Deciding About Hormone Therapy Use

Many women experience hot flashes, vaginal dryness, and other physical changes with menopause. For some women, the symptoms are mild and do not require any treatment. For others, symptoms are moderate or severe and interfere with daily activities. Hot flashes improve with time, but some women have bothersome hot flashes for many years. Menopause symptoms often improve with lifestyle changes and nonprescription remedies, but prescription therapies also are available, if needed. Government-approved treatments for bothersome hot flashes include hormone therapy (HT) containing estrogen, as well as a nonhormone medication (paroxetine).

Hormone therapy involves taking estrogen in doses high enough to raise the level of estrogen in your blood in order to treat hot flashes and other symptoms. Because estrogen stimulates the lining of the uterus, women with a uterus need to take an additional hormone, progestogen, to protect the uterus. Women without a uterus just take estrogen. If you are bothered only by vaginal dryness, you can use very low doses of estrogen placed directly into the vagina. These low doses generally do not raise blood estrogen levels above postmenopause levels and do not treat hot flashes. You do not need to take a progestogen when using only low doses of estrogen in the vagina. (The MenoNote “Vaginal Dryness” covers this topic in detail.)

Every woman is different—and you must make a decision about whether to use HT based on the severity of your symptoms, your personal and family health history, and your own beliefs about menopause treatments. Your healthcare provider will be able to help you with your decision.

Potential benefits

Hormone therapy is one of the most effective treatments available for bothersome hot flashes and night sweats. If night sweats are waking you throughout the night, HT may improve sleep and fatigue, mood, ability to concentrate, and overall quality of life. Treatment of bothersome hot flashes and night sweats is the principal reason women use HT. Hormone therapy also treats vaginal dryness and painful sex associated with menopause. Hormone therapy keeps your bones strong by preserving bone density and decreasing your risk of osteoporosis and fractures. If preserving bone density is your only concern, and you do not have bothersome hot flashes, other treatments may be recommended instead of HT.

Potential risks

As with all medications, HT is associated with some potential risks. For healthy women aged younger than 60 years with bothersome hot flashes who are within 10 years of menopause, the benefits of HT generally outweigh the risks. Hormone therapy might slightly increase your risk of stroke or blood clots in the legs or lungs (especially if taken in pill form). If started in women aged older than 65 years, HT might increase the risk of dementia. If you have a uterus and take estrogen with progestogen, there is no increased risk of cancer of the uterus. Hormone therapy (combined estrogen and progestogen) might slightly increase your risk of breast cancer if used for more than 4 to 5 years. Using estrogen alone (for women without a uterus) does not increase breast cancer risk at 7 years but may increase risk if used for a longer time.

Some studies suggest that HT might be good for your heart if you start before age 60 or within 10 years of menopause. However, if you start HT further from menopause or after age 60, HT might slightly increase your risk of heart disease. Although there are risks associated with taking HT, they are not common, and most go away after you stop treatment. In general, HT is associated with fewer than 2 additional harmful events per 1,000 women per year. For example, the increased chance of breast cancer with HT use is 1 extra case per 1,000 women per year.

Potential side effects

Hormone therapy can cause breast tenderness, nausea, and irregular bleeding or spotting. These side effects are not serious but can be bothersome. Reducing your dose of HT or switching the form of HT you use often can decrease side effects. Weight gain is a common problem for midlife women associated with both aging and hormone changes. Hormone therapy is not associated with weight gain and may lower the chance of developing diabetes.

Hormone therapy options

Each woman must make her own decision about HT with the help of her healthcare provider. If you decide to take HT, the next step is to choose between the many HT options available to find the best dose and route for you. With guidance from your healthcare provider, you can try different forms of HT until you find the type and dose that treats your symptoms with few side effects.

Pill or non-pill

Hormone therapy is available as a daily pill, but it also may be taken as a skin patch, gel, cream, spray, or vaginal ring. Non-pill forms may be more convenient. Hormone therapy pills need to be taken every day, but skin patches are changed only once or twice weekly, and the HT vaginal ring is changed only every 3 months. Hormone therapy taken in non-pill form enters your blood stream more directly, with less effect on the liver. Studies suggest that this may lower the risk of blood clots in the legs and lungs compared with HT taken as a pill.

Estrogen alone or estrogen plus progestogen

If you have a uterus, you will need to take progestogen with your estrogen. Many pills and some patches contain both hormones together. Otherwise, you will need to take two separate hormones (eg, estrogen pill with progestogen pill or estrogen patch with progestogen pill). Taking both hormones every day usually results in no bleeding. Women who prefer regular periods can take estrogen every day and progestogen for about 2 weeks each month. Another option is to take estrogen combined with a nonhormone medication (bazedoxifene) to protect the uterus. If you do not have a uterus, you can take estrogen alone, without a progestogen.

Dose of estrogen

As with all medications, you should take the lowest dose of estrogen that relieves your hot flashes. You can work with your healthcare provider to find the right dose for you. It typically takes about 8 to 12 weeks for HT to have its full effect, so doses should be adjusted slowly. Even low doses of estrogen will preserve your bone density and reduce your risk of a fracture.

Stopping hormone therapy

There is no “right” time to stop HT. Many women try to stop HT after 4 to 5 years because of concerns about potential increased risk of breast cancer. Other women may lower doses or change to non-pill forms of HT. Hot flashes may or may not return after you stop HT. Although not proven by studies, slowly decreasing your dose of estrogen over several months or even over several years may reduce the chance that your hot flashes will come back. You and your healthcare provider will work together to decide the best time to stop HT. If very bothersome hot flashes or night sweats return when you stop HT, you will need to reassess your individual risks and benefits to decide whether to continue HT. Because there may be greater risks with longer duration of use and as you age, you and your healthcare provider will work together to decide what is the best option for you.