrogen-containing vaginal rings that do not treat hot flashes but treat symptoms of vaginal dryness. Very little of the estrogen in these rings gets into the body and the risk of side effects is small. They are only used for women who mainly have vaginal dryness.
Some compounding pharmacies make bioidentical hormone therapy treatments. These are the identical hormones secreted by the ovaries, including estrogen, progesterone, and small amounts of testosterone (for female libido). These are not given orally as they would not survive the acidic environment of the stomach but are used in a cream that is rubbed into the skin.
Some pharmaceutical companies make non-identical estrogen patches that are worn for a week or so and then replaced with fresh patches.

Any of these types of estrogen replacement therapy can be successfully given for menopausal symptoms.

Hormone replacement therapy can be given cyclically so that you have a period every month or every three months. In some women, it is given continuously so that there are no periods.

Women with no uteruses are often given estrogen alone in order to control their symptoms and, of course, there is no bleeding at all.

Risks of HRT

In the 1990s, the use of hormone replacement therapy was commonplace. That was until the Women’s Health Initiative (WHI) discovered that some women were at an increased risk of developing heart disease when taking this type of therapy.

Many women stopped taking this type of therapy and it was recommended only for women who suffered from severe symptoms and had little risk for heart disease.

As mentioned, because of the risks, HRT is usually only recommended for women who take the risk of increased cardiovascular disease and choose to take hormone therapy anyway.

There is still much confusion as to who should take hormone replacement therapy and who shouldn’t, even among doctors. After the studies came out indicating that taking HRT was risky, the use of hormone therapy dropped by 66% as many women decided not to take the risk.

The biggest problem with the WHI study was that the women who suffered from cardiovascular disease were over 60 years of age and had other risk factors for heart disease besides taking HRT. This may mean that women not in these categories may safely take HRT without risk of problems.

The facts about HRT risks:

While various concerns exist in regards to the potential risks to women’s health, recent finding show that it remains the most effective solution for symptoms of menopause, and the prevention of osteoporosis.
HRT may provide protection against heart disease for women of certain ages.
Hormone replacement therapy increases the risk of breast cancer by two-fold. Combination estrogen/progesterone therapy increases the risk of breast cancer more than just taking estrogen. The longer a woman takes hormone replacement therapy, the greater is the breast cancer risk. The risk returns to a normal level after you have stopped taking HRT for five years.
Hormone replacement therapy can slightly increase your risks of coming down with ovarian cancer. This risk increases the longer you take the medications. After a few years, the ovarian cancer risk returns to normal.
There is no increased risk of uterine cancer (endometrial cancer), particularly if you take progesterone along with estrogen as part of your regimen.
There is a risk of taking hormone replacement therapy and developing a stroke if you are a smoker and are also are overweight. The risk is mainly for women who are over the age of 60 and still taking the medications.
Hormone replacement therapy increases the risk of deep vein thrombosis (DVT). A DVT is a blood clot in the deep veins of the calves or thighs.
The risk of taking HRT and getting a heart attack is increased, particularly in women who are overweight and are over the age of 60 years. Younger, thinner women have no increased risk of heart disease, especially if they do not smoke and stop taking the medications around aged 60 years.

To be safe, hormone replacement therapy should be taken in one’s 40s and 50s and should be reconsidered if the woman begins smoking, has a history of heart disease, has a family history of heart disease, and reaches the age of 60 years.

Women on HRT need to be re-assessed by their doctor at least once a year.

Uses For HRT

Hormone replacement therapy is primarily used for the treatment of symptoms related to menopause. These include the following:

Hot flashes that are particularly severe
Night sweats, in which you wake up at night drenched in sweat.
Vaginal dryness, which can make intercourse painful.
Urinary tract infections related to menopause
Urinary tract incontinence related to menopause
Mood swings in menopause
Prevention of osteoporosis
Lack of libido from a decrease in testosterone made by the ovaries.

If the problem is just related to vaginal dryness or urinary tract symptoms, the oral form of estrogen does not need to be used and the other types of getting estrogen are used, such as the vaginal ring impregnated with estrogen or estrogen cream. As mentioned, these are safer than using estrogen through oral means.

