Menopause Hormone Therapy: Benefits and Risks

Menopausal hormone therapy is the most effective treatment for bothersome hot flushes and night sweats. It can also prevent bone loss while treatment continues. But “hormone therapy” is not one uniform product: benefits and risks change with age, time since menopause, medical history, dose, route and whether a progestogen is required.

The decision is therefore not “Are hormones good or bad?” It is “What symptom are we treating, which formulation fits, and what are this person’s risks?”

What systemic and local therapy do

Systemic oestrogen—taken as a tablet or delivered through the skin—treats symptoms throughout the body, especially hot flushes and night sweats. A person with a uterus generally also needs endometrial protection with a progestogen because oestrogen alone can increase the risk of endometrial cancer.

Low-dose vaginal oestrogen acts mainly in vaginal and urinary tissues. It is used for dryness, painful sex and some urinary symptoms and has much lower systemic absorption than standard systemic therapy. Isolated genitourinary symptoms often do not require whole-body treatment.

Who generally has the most favourable balance?

Major menopause guidance finds the benefit–risk balance most favourable for healthy, symptomatic people younger than 60 or within 10 years of menopause onset, provided there is no contraindication. This is not a guarantee of zero risk; it is a starting point for individual assessment.

Starting systemic therapy later—particularly after age 60 or more than 10 years after menopause—carries greater absolute risks of coronary disease, stroke, venous thromboembolism and dementia. Hormone therapy should not be started solely to prevent cardiovascular disease or dementia.

The risks are not identical for every formulation

Oral oestrogen passes through the liver before entering the circulation and is associated with a higher risk of blood clots than transdermal oestrogen in observational evidence. Patches or gels may therefore be preferred when clot or metabolic risk is a concern, although route does not remove every risk.

Breast-cancer risk depends partly on duration and regimen. Combined oestrogen–progestogen therapy has a different profile from oestrogen alone. Personal and family history, prior breast biopsies and screening history should be considered rather than reduced to a single headline.

Systemic hormone therapy is usually avoided or requires specialist input with unexplained vaginal bleeding, previous breast or endometrial cancer, coronary heart disease, stroke, heart attack, blood clots or significant liver disease. Individual circumstances can be complex, especially after cancer.

“Bioidentical” does not automatically mean safer

Regulated products may contain hormones chemically identical to those produced by the body. Custom-compounded preparations are different: they may be useful in rare allergy or formulation situations but generally lack the same evidence for consistency, purity and safety. Saliva testing is not a reliable way to tailor menopausal hormone doses.

Questions worth asking

• Which symptom are we trying to improve, and how will we judge success?
• Do I need systemic treatment or would local vaginal treatment fit better?
• If I have a uterus, how will the endometrium be protected?
• Would a patch or gel be preferable to a tablet for my risk profile?
• What bleeding should be expected, and what bleeding needs investigation?
• When will we review benefits, side effects and whether treatment should continue?

There is no universal rule that treatment must stop at a specific birthday. Continued use should be periodically reviewed, using the lowest effective dose that meets the treatment goal.

Making a treatment decision

Hormone therapy can be highly effective when it is matched to the symptom and the individual. Timing, route and medical history matter. A balanced consultation should cover meaningful benefits as clearly as risks and include nonhormonal alternatives when systemic therapy is unsuitable or unwanted.

This article is for education and does not replace individualized prescribing advice or cancer and cardiovascular risk assessment.

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References

1. The North American Menopause Society. “The 2022 Hormone Therapy Position Statement.” Menopause (2022)
2. Cho L, et al. “Rethinking Menopausal Hormone Therapy: For Whom, What, When, and How Long?” Circulation (2023)
3. Zhang G-Q, et al. “Menopausal hormone therapy and women’s health: an umbrella review.” PLOS Medicine (2021)