Hormone therapy (HT) is the most effective proven treatment for many menopause symptoms. Yet there is an overwhelming amount of information out there about the risks and benefits – some of it conflicting. Read on for more on the facts and evidence about the risks and benefits of HT, helping you to be better informed.
Discover your personalized treatment options
What is HT?
Hormone therapy (HT) is a treatment for perimenopause and menopause symptoms. It can also protect the health of your bones and heart and reduce your risk of diabetes. It comes in the form of pills, patches, creams, and gels among others. It has been consistently proven to be the most effective treatment for a range of perimenopause and menopause symptoms such as mood changes, hot flashes, painful sex, overactive bladder and UTI symptoms.
It’s important that you discuss any symptoms with your healthcare provider to be sure of your diagnosis before you consider HT treatment. Other medical issues can mimic perimenopause and menopause symptoms.
Likewise, HT may not be suitable for you because of your medical history or you may just prefer not to take it. That’s ok, HT isn’t for everyone – there are alternative, non-hormonal medications, and lifestyle change can help too. Your healthcare provider will help you make an informed decision.
HT, HRT, and MHT – what’s the difference?
Research and self-education can improve your menopause experience and speed up the process of finding the right treatment for you. Confusing terminology can get in the way of this! We want to clear things up if you have come across the terms HRT, HT, or MHT and you’re not sure what they mean. The truth is, there is little difference between these abbreviations.
- HRT stands for hormone replacement therapy. Many symptoms of menopause are caused by a dramatic reduction in levels of certain hormones such as estrogen. This name suggests that the medication works by replacing the hormones that are no longer produced by your body during menopause
- HT, or hormone therapy, is a term that is growing in popularity as the way to describe this type of treatment, as HT does not technically ‘replace’ hormones. It is more accurate to say that the hormones in HT safely and effectively treat symptoms caused by changes in your body during menopause
- MHT, or menopausal hormone therapy, is a more precise phrase than HT. Hormones are used in lots of different medical treatments, so MHT is used to specifically describe HT for menopause and is often preferred by research scientists for this reason. You may see this phrase used in scientific research papers
How do you know if you need HT?
Ultimately this is a personal choice and depends on how your symptoms are affecting you. Many women manage their menopause without any form of treatment, while others find HT helpful.
This is often a tricky decision to make. Menopause symptoms can be vague and develop over years, making it difficult to describe exactly how they are affecting you. If this is the case, keeping a diary or using a menopause symptom tracker, may help you to get an objective overview.
If your perimenopause or menopause symptoms are having a significant impact on your quality of life, are disrupting your work or daily activities, or are not responding to lifestyle changes, it is a good idea to at least think about HT.
There is also a wide range of non-hormonal treatments and lifestyle changes that you may find useful, from dietary changes to exercise plans.
Can you have HT?
While using HT is a personal choice, there are certain circumstances in which your healthcare provider may advise against it. These are mostly due to pre-existing conditions that increase your risk of serious side effects or that might accelerate the development of another medical problem. In almost all cases, these concerns apply only to systemic HT, not vaginal HT which is safe in almost all circumstances.
Healthcare providers are currently advised not to prescribe systemic HT if you have any of the following:
- Currently in the process of diagnosis or treatment of breast cancer
- Any other known or suspected estrogen-dependent cancers (meaning those which grow in response to the presence of estrogen, most commonly found in cancers of the ovary, uterus, or endometrium)
- Vaginal bleeding of unknown cause (including bleeding in between periods, bleeding after sex, or unexplained heavy bleeding)
- Untreated endometrial hyperplasia (abnormal thickening of the lining of the uterus)
- Many people with a personal history of venous thromboembolism (blood clots) including pulmonary embolism (PE) and deep vein thrombosis (DVT)
- Some people with angina or myocardial infarction (heart attack), whether past or present
- Liver disease with evidence of abnormal liver function
- Pregnancy or breastfeeding
- Genetic disorders that increase your risk of blood clots including Protein S and Protein C deficiency and anti-phospholipid antibody syndrome.
- Porphyria cutanea tarda – a rare metabolic disease
They are also advised to prescribe only with caution in several conditions, including:
- Personal history of breast cancer, a strong family history of breast cancer, or evidence of a high-risk genetic predisposition
- Significant risk factors for venous thromboembolism – blood clots including DVT or PE. These include being aged over 60, smoking, having medical complications related to being overweight, or having a history of some cancers
- Age over 60 or more than 10 years from your last menstrual period
If you have one or more of these risk factors, your healthcare provider needs to discuss your overall health and specific risk factors versus the benefits of taking HT with you. Your healthcare provider may want to monitor you more closely or choose a type of HT specifically to minimize your risks. They may also advise that HT is too risky in your circumstances. If this is the case, take a look at the many treatment options that are available to you besides HT. Non-hormonal medications, good nutrition, exercise, and stress management can all have a positive effect on menopause symptoms.