Benefits of HRT

For most women who are under the age of 60 and who have no risks for heart disease, the benefits of hormone replacement therapy outweigh the risks and it is generally considered safe:

The main benefits of taking hormone replacement therapy include the following:

HRT is beneficial in the management of vasomotor symptoms, such as hot flashes and night sweats. It lessens the severity of hot flashes by about 87% when compared to taking a placebo medication.
HRT will improve the quality of sleep and the presence of muscle pain in menopausal women.
HRT has been found to work with mood swings related to menopause as well as the common depressive symptoms many women get around the time of menopause. It can be used along with therapy to help women suffering from menopausal-related depression.
Hormone replacement therapy can improve the symptoms of vaginal dryness and sexual dysfunction associated with menopause. The vaginal lining atrophies when estrogen is not around so that it can hurt during intercourse and HRT can reverse or prevent these changes.
HRT acts on the bladder to reduce symptoms of urinary frequency common in menopause. As mentioned, local application of estrogen can do the trick without having to worry about the systemic effects of this type of therapy.
Hormone replacement therapy can reduce the chances of developing osteoporosis or thinning of the bones. There is an improvement in bone mineral density all over the body so that the risk of fractures reduces when you take HRT for several years. It is especially helpful in women who reach menopause prior to the age of 50 or who have premature menopause, which occurs at the age of 40 years or less. If a woman has a greater risk of fractures, HRT should be considered even if no other symptoms of menopause exist. If the HRT is discontinued, however, the bone mineral density will start to drop again. This makes a case for taking hormone replacement therapy past the age of 60 in high-risk women.
The relationship between hormone replacement therapy and heart disease is very controversial. Estrogen has been known to raise HDL cholesterol (the good kind) and reduces the level of LDL cholesterol (the bad kind). This means that it has the potential to reduce the chance of having a heart attack in select women, especially if it is begun within ten years of developing menopausal symptoms.
According to the Women’s Health Initiative, the risk of colon cancer was lessened in women who took both estrogen and progesterone. The taking of estrogen alone has not been found to change the risk of colon or rectal cancer.
Hormone replacement therapy increases collagen in the system. Collagen is a connective tissue that, when present, prevents wrinkles and keeps the skin looking young and refreshed.
Hormone replacement therapy increases the strength of the muscles and improves their mass. This means that you will potentially be stronger if you take HRT at the time of menopause.
Hormone replacement therapy has an effect on the healing of wounds and reduces the risk of having wound complications after sustaining an injury.
There may be a slight decrease in the chances of developing Alzheimer’s disease and other types of dementia when taking hormone replacement therapy.
Women who have migraine headaches tend to get more of them around the time of menopause due to the fluctuation of hormones. Hormone replacement therapy can reduce the risk of having migraines during menopause because it keeps the hormone levels stabilized. It appears that taking the estrogen patch works better than taking the hormone replacement therapy in pill form.

Alternatives To HRT

Because hormone replacement therapy has some risks, women often turn to alternative medicine therapies to deal with symptoms of menopause. You may want to alleviate symptoms but, because of risks or your doctor’s recommendations, HRT may not be for you.

Fortunately, there are some alternative medical therapies that might work to control your symptoms. These include the following:

Some women resort to using herbal therapies instead of hormone replacement therapy. Some herbal remedies include black cohosh (which has estrogenic properties), evening primrose oil, and St. John’s Wort, which is often used for problems with sleep and depressive symptoms related to menopause. See an herbalist about the kinds of herbs that may help you when HRT is not an option.
Alternative medicine practices can also be helpful when HRT is contraindicated. Some women instead use acupuncture, acupressure, or homeopathy rather than taking HRT. Practitioners of these alternative medical practices, such as a holistic doctor can be consulted to see if they are helpful in controlling the symptoms of menopause.
Certain complementary medical practices can be used instead of HRT, such as aromatherapy or massage therapy.
Doctors can prescribe antidepressant therapy, such as serotonin reuptake inhibitors or other antidepressants, when most of the menopausal symptoms are related to mood swings and other mental health problems like depression.
Stress management can improve symptoms, as chronic or severe stress can have a significant impact on the occurrence of and severity of symptoms.

Key Considerations Before Starting HRT

There are several things you need to ask yourself before beginning a regimen of hormone replacement therapy.

These include the following:

Are the symptoms of menopause bad enough to take the risk of taking HRT?
Am I a smoker or overweight, which increase the risk of developing HRT-related side effects such as heart disease and strokes?
How long should I plan to take hormone replacement therapy? The longer you take the medications, the greater are the risks of taking this type of therapy?
Is taking hormone replacement therapy worth the risk?
What does my doctor feel about my taking hormone replacement therapy? The studies have been somewhat confusing but your doctor can help you sort through the studies to determine your risk of taking HRT.
Do I have an increased risk of depression or mood swings that might be benefitted by taking hormone replacement therapy?

