Hormone replacement therapy (HRT), also called hormone therapy, works by replacing hormones such as estrogen and, in some cases, adding progesterone as hormone levels decline. HRT may also help reduce the risk of health problems related to low estrogen, such as osteoporosis.

The decision to start HRT is personal and will be different for everyone. Clinicians consider several factors when deciding whether HRT is an appropriate and safe option for your symptoms.

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To decide if HRT is right for you, start by tracking your symptoms and how they affect you. There are online apps and other tracking tools that can help you take note of:

• When symptoms start and stop
• What makes your symptoms better or worse
• How any other medications or supplements affect your symptoms
• How severe your symptoms are, including what they prevent you from doing

HRT is recommended for certain menopause symptoms that are severe enough to disrupt your daily life and is effective at treating the following symptoms:

• Moderate to severe hot flashes and night sweats
• Vaginal dryness and itching
• Pain or burning with sexual intercourse
• Urinary frequency or urgency and recurrent urinary tract infections, particularly with vaginal estrogen

HRT may also help with insomnia and some mood changes.

Hormone therapy may also increase your bone density and lower the risk of osteoporosis. Research shows that people taking hormone therapy are at a lower risk of bone fractures.

Timing changes the balance of benefits and risks of hormone therapy. Research finds that balance is most favorable when HRT starts before age 60 or within 10 years of menopause. Clinicians call this the window of opportunity.

Falling outside the window of opportunity doesn’t rule hormone therapy out completely, but it changes the conversation.

Starting HRT more than 10 years after menopause carries more risk than starting early. Systemic hormone therapy, which travels through the bloodstream to affect the whole body, is available as pills, patches, gels, sprays, and other forms. Beginning systemic hormone therapy well after menopause is linked to higher cardiovascular and stroke risk.

Starting and continuing are different questions. No age automatically requires you to stop. For some women, continuing hormone therapy after age 60 may still be appropriate based on their symptoms, health risks, and preferences.

Vaginal estrogen is an option at any age. This is a lower-dose cream, tablet, or ring placed inside the vagina to treat symptoms such as vaginal dryness, pain with intercourse, or frequent urinary tract infections. Estradiol in these formulations is absorbed into the bloodstream in much smaller amounts than systemic hormone therapy. It is local therapy, not systemic hormone therapy.

You don’t have to wait for your periods to stop. Many women have more irregular periods during perimenopause, which begins before the final menstrual period and can last several years. Hormone therapy can help treat perimenopausal symptoms even if you are still having periods.

Primary ovarian insufficiency occurs when the ovaries don’t function as expected before age 40. Menopause between ages 40 and 45 is generally called early menopause. Menopause can also happen earlier than usual after surgery to remove the ovaries.

If you reach menopause before age 45, doctors often recommend hormone therapy, as long as you don’t have a condition that makes it unsafe. Losing ovarian hormones earlier than usual means spending more years with lower estrogen levels, which can raise the long-term risk of osteoporosis and cardiovascular disease. Because these risks can increase over time, hormone therapy may be recommended whether or not you have bothersome symptoms.

The goal is to replace the hormones your ovaries would normally produce and continue treatment until at least the average age of menopause, around age 51 to 52. At that point, you and your clinician can reassess the benefits and risks of continuing HRT longer.

For some people, the risks of hormone therapy can outweigh the benefits. Talk through your health and family history with your healthcare provider to learn whether hormone therapy is safe for you. Tell your provider if any of the following apply to you:

• A history of heart disease, stroke, or blood clots — Hormone therapy may increase the risk of blood clots. Combination hormone therapy, which includes both estrogen and progesterone, slightly increases the risk of stroke.
• A past breast cancer diagnosis — Systemic hormone therapy is generally not recommended for women with a history of breast cancer, especially hormone-sensitive breast cancer. Combination hormone therapy may slightly increase breast cancer risk after five years of treatment. In some cases, treatment may still be considered after discussing the benefits and risks with your oncologist and healthcare provider.
• Liver or gallbladder disease — These conditions may also prevent you from safely taking hormone therapy.

How you take hormone therapy matters, too. Oral hormone pills may increase the risk of blood clots more than hormone therapy delivered through a skin patch or gel.

Whether you still have a uterus also affects what your doctor may prescribe. Taking systemic estrogen without progesterone can cause the uterine lining to thicken, which may increase the risk of endometrial cancer.

If you have a uterus, your doctor will usually recommend a combination of estrogen and progesterone. Low-dose vaginal estrogen works differently and generally doesn’t require added progesterone. However, it won’t relieve symptoms such as hot flashes, night sweats, or trouble sleeping.

How To Prepare for a Conversation About HRT

It may help to do some research before discussing hormone therapy with your healthcare provider. Knowing some of the benefits and risks can help you feel more confident asking questions.

To prepare:

• Make a list of your symptoms — Consider tracking them for a few weeks beforehand. Note how often they happen and how much they interfere with your day.
• Write down your family history — Make sure to include any cancers or types of heart disease that run in your family.
• Bring three to five questions — If you’re overwhelmed about where to start, a short list is plenty.

Questions worth asking:

• Based on my health and family history, do the benefits of hormone therapy outweigh the risks for me?
• Which type and form would you recommend, and why that one?
• How long might I stay on it, and when will we revisit that decision?
• How soon should I expect to notice a difference?
• What are my options if hormone therapy isn’t a good fit?

Ask how long you may need HRT, but don’t expect a fixed answer. The general approach is to use the lowest dose that controls your symptoms, with the length of treatment based on your own benefits and risks rather than a set time limit. That will look different for everyone, and it’s a decision you and your healthcare provider revisit over time.

Finding the right type, dose, and formulation of hormone therapy may take some adjustment. Tracking your symptoms once you start HRT can provide valuable information to help you and your provider decide the next steps in terms of:

• Formulation
• Dose
• Duration

When To Revisit Your HRT Decision

The decision to start hormone therapy may need to be revisited over time. If you decide to start hormone therapy, plan to see your doctor regularly, especially when first starting HRT. Your doctor will monitor you for symptom improvement and any side effects at in-person or telehealth appointments.

During hormone therapy, your doctor may adjust the type or dose based on how your body responds to it. Possible side effects include:

• Irregular vaginal bleeding
• Breast tenderness
• Mood changes
• Headaches
• Bloating
• Skin changes
• Increased breast density (often seen on mammograms or breast imaging)

In most cases, side effects are temporary and get better on their own within a few months. If your side effects are mild and don’t bother you, it may be OK to continue hormone therapy while they improve.

If you and your doctor decide to stop hormone therapy, ask about alternatives. There are other prescription medications that treat hot flashes but do not contain hormones. For example, research has found that weight loss, cognitive behavioral therapy, and clinical hypnosis may improve hot flashes.

If you decide to stop vaginal hormone therapy, try using a vaginal lubricant or moisturizer to help with dryness. There are also prescription medications available to treat vaginal pain with intercourse.

Talk to Your Healthcare Provider

Deciding whether hormone therapy is right for you depends on your symptoms, age, health history, and personal preferences. Your healthcare provider can help you weigh the benefits and risks and choose the type and dose that best fit your needs. If you start hormone therapy, revisit the decision regularly as your symptoms and health needs change.