Perimenopause symptoms like hot flashes or mood swings can affect daily life for years, not just a few rough weeks. Effective treatments are available, but decades of confusing headlines about menopause hormone therapy — also called hormone replacement therapy (HRT) — have left many women unsure if it’s safe.

ThisIsMenopause spoke with two certified menopause practitioners to better understand the current evidence.

What Is Menopause Hormone Therapy?

Menopause hormone therapy uses hormones to treat symptoms caused by lower hormone levels during menopause. The two main hormones used are estrogen and progesterone (or similar hormones called progestins).

“When we talk about menopause hormone therapy, we’re talking about combinations of treatments that involve hormones like estrogen, or estrogen and progesterone,” said Margaret Ladner, a certified nurse-midwife and the founder of Attune Menopause Care in Chicago.

During menopause, the ovaries make less estrogen. This drop can lead to symptoms like hot flashes, night sweats, and vaginal dryness. Hormone therapy replaces some of these hormones to help relieve symptoms such as:

• Hot flashes
• Night sweats
• Vaginal dryness
• Pain during sex
• Sleep problems
• Some mood symptoms
• Bone loss

Many women notice improved sleep and daily functioning once symptoms like night sweats are under control. Ladner said most women start to feel better within six to eight weeks.

However, hormone therapy does not treat every symptom. Ladner explained that perimenopause often involves many changes at once, including mood changes, sleep problems, and irregular bleeding. Because of this, treatment usually focuses on the symptoms that most affect your quality of life.

Individualized Hormone Therapy

Menopause affects every woman differently. Some may have hot flashes, while others struggle more with sleep, mood changes, or vaginal symptoms. Because of this, treatment should always be individualized.

“Menopause treatment and menopause therapies are so tailored to individual symptoms. It is really a conversation between the clinician and the patient,” said Marriya Bassa, a certified nurse-midwife and women’s health nurse practitioner at Unity Health Care in Washington, D.C.

Ladner agreed: “There isn’t a one-size-fits-all.”

When deciding whether hormone therapy is right for you, your doctor may consider:

• Your most bothersome symptoms
• Your age and whether you are in perimenopause or have reached menopause
• Your uterus status (whether you still have a uterus)
• Your personal and family medical history
• Your risk factors, such as heart disease or cancer

The Role of Estrogen in Hormone Therapy

Estrogen is the main hormone used to treat many menopause symptoms.

Bassa explained that estrogen levels naturally drop during menopause because the ovaries produce less of the hormone. This decrease can cause what doctors call vasomotor symptoms, including hot flashes and night sweats. Research shows that estrogen therapy is the most effective treatment for vasomotor symptoms.

Lower estrogen can also lead to vaginal dryness and painful sex. These symptoms are part of a condition called genitourinary syndrome of menopause (GSM). Estrogen therapy helps replace some of the lost hormones and relieve GSM symptoms.

Reasons Progesterone May Be Used

Progesterone plays an important role in hormone therapy, especially for women who still have a uterus.

Bassa explained that if someone with a uterus takes estrogen alone, the lining of the uterus can grow too much. Over time, this can raise the risk of endometrial hyperplasia (when the uterine lining becomes too thick) or endometrial cancer. Adding progesterone helps protect the uterine lining.

“Progesterones have also been shown to help improve sleep, which can help improve mental clarity,” Bassa added. However, she noted that some people don’t tolerate progesterone well because it can affect mood.

Systemic vs. Local Hormone Therapy

Hormone therapy can be delivered in different ways, depending on which symptoms you want to treat. The two main types are systemic therapy and local therapy.

Systemic therapy affects the whole body and is commonly used for symptoms like hot flashes and night sweats. Systemic estrogen can be taken as pills or delivered through the skin using patches, gels, or sprays.

Local hormone therapy targets specific areas, usually the vagina. These treatments help with vaginal dryness, pain during sex, and some urinary symptoms. Ladner said local estrogen therapy can improve the following symptoms:

• Vaginal dryness
• Vaginal pain
• Pain with intercourse
• Bladder issues
• Incontinence
• Frequent urinary tract infections

Local estrogen uses much lower doses and generally carries fewer risks throughout the body.

Potential Risks of Hormone Therapy

Like any medication, hormone therapy has potential risks. The main risks studied include:

• Blood clots
• Stroke
• Heart disease
• Breast cancer

Much of the public discussion about these risks comes from the Women’s Health Initiative study published in the early 2000s. The study found increased risks for certain health conditions with some types of hormone therapy.

However, researchers later identified important details that affect how these results are understood. Many participants were in their early 60s and more than 10 years past menopause. Later research suggests that starting hormone therapy earlier — within about 10 years of menopause — may have a different balance of risks and benefits.

What To Know About Breast Cancer Risk

Breast cancer risk is one of the most common concerns about hormone therapy.

Ladner explained that the Women’s Health Initiative study found about 6 additional cases of breast cancer per 10,000 women per year among those using certain types of hormone therapy. She noted that this increased risk is similar to some lifestyle-related risk factors, such as:

• Regular alcohol consumption
• Obesity
• Lack of physical activity

The American Cancer Society says that cancer risk from hormone therapy varies based on which hormones are used, how they’re given, and how long they’re used.

If you have a family history of breast cancer or other risk factors, talk with your doctor about what’s best for you.

Long-Term Benefits of Hormone Therapy

Hormone therapy may provide benefits beyond symptom relief. Bassa said research suggests menopause hormone therapy may have positive effects on:

• Bone health
• Heart health
• Cognitive function

One of the clearest benefits is protection against bone loss and osteoporosis. Hormone therapy can lead to “really dramatic preservation of bone health,” Ladner said. Studies show estrogen therapy can help reduce fracture risk in postmenopausal women.

How Long Can Someone Stay on Hormone Therapy?

There’s no set timeline for hormone therapy. Some women use it for a few years, while others continue longer, depending on their symptoms and overall health.

Treatment decisions should always be individualized, Ladner said. “There should be no set time when we’re like, ‘You should be cut off from hormone therapy.’”

Many healthcare providers regularly review the risks and benefits with women and adjust treatment as needed. Local vaginal estrogen therapy may be used longer because it has very little absorption into the bloodstream.

Work With Your Healthcare Provider

“I wish I had been proactive about seeking treatments,” one woman shared with ThisIsMenopause. If you’re considering hormone therapy, it can help to prepare questions before your appointment.

Ladner encourages people to find providers who will understand menopause care: “You should try to identify a provider who will listen to you and who is versed in current research on managing menopause.”

Menopause hormone therapy can help many women manage symptoms like hot flashes, night sweats, sleep problems, and vaginal dryness. However, treatment should always be personalized. Working with a knowledgeable healthcare provider can help you weigh the benefits and risks and decide whether hormone therapy is right for you.