In the end, it is up to you and your doctor as to whether or not you are a good candidate for taking hormone replacement therapy.

HRT: Frequently Asked Questions

Many women have questions about whether or not they should take hormone replacement therapy. Some questions you might ask include the following:

Question: Is hormone replacement therapy safe to take?

Answer: For women between the ages of 30-60, there appears to be no increased risk of any disease while taking estrogen replacement therapy. Women who smoke or women over the age of 65 (especially if they are overweight) should strongly consider taking an alternative to HRT or just dealing with the symptoms without taking any medications.

Question: What form of HRT should I take?

Answer: HRT comes in many different forms. You can choose to take just estrogen if you don’t have a uterus (after having a hysterectomy) or you can take combination therapy. You can choose to take pills or patches that contain the hormones and you can choose to take just estrogen creams, estrogen-impregnated vaginal rings if the only symptoms you have are vaginal, or urinary tract symptoms. If you have access to a compounding pharmacy, there are bioidentical hormone treatments that can simply be rubbed into the skin, where they are absorbed and can act on the body without having to take artificial hormones.

Question: Will HRT help control the mood swings or depression associated with menopause?

Answer: If you have a history of depression or mood swings that interfere with the quality of your life, you may decide to take hormone replacement therapy even if you have no other symptoms of menopause. Some women take HRT along with antidepressants, mood stabilizers, or psychotherapy in order to feel better during this time of their lives. These things do not adversely interact with hormone replacement therapy and can be used at the same time.

Question: Will hormone replacement therapy protect my bones?

Answer: Osteoporosis prevention is one of the reasons why a woman might take hormone replacement therapy. It is especially helpful in women who are Asian or who are slim in build as these women already have an increased risk of developing osteoporosis if they don’t take some kind of preventative intervention, such as HRT. The taking of hormone replacement therapy can improve the density of the bones and can reduce the risk of getting fractures of the hip, spine, and wrist from menopause-related osteoporosis.

Question: How long can I take it?

Answer: Exactly how long you take hormone replacement therapy depends on you, your risk factors, and your doctor’s recommendation. Some women take hormone replacement therapy just until they are past menopause, which may take up to 5 years from the onset of hot flashes. Other women, especially those with thin bones or who have a low risk of heart disease can take hormone replacement therapy indefinitely.

Remember that the risks of taking hormone replacement therapy increase among women past the age of 60 so this might be the cut-off date for when you stop taking the medications altogether. Most women are past menopause by that time and will not have a reoccurrence of menopausal symptoms after stopping the medication but will begin to age faster after HRT is stopped.

Question: What happens if I stop HRT?

Answer: If you stop taking hormone replacement therapy, many of the benefits of taking the regimen will be lost after a couple of years. The bones might begin to lose calcium at a faster rate and women with depressive symptoms may develop them again after HRT is discontinued. If your ovaries have already stopped the fluctuation of hormones and have ceased to function, there may be no increase in menopausal symptoms, such as hot flashes or night sweats. Vaginal dryness may begin to occur after stopping HRT but this can be rectified by using vaginal cream containing estrogen or by using vaginal lubricants, such as KY Jelly for intercourse.

In some women, especially those at risk for heart disease, their risk for developing a heart attack may increase after stopping the hormone replacement therapy. The HDL cholesterol levels will decrease and the LDL cholesterol levels will decrease, which can alter the chances of developing a stroke, heart attack, or peripheral vascular disease after menopause. You should talk to your doctor after you decide you don’t want to take hormone replacement therapy any more. Don’t just stop it on your own.

Question: How can I lower my risks?

Answer: You can lessen the risks of taking hormone replacement therapy by quitting smoking and by being of a normal weight. Remember that these things also contribute to getting heart disease so, if you exercise and eat right, you may be able to lose enough weight so, by the time you reach menopause, you will lower your risk of having heart disease by the time you start taking HRT. These things are good practices to undertake anyway so that you can reduce your risks of disease, whether or not you are taking hormone replacement therapy.

Question: Does it matter if I take a pill or a cream?

Answer: The choice of taking pills containing estrogen or progesterone, or using a cream, depends on your symptoms. If most of your symptoms are related to hot flashes, mood swings, and night sweats, you’ll want to take the systemic form of hormone replacement therapy, as the vaginal creams do not do much to prevent these symptoms.