HT benefits and risks
Why is HT controversial?
While an effective treatment for menopause symptoms, HT is not without controversy.
In the early 2000s, a large-scale, randomized clinical trial into the long-term safety and efficacy of HT concluded that oral HT came with more risks than benefits. Specifically, the earliest data published seemed to demonstrate an increased risk of breast cancer and coronary heart disease. This trial was the Women’s Health Initiative study, with the first results published in 2002.
This understandably caused a wave of concern throughout the media and the medical community alike. Many patients stopped taking HT, and many healthcare providers stopped prescribing it.
However, a closer look at the study results showed that the reality was not as clear-cut as originally thought. This was in part due to the design of the study, which only included a very limited number of HT preparations. Further analysis also showed that the majority of the women included in the study were over 60 and/or a decade past their last period, so it was unclear whether the conclusions of this study could be applied to younger women who were less than 10 years from menopause – where the benefits of HT are more substantial.
Recent studies
Over the following years, data was re-analyzed and studies have been done to investigate further. Thanks to this, we now have a much better understanding of the risks of HT, and the concerns identified in the early 2000s. As well as having more information about HT, we also have more access to different forms and routes of systemic HT compared with those included in the study 20 years ago.
Transdermal HT – in the form of patches or hormone gels applied to the skin – is known to be lower risk for many women than the oral medications studied in the Women’s Health Initiative study, and is now widely used.
The risks of HT are not being ignored, but they are now much better understood and can be weighed more individually against the benefits of this useful and popular treatment.
What are the benefits of HT?
The biggest benefit of HT is that it provides the most effective available treatment of many menopause symptoms including:
- Night sweats
- Hot flashes
- Mood changes (including low mood)
- Sleep issues
- Genitourinary syndrome of menopause (GSM)
Long-term health impact
The other important benefits from HT are positive effects on long-term health. There is good evidence in several areas:
Osteoporosis: Osteoporosis affects 1 in 3 women. The thinning of the bones associated with this condition makes fractures – even without a significant fall or injury – more likely. The evidence that HT protects your bone density, reduces the risk of so-called fragility fractures, and prevents osteoporosis, is consistent and widely accepted. This benefit continues throughout the time you take HT.
Heart disease: There is evidence that HT may be beneficial for heart health. Those who start estrogen-only or combined HT before age 60 or within 10 years of their last period may have a reduced risk of both coronary heart disease and death from cardiovascular disease. One Danish study of over a thousand women found that the relative risk of coronary heart disease decreased by 50%. This protective effect only seems to happen for those who begin HT in perimenopause or in the earlier years of their menopause, sometimes referred to as the “estrogen window of opportunity theory”.
Despite these findings, the North American Menopause Society’s (NAMS) current stance is that evidence is not yet strong enough to confirm this effect. This means that while a reduced risk of heart disease may be a welcome side-effect of HT when used to control your menopausal symptoms, it is not recommended that you start HT solely for this reason.
Type 2 diabetes: There is good evidence that HT is associated with a 30% reduced risk of developing type 2 diabetes. In addition, HT improves glycemic control in women who have type 2 diabetes.
What are the risks of HT?
As with all medications, HT comes with certain risks. As mentioned earlier, the medical community is constantly learning about the extent of these risks, as well as the different ways we can protect against them. It’s important to have a thorough conversation with your healthcare provider so that they can assess your risk profile. This will help you make a fully informed decision about the HT that is right for you. Let’s take a look at the risks of HT as we understand them today…
Discover your personalized treatment options
Does HT cause breast cancer?
Estrogen-only HT does not appear to increase your risk of breast cancer. There is even some evidence that suggests that estrogen-only HT may reduce your risk. If you do not have a uterus – and don’t need progesterone, this is the category you fall into.
Similarly, vaginal estrogens – used to treat vaginal and urinary symptoms – are not associated with an increased risk of breast cancer.
While that is good news for those on estrogen-only HT, it doesn’t hold true for all forms of HT. Combined HT, containing both estrogen and progesterone – may be associated with an increased risk of breast cancer. Despite this, the risks are small when compared with some other risk factors. For example, being overweight or drinking more than one drink per day appears to increase your risk by as much or more than taking combined HT.
Read more here about HT and breast cancer risk.
Does HT cause blood clots?
It depends on the type of HT you are prescribed.
When we talk about blood clots in HT, we generally mean those that form in the deep veins of the body. The medical term for this is venous thromboembolism (VTE), and this group of conditions includes pulmonary embolism (PE) and deep vein thrombosis (DVT).
Oral HT does come with an increased risk of blood clots. The exact amount of increased risk varies between the different types of hormone in the HT preparation. In one study, the baseline risk of blood clots was low in women over 50 who took HT and had no extra risk factors – around two blood clots per 1,000 women per year. In that study, the highest risk preparation of oral HT was associated with a risk of around 4 blood clots per 1,000 women per year. The lowest risk preparation – only appropriate for women without a uterus – was associated with a risk of 2.2 blood clots per 1,000 women per year.
