Hot flashes. Night sweats. Brain fog. The onset of menopause introduces a host of bothersome symptoms – many of them exhausting and life changing. Sex is painful, and your moods become erratic. You grow desperate for relief. But the world shrugs it off and we are told: “This is normal in menopause, deal with it.” 


You don’t buy it (nor should you), so you do your own research. You search the internet, talk to friends and your providers, and you discover hormone replacement therapy (HRT) may be an option for you. Now you’re eager to learn more. 

Here’s the good news: studies show that for most healthy young women who are within 10 years of starting menopause, HRT is not only safe, but likely to prolong your life. It also reduces your risk of developing major medical illnesses such as heart disease, diabetes, and colon cancer. 

So, what exactly is HRT, and is it safe for you? 

HRT typically consists of the hormones estrogen and progesterone. Women who take HRT are given estrogen in doses at just the right level to treat menopause symptoms such as hot flashes. If you have a uterus, you’ll also need to take progesterone, which protects the lining of the uterusfrom uterine cancer.

Like all medications, HRT comes with potential benefits and risks. The good news is, in the vast majority of women, the benefits far outweigh the risks.

The Potential Benefits

HRT is the most effective treatment for hot flashes and night sweats, the primary reason most women turn to HRT. Other potential benefits include:

  • Improved sleep
  • Diminished fatigue
  • Boost in mood
  • Enhanced ability to concentrate
  • Relief of vaginal dryness 
  • Reduced pain during sex
  • Increase in bone density
  • Lower risk of osteoporosis and fractures
  • Lowers risk of colon cancer

Taken under the supervision of a menopause expert, HRT can improve a woman’s overall health and quality of life. And it’s important to again stress that if you’re healthy, under age 60, and within 10 years of menopause, studies have shown that HRT will likely reduce your mortality rate and heart disease risk, as well as your likelihood of developing a major illness.

The Potential Risks

HRT may slightly increase your risk for stroke or blood clots in the legs or lungs, especially if taken orally. Data suggests this risk is significantly reduced if you use transdermal estrogen, such as a patch or gel. 

If you start treatment after age 60, or if 10 or more years have passed since the start of menopause, HRT may raise your heart disease risk. If you begin HRT after age 65, it may raise the risk for dementia as well. So, the take home message is this: starting HRT at a young age imparts many benefits. But if you’re older, you may have more risks.  

The length of time you take HRT can also make a difference. Taking both estrogen and progesterone can raise your risk for breast cancer if you take the combination for more than four to five years. Taking estrogen alone in women who have had a hysterectomy did not pose thesame risk. 

In some women, HRT can cause side effects such as breast tenderness, bleeding, or nausea. This typically resolves as your body adjusts to the hormones. If not, reducing your dose, or switching the type of HRT may diminish or eliminate these side effects. Any bleeding should be brought to the attention of your provider. 

A very small percentage of women should not take HRT. This includes women who have a prior history of a stroke, blood clot, heart disease, liver disease, or breast cancer. And while HRT use for less than four to five years has not been shown to increase breast cancer risk, hormones can cause breast cancer to grow faster, if you do happen to develop breast cancer or precancer. For this reason, I recommend women on HRT have regular mammogram screenings.  

The Right Choice

When starting HRT, I recommend working with a trained menopause provider in order to safely determine the type of HRT that will work best for you, the appropriate dose, and the duration of therapy. HRT can be taken daily as a pill, but it’s also available as a skin patch, gel, cream, spray, or vaginal ring. 

In general, experts recommend you begin by taking the lowest dose of estrogen possible to achieve relief from your symptoms. The dose can then be increased slowly over time in order to get the maximum benefit. Be patient as it typically takes 8 to 12 weeks for HRT to have its full effect, so it’s important to adjust your dose slowly. 

In my practice, once a patient reaches an ideal dose, I see them annually, and we continue to assess the risks and benefits of HRT as a team, based on their general health and symptoms. If we decide to lower the dose, we do this slowly over time. There is no specific recommended length of time to be on hormones, as all patients are unique. The decision to stop depends on you, your symptoms, and your medical history. I recommend you work with a certified menopause provider, like myself, to determine the best time for you to start weaning your HRT.

What about the small percentage of women who are suffering from menopause symptoms but cannot take HRT due to a medical contraindication? Fortunately, there are other options available. I’ll discuss those in an upcoming blog. 

Sandra Fleming, MD, FACOG, NCMP