Hormone Replacement Therapy: Is It Right for You?
Feb 08, 2023 Koren Wetmore
If you’re in the middle of a menopause journey, you’re not alone. Each year, about 1.5 million women in the U.S. enter the transition to menopause known as perimenopause.
It can start as early as your 30s, spurred by natural processes that gradually lower your hormone levels—or it can occur abruptly through the surgical removal of your uterus and ovaries, launching you into menopause almost overnight.
"The attitude toward hormone therapy has changed in recent years. Most medical societies support not only the 'lowest dose for the shortest time' but also 'the appropriate dose for the appropriate amount of time.'"
Symptoms such as brain fog, mood changes, hot flashes and insomnia may have you desperate for relief. Today the choice to use hormone replacement therapy (HRT) is very personalized, based on a woman’s needs and potential risk factors, says Cedars-Sinai Fertility and Reproductive Medicine Center reproductive endocrinologist Dr. Jessica Chan.
"It’s a shared decision-making process with your doctor," she says. "The attitude toward hormone therapy has changed in recent years. Most medical societies support not only the 'lowest dose for the shortest time' but also 'the appropriate dose for the appropriate amount of time.'"
What is hormone replacement therapy?
By replenishing your hormone supply, HRT reduces your menopausal symptoms. It can also protect you from diseases such as osteoporosis.
HRT involves taking estrogen and, if you still have your uterus, another hormone called progestin (progesterone). Estrogen can be taken as pills, skin patches or gels. If you’re prescribed progesterone, it may be combined with estrogen in a pill or patch, but will more likely be given separately to prevent breakthrough bleeding.
How hormones can help
Estrogen and progesterone play vital roles in your body. Progesterone primarily helps with pregnancy and the health of your uterus. Along with its reproductive roles, estrogen also protects your bones, lowers cholesterol, fuels your brain through glucose metabolism and keeps the lining of your vagina healthy.
"We often think of estrogen as being part of the menstrual cycle and reproduction, but there are estrogen receptors in a woman’s brain, bones, heart and blood vessels, so its decline impacts multiple systems," says Dr. Chan. "That’s why during menopause a woman experiences things like cognitive decline, mood changes and a higher risk for osteoporosis."
HRT risks and benefits
Bone Health. The most obvious benefit of HRT is the easing of menopausal symptoms. Evidence suggests that it also protects your bones. A study of more than 25,000 postmenopausal women aged 50-79 found that hormone therapy reduced the risk of fractures. This is especially important for those whose uterus and ovaries were removed before age 45. Women who experience this “surgical menopause” have a higher risk of bone loss and osteoporosis.
Alzheimer’s risk. HRT may help your brain by protecting nerve cells. The drop in estrogen during menopause lowers the brain’s ability to get energy from glucose, our body’s main fuel source. To adapt, the brain switches to using fats, or lipids, for fuel. Unfortunately, it harvests this fat from the brain’s white matter and uses it to produce ketones—chemicals created in the liver— to provide energy.
When started before a woman reaches menopause (during the perimenopause transition), HRT reduces the risk of this fuel switch and can cut a woman’s Alzheimer’s disease risk in half. Once a woman reaches menopause, HRT no longer appears to have this brain-protecting effect.
For postmenopausal women, a ketogenic diet may help protect their brain by providing ketones and reducing the buildup of amyloid plaques, which have been associated with Alzheimer’s.
Stroke and cancer. Risks associated with HRT include stroke, blood clots and cancer. Your risk level depends on your age, medical history, the hormones you take and the delivery method. Transdermal estrogen patches, for example, carry a lower risk of stroke and blood clots than oral estrogen. Women who still have a uterus need combination therapy (estrogen and progesterone) to prevent uterine cancer. Yet, according to the American Cancer Society, that same hormone combination can increase your risk of breast cancer.
Your doctor can help you sort out these risks and benefits to determine whether HRT is the right choice for you.
Alternatives to HRT
If you and your doctor decide that HRT is not your best option, alternatives are available. These include antidepressants and gabapentin, an anti-seizure medication, which can reduce hot flashes and help with sleep problems.
“For patients who can’t take hormone therapy, these medications work fairly well, especially for women who experience severe mood symptoms associated with the menopausal change,” Dr. Chan says.
Non-prescription alternatives such as soy supplements and red clover extract may help reduce menopause symptoms, but studies remain inconclusive.
Duration of therapy
How long you remain on HRT depends on your personal risk factors and symptoms.
"Symptoms are the worst within the first five years after menopause. So, at some point, your doctor may discuss tapering off the medication," Dr. Chan says. "Eventually a woman’s body gets used to lower amounts of native estrogen. So, over time, we can lower the dose until we can potentially stop therapy and see how she feels."
When to see a specialist
If you’re under 40 and experiencing menopausal symptoms, or you’ve reached menopause—no periods for a year—and symptoms are affecting your quality of life, it may be time to see a specialist, says Dr. Chan.
Together, you can decide whether HRT or an alternative therapy might bring you relief.