Hormone Therapy for Menopause

Are you considering hormone therapy to manage your menopause symptoms? Or perhaps your healthcare provider suggested this treatment option to you. Either way, you are likely a little anxious about taking hormones. It is not surprising or unusual if you feel this way. There is a lot of misinformation and confusion out there, even among the medical community regarding the risks and benefits of using hormones to manage menopause. This, unfortunately, has left a lot of women to suffer unnecessarily with severe menopausal symptoms.

Senior patient talking with doctor while sitting on bed against wall at hospital
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Many people, including healthcare providers, are still reacting to the initial results from the WHI HT trial that suggested increased risk especially—for breast cancer—associated with menopausal hormone therapy. But, a lot has been learned since then. Not only have the original results been reanalyzed, but new studies have been conducted looking at safety and effectiveness.

In its most current 2017 position statement, the North American Menopause Society makes three very important points:

  • Benefits are most likely to outweigh risks for symptomatic women who initiate hormone therapy when aged younger than 60 years or who are within 10 years of menopause onset.
  • Hormone therapy should be individualized, taking into account the indication(s) or evidence-based treatment goals, consideration of the woman’s age and/or time since menopause in relation to initiation or continuation, the woman’s personal health risks and preferences, and the balance of potential benefits and risks of hormone therapy versus nonhormone therapies or options.
  • The type of hormone therapy, specific options, dose, and regimen should be individualized, using shared decision making and determined on the basis of known adverse effects profiles and safety information, along with an individual woman’s health risks and personal preferences.

In other words:

  • It is safest to start hormone therapy early in menopause.
  • One size doesn't fit all. Hormone therapy treatment plans must be individualized.
  • Choosing the type of hormone therapy must also be individualized.

This is vastly different than your mother's hormone therapy when the only option was a pill derived from the urine of pregnant horses. Today, there are many different types, dosages, and formulations of hormone therapy depending on your specific needs. Here is a general overview of your options.

Oral Estrogen Therapy

This type of hormone therapy comes in typical pill form. Although the original conjugated equine estrogen formulation is still available, several other synthetic estrogens have been created. These synthetic estrogens are very similar to the estrogen made by your ovary and are therefore considered bioidentical. There are several different strengths available, allowing for a range of dosing options. If you still have a uterus, you will also need to take some form of a progesterone to protect your endometrium from the effects of estrogen.

Transdermal Estrogen Therapy

This type of hormone therapy relies on skin absorption of the hormone rather than oral absorption. This has a few benefits. Because it doesn't have to be absorbed by your intestines, it can be prescribed in lower doses. It also maintains a more stable hormone level in your body, which can be important in certain situations, especially if you are suffering from migraine headaches. Also, because by going through your skin it doesn't need to pass through your liver, it doesn't cause an increase in your triglycerides (an unhealthy cholesterol) and can minimize the risk of gallbladder-related adverse effects. Types of transdermal options include:

  • Patches
  • Gels
  • Topical emulsions
  • Sprays

The absorption of transdermal estrogen can be variable depending on the type and how they are applied. Again, If you still have a uterus you will also need to take some form of a progesterone to protect your endometrium from the effects of estrogen.

Vaginal Estrogen Therapy

This type of hormone therapy typical results in lower levels of estrogen in your bloodstream. Because of this, it is typically only used to treat the genitourinary symptoms of menopause—things like vaginal dryness, painful sex, and some bladder symptoms. The one exception is the higher dose vaginal ring Femring. Vaginal estrogens are available in:

Except for the higher dose ring, these vaginal preparations can be used safely without a progesterone even if you still have your uterus.

Progestin-Progesterone Options

If you are starting hormone therapy and you still have your uterus you will need to use some type of a progestin or progesterone to protect the lining of your uterus. Over time, unopposed estrogen, that is taking estrogen without balancing it with progesterone, can lead to endometrial hyperplasia or even endometrial cancer. You can either use a synthetic progestin like what is used in hormonal contraception or you can use an actual progesterone which is identical to the progesterone produced by your ovaries. These progestin/progesterone options are available as:

  • Pills
  • Vaginal gels
  • Vaginal inserts

The progestin-containing IUDs are also an option.

Combination Estrogen and Progestin Therapy

For some women, it may be preferable to use a hormone product that contains both hormones together. This type of hormone therapy is available both pill form and as a transdermal patch.

A Word From Verywell

Although menopause itself is not a disease the hormone changes associated with this normal aging process can cause very significant symptoms that can be improved with hormone therapy. Hormone therapy may also be recommended to you to help prevent osteoporosis especially if you are at an increased risk. Whatever your reasons are for considering hormone therapy your healthcare provider will help you to make the best choices to help you live very well through menopause.

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  • North American Menopause Society (2017).The 2017 Hormone Therapy Position Statement of The North American Menopause Society. Menopause, 24, 728-753.