Transdermal patches, sprays, or gels do not appear to be associated with an increased risk, but more research is needed. This happens because of the way the hormones are absorbed through the skin and directly into the bloodstream. Your healthcare provider is likely to recommend a transdermal preparation as a first choice, especially if you have any other risk factors.
Vaginal HT does not affect your risk of blood clots.
Does HT increase your risk of stroke?
Oral HT does appear to increase the risk of stroke in older people (over the age of 60). But, when starting hormone therapy before age 60 and within 10 years of menopause, the risk of stroke is less than 1 additional care per 1000 women per year.
Transdermal and vaginal HT are not associated with this increased risk. If you have any risk factors for stroke, your healthcare provider may recommend a transdermal type of HT if suitable.
Which HT is best for me?
The best prescription is one that controls your symptoms with the lowest possible amount of risk. It can be tricky to find the right one, but your healthcare provider will be able to advise on the best preparation for your circumstances.
When recommending any type of HT, your healthcare provider will be asking themselves two questions:
- Which hormones do you need?
- Which is the best way to supply them?
Which hormones do I need?
All forms of HT should supply you with some form of estrogen, as this is the hormone that will help ease your menopause symptoms – thanks, estrogen! Your healthcare provider will usually recommend trying a lower dose to begin with, although this can be increased if needed at follow-up appointments.
If you still have your uterus, you need to take progesterone too. This is because estrogen alone can cause abnormal thickening of the uterine lining which can sometimes lead to endometrial cancer. Progesterone has a protective effect that removes this risk. This is only a risk with oral or transdermal therapies. Vaginal estrogen treatments, except for the Femring, do not increase your risk of cancer of the uterine lining.
You may also read about testosterone, which is sometimes prescribed as a gel and absorbed through the skin. This is used less frequently than standard HT but is sometimes recommended where the loss of libido is an issue.
How should I take my HT?
In general, healthcare providers tend to recommend starting with the lowest-risk preparation. Here are some examples…
Vaginal estrogen
If you only need help with vaginal and urinary symptoms, vaginal estrogen will likely be recommended. This is a particularly low risk given the type of estrogen used and the fact that the hormone is not absorbed into your bloodstream (or only in very small amounts). Vaginal estrogens do not affect the womb lining and can therefore be prescribed without adding in progesterone.
Patches, gels or sprays
If you need HT to help with other symptoms of menopause, transdermal HT is usually the lowest-risk option. This comes in the form of patches, gels, or sprays.
Oral HT
If you find the patches inconvenient or struggle with certain skin conditions, patches or gels may not be suitable and oral HT may be best for you. Also, some experts think that certain people with high cholesterol might benefit from oral HT.
As you can see, there are plenty of options! Your own healthcare provider will be able to advise on the best starting point for you. Read more about different types of HT.
How does HT make you feel?
Hopefully a lot better! The majority of women who take HT for menopause symptoms will start to see an improvement within a few weeks, although it can take several months to see the full benefit of treatment.
As with any medication, there are a few side effects to look out for.
Read more here on HT side effects.
Talking to your healthcare provider about HT risks
There is a huge amount of information about HT out there. Being informed about your HT risks and options is important, but where should you start?
Make sure to use a reputable source of information. These include:
- The Menopause Society (formerly the North American Menopause Society)
- National Institute on Aging, NIH
- British Menopause Society – Hormone Therapy Replacement Guide
- Stella also has a wealth of information from clinicians and experts in specific areas
Final word
Depending on what you read, HT can be portrayed as either a danger to health or a wonder drug. The truth is that it’s neither.
HT is a useful part of our menopause toolkit, but it is not a one-size-fits-all solution to every menopause symptom.
The fact that we are still learning about this treatment even after decades of prescribing it tells you that this is a complex and nuanced area. If you feel like HT may be right for you, it’s a good idea to read about the subject and ask your healthcare provider for their advice. They can guide you to the best treatment for you personally – whether that is HT or something else entirely.
It’s also important to check in for a review with your healthcare provider at least every year once your treatment has been established – over time your risk factors, symptoms and health may change, and your prescription may need to as well.
Read more about menopause on our blog or in our symptoms library.
- NAMS statement in 2022: The 2022 hormone therapy position statement of The North American Menopause Society. Menopause: The Journal of The North American Menopause Society, Vol. 29, No. 7, pp. 767-794. DOI: 10.1097/GME.0000000000002028
- Paschou, S.A., Athanasiadou, K.I. & Papanas, N. Menopausal Hormone Therapy in Women with Type 2 Diabetes Mellitus: An Updated Review. Diabetes Ther 15, 741–748 (2024). https://doi.org/10.1007/s13300-024-01546-1
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