As you get closer to menopause, your ovaries slowly make less of the hormone estrogen. This change starts during perimenopause, the time leading up to menopause. Lower estrogen and other hormone changes can cause symptoms like vaginal dryness and hot flashes.

Taking estrogen for menopause can help relieve these symptoms and improve quality of life during perimenopause and menopause. To better understand estrogen’s role in menopause hormone therapy, we spoke with certified nurse midwife and women’s health nurse practitioner Maariya Bassa, MSN, CNM, WHNP-BC. Bassa is the medical director for Quality at Unity Health Care in Washington, D.C.

What Is Estrogen?

Estrogen is one of the two main sex hormones in your body. Most of your estrogen comes from your ovaries during your reproductive years, but some also comes from fat tissue and your adrenal glands.

Estrogen, along with progesterone, helps support reproductive health by regulating menstruation and ovulation and preparing the uterus for pregnancy. During puberty, it supports the development of sex characteristics like hips and breasts.

Although you might think of estrogen as a reproductive hormone only, it’s also active in other body systems and processes. Estrogen’s activity in your brain helps support clear thinking and focus. It also helps with blood flow and keeps your bones and muscles strong. When you lose estrogen during perimenopause and menopause, your risk of osteoporosis (low bone density) increases. This is why many women going through menopause have a higher risk of bone fractures.

Estrogen’s Role in Menopause Hormone Therapy

Estrogen is the main hormone used in menopause hormone therapy (also called hormone replacement therapy or HRT). It may be the only hormone included in treatment if a woman has had a hysterectomy (removal of the uterus).

Bassa explained how declining estrogen can lead to symptoms commonly associated with menopause. “Through normal phases of natural menopause, you’re going to see a reduction in ovarian estrogen production. And so that leads to a reduction in systemic estrogen,” she said.

“So that’s going to cause a lot of the vasomotor symptoms that we associate with menopause. Things such as hot flashes.” Vasomotor symptoms include hot flashes and night sweats, which can affect sleep, focus, and mood.

Estrogen therapy can also help with other perimenopause symptoms, including, but not limited to:

• Genitourinary syndrome of menopause (GSM), or symptoms involving your vaginal and urinary tissues
• Disrupted sleep
• Mood swings and irritability
• Brain fog

Menopause hormone therapy can also help lower the risk of some long-term health problems, such as diabetes, heart disease, and osteoporosis.

There is also considerable interest in how hormone therapy may affect dementia risk. The results have been mixed, and more research is needed.

Possible Drawbacks of Estrogen Hormone Therapy for Menopause

Menopause hormone therapy can also have some possible risks and drawbacks, which you should discuss with your doctor. Based on your personal and family health history, taking estrogen hormone therapy for menopause might increase your risk for:

• Stroke and blood clots
• Heart disease, if started a decade after you’ve entered menopause
• Breast cancer, especially with long-term use
• Gallbladder disease

Taking too much estrogen can lower sex drive and cause unintentional weight gain. It’s important to follow your doctor’s instructions closely while undergoing menopause hormone therapy.

Options for Administering Estrogen

Some menopause hormone therapy treats only the vaginal tissues (local estrogen therapy), while other types enter the bloodstream and affect many organs and tissues (systemic estrogen therapy).

Local Estrogen

“You’ve got a ring, a tablet, and vaginal creams available,” Bassa explained. “If you needed localized treatments for your genitourinary atrophy (vaginal thinning and dryness), [they] wouldn’t necessarily help with hot flashes, but would help with your GSM symptoms and more of your atrophy symptoms.” Local vaginal estrogen gradually releases estrogen into your vaginal tissues to treat vaginal dryness and other GSM symptoms.

Systemic Estrogen

Systemic options can treat vasomotor symptoms as well as other symptoms like brain fog, mood issues, and more. “We’ve got oral estrogen available, and then we’ve got transdermal options,” Bassa explained. “Transdermal options are going to include your patches, your gels, your sprays, as well as your intravaginal rings.” Gels, sprays, and patches allow estrogen to pass through your skin and enter your bloodstream.

One major benefit of transdermal hormone therapy is that it has less of an impact on your liver than oral pills or tablets. “[An oral pill] has more of an impact on your liver,” Bassa said. “A transdermal patch doesn’t necessarily have those risks.”

It’s important to be careful while using transdermal hormone therapy because the hormones can transfer to other people or animals through skin contact. “If animals or children are touching those areas, the [hormones] on the skin can actually be passed to other people or even your animals,” Bassa said. “And so then these other mammals can also start to develop some of those symptoms of the increased [hormones].”

Bassa also noted that insurance may be less likely to cover transdermal options. “Unfortunately, some costs are associated with transdermal options. If insurance doesn’t cover it and the patient has no risk factors for why they couldn’t take an oral tablet, then that would lead us to prescribe the oral tablet.”

Other Considerations for Menopause Hormone Therapy

Estrogen-only menopause hormone therapy starts at a low dose and can treat your menopause symptoms if you’ve had a hysterectomy (removal of the uterus).

If you still have your uterus, you’ll have to take combination hormone therapy with estrogen and progestin (a synthetic form of the hormone progesterone). In menopause hormone therapy, progesterone helps lower the risk of endometrial cancer in women who still have a uterus.

Talk to Your Healthcare Provider

According to Bassa, “Menopause treatment is so tailored to individual symptoms, and it is so much of a conversation between the clinician and the patient of what are the symptoms that we’re actually looking to treat as opposed to, well, this is just standard treatment.”

If menopause symptoms are making daily life hard, ask your doctor whether hormone therapy or other treatments may help. Your doctor will look at your symptoms and health risks before recommending treatment. They can help choose the option that best fits your needs and show you how to use it correctly.