If, on the other hand, vaginal dryness and urinary tract symptoms are the only things you are experiencing, the vaginal cream or the vaginal ring with estrogen in it will suffice. Talk to your doctor about what symptoms you are having so you can make an informed decision about which therapy you should consider. Generally, the pills and vaginal cream are not taken together and you will be taking one or the other type of therapy.

Question: What about “bioidentical hormones”?

Answer: Some women may decide to take bioidentical hormones rather than synthetic hormones for HRT because they believe they are safer to take. In fact, according to the Food and Drug Administration (FDA) there is no difference in safety when taking bioidentical hormones rather than the synthetic ones. There is also no evidence that bioidentical hormones are any more effective than synthetic hormones.

Manufacturers refer to “natural” hormones or “bioidentical hormones” when they are talking about hormones that have the same chemical representation as the hormones made by the body. There are several kinds of bioidentical hormones that have already been approved by the FDA for use instead of synthetic hormones.

Bioidentical hormones refer to preparations that come from animal or plant sources and those that are not created in a laboratory. These bioidentical hormones, however, still need to be processed commercially in order to be bioidentical. The traditional form of HRT doesn’t always mean that the products are not bioidentical. There are some FDA-approved medications, including Climara, Estrace, and Vivelle-Dot that contain bioidentical hormones. The medication known as Prometrium is also bioidentical containing plant-derived progesterone.

Those companies that market bioidentical hormones believe that their products are advantageous when compared to hormone therapy. They say that they are produced in forms and dosages that are different from those products produced by companies that make synthetic hormones. These products must be made at a compounding pharmacy that specializes in creating medications that are custom-designed for the individuals. The downside is that these hormones have not been subjected to the same quality assurance standards as traditional hormones and do not have standardized dosages.

Bioidentical hormones are custom designed for you and are based on a saliva test that assesses your individual hormonal needs. Unfortunately, the hormone amounts in the saliva don’t always reflect the blood levels of these hormones nor do they necessarily correspond to your specific menopausal symptoms.

While some women will receive an extra benefit from taking bioidentical hormones made by a compounding pharmacy, there are few research studies that indicate these types of hormones are advantageous over commercially prepared hormonal medications.

You should have a frank discussion with your doctor about the pros and cons of taking bioidentical hormones versus taking standard, traditional hormone replacement therapy.

Question: How will I feel?

Answer: The first thing you will notice is a reduction in hot flashes and night sweats. It generally takes about four weeks to discern any difference between your symptoms after starting the HRT therapy. You should notice fewer mood swings and your overall level of mood should increase. You will gradually notice less vaginal dryness and your urinary symptoms will return to normal. While you will not feel any different, your bone loss will be diminished and you will have a lower risk of developing osteoporosis after you begin taking hormone replacement therapy. Most women feel that their overall quality of life is improved after starting HRT.

Question: Will I gain weight?

Answer: Menopause is a time in a woman’s life that weight gain starts to occur. Rather than gaining weight, you may actually stay the same or lose weight while taking hormone replacement therapy. Of course, it still means that you should exercise on a regular basis and eat a healthy diet so you don’t gain weight. Things like weight lifting won’t change your weight but will increase your muscle mass and will decrease your body fat so they are good things to do around menopause along with taking your medications and doing aerobic activities like walking, running, cycling, or swimming. You need both types of exercise (anaerobic and aerobic) to stay at a normal weight and to have strong muscles.

Question: How do I know if it’s right for me?

Answer: The decision to take hormone replacement therapy is an intensely personal one and is one you should talk about with your doctor before beginning menopause. You have to look at your risk factors in taking the medication versus the benefits to your quality of life if you choose to take (or not to take) hormone replacement therapy.

Talk in detail with your doctor about HRT, including its risks and benefits as they pertain to you, before making your decision. You can always start taking the medication and then discontinue it if you don’t feel any benefit or if you are worried about the risks of taking it.

Conclusion

Hormone replacement therapy can be of a great benefit to women who are suffering from menopausal symptoms and are suffering from a poor quality of life because of the severity of the symptoms.

You need to take a serious look at your risk factors for taking the medication and compare the benefits you receive from taking it.

Hormone replacement therapy can be a lifesaver for women suffering from intractable menopausal symptoms, especially if non-medical therapies do not work.

As with any type of medication change, you should have a discussion with your doctor as to whether or not you should start HRT. It is not without risks but has benefits to the quality of life in women undergoing menopausal changes that are interfering every day life.