How much do you really know about hormone replacement therapy?

If you broke your ankle, you’d ask for a cast. If you have a headache, you’re opening up that bottle of ibuprofen. But so many women experience menopause symptoms — hot flashes, night sweats, brain fog, irritability — that are hugely disruptful to their day-to-day lives, and yet, they don’t get treated for them.

It’s not that there isn’t a treatment for perimenopause and menopause symptoms, because there is: hormone replacement therapy (HRT), also called menopausal hormone therapy (MHT). It’s that the majority of women (like up to 60 percent of those with moderate to severe menopause symptoms) don’t use it. This could be caused by a mix of factors, like providers not bringing it up as an option or fears of HRT’s risks and side effects. 

But menopause experts are starting to see a change. “Back in the day, I think women had to be miserable before they were ever offered hormone therapy,” says Dr. Alicia Robbins, M.D., an OBGYN and Menopause Society Certified Practitioner based in Greenwich, Connecticut. “Now, women are being more proactive and saying that they don’t want to feel this way for 10 or 20-plus years.” Curious about hormone therapy? This guide will tell you more about how it works, options you can discuss with your clinician, potential safety concerns, and more. Let’s dive in.

Hormone replacement therapy is a category of prescription medications that supplement your body with some of the hormones (estrogen and progesterone) that have declined during the menopause transition. Because hormonal fluctuations and deficiencies during menopause are to blame for many menopause symptoms, HRT can help you feel better. It comes in different forms:

• Estrogen only

• Progesterone only

• Estrogen and progesterone together 

While estrogen is largely responsible for improving symptoms, you need to take progesterone alongside it if you have a uterus. This is to help protect the uterine lining from growing too thick (a side effect of estrogen supplements) and help reduce the risk of uterine cancer. 

Some women who are mainly dealing with sexual dysfunction may take testosterone supplements, but this is not typically considered part of HRT.

HRT can be broken down into two main types:

Systemic therapy: The hormones are absorbed into your bloodstream, where they can have wide-ranging effects all over your body, such as treating symptoms like hot flashes and night sweats as well as improving vaginal symptoms. It comes in a few formats:

• Oral pill

• Patch

• Spray

• Gel

• Vaginal ring

Local or vaginal estrogen therapy: Instead of entering your bloodstream, the estrogen stays local where it can help do things like lubricate vaginal tissues. It contains a lower amount of estradiol (the estrogen hormone) compared to systemic therapy, and in most cases doctors will not add progesterone to local estrogen therapy. The medication is also available in several forms:

• Cream

• Tablet

• Capsule

• Ring

HRT can’t improve all menopause symptoms, but it can improve some of the most bothersome and common ones. Systemic estrogen therapy is considered to be the first-line therapy to treat vasomotor symptoms of menopause — otherwise known as hot flashes and night sweats — which affect about three-quarters of women. But we know that there are so many (so many) more symptoms of menopause, and Robbins will also prescribe it to women who are struggling with issues like sleep disruption, problems with mood, joint pain, and brain fog. 

Addressing hormone fluctuations may have a direct benefit on these issues, as well as an indirect one. For example, if you have fewer night sweats, you may have better sleep and, as a result, less brain fog. And on the list of benefits, think beyond menopause symptoms. Menopause can negatively affect your heart, brain, and bone health, which HRT can help counter. 

Progesterone also has some benefits beyond protecting your uterus from the effects of the estrogen. “One of the first things that tends to decrease in perimenopause is progesterone,” says Robbins. “This hormone is important for falling asleep and has an anti-anxiety effect.” 

Localized estrogen can help with symptoms that fit under the genitourinary syndrome of menopause (GSM), such as vaginal dryness, pain with intercourse, and urinary incontinence or frequency. 

Clinicians can prescribe just systemic or just local hormone therapy, or they can prescribe them together — especially if you have both hot flashes and GSM. “Sometimes systemic therapy is enough to reach its way down to the pelvic floor,” says Robbins. “And sometimes, that doesn’t provide enough symptom relief and then we add in local vaginal therapy.”

One of the most common complaints in menopause is the weight creep that happens over the years. Although this gradual gain may be more due to aging rather than hormonal changes, there are body shape shifts that happen at midlife, and more women find that fat migrates to their abdominal area, which is a type of inflammatory fat that has a negative metabolic effect and is associated with chronic health problems. 

Hormone therapy is not a weight-loss medication, but it may indirectly have an impact on your weight and body composition. HRT may enhance sleep quality, decrease disruptive hot flashes and night sweats, and improve quality of life — all things that can make it feel a little easier to stick with a healthy diet and stay active. And some research of post-menopausal women shows that HRT may help reduce the tendency toward abdominal fat accumulation that occurs during menopause.

In addition, one recent meta-analysis found that hormone therapy — either combination or estrogen alone — reduced insulin resistance (when your body can’t use its insulin effectively to move glucose out of your blood). Estrogen improves insulin sensitivity in tissues, which may also decrease inflammation. And by improving your body composition (less abdominal fat), estrogen can further promote healthy insulin function. “Once you get hormones more in balance, you can get better control over insulin resistance and other measures of metabolic health, which can help with weight,” says Dr. Meryl Kahan, M.D., a board-certified gynecologist and Menopause Society Certified Practitioner in New York City. 

One thing to note is that HRT can help with weight loss if you’re already taking a GLP-1 receptor agonist (such as semaglutide). “Studies show that women do lose more weight when they take both together,” says Kahan. For instance, one study in post-menopausal women found that HRT plus semaglutide can lead to 30% more weight loss than taking semaglutide alone.

All medication requires comparing the benefits and health risks when deciding if it’s right for you, and HRT is no different. The Menopause Society says that for healthy women with menopause symptoms, the benefits of starting HRT outweigh the risks if you are younger than 60 and within 10 years of menopause (this is the moment you’ve gone 12 months without a period, which happens on average at age 52). 

“We have found that the earlier you start systemic hormone therapy, the more benefit you get in terms of cardiovascular risk and cognition,” says Robbins. But you need to do it in the right window. “We think this is because once you are 10 years past menopause, the pathology of plaque in arteries and amyloid beta depositions in the brain have already been there,” says Robbins. “When starting hormones on the earlier side, it may help slow down the progression of these conditions.”

There’s also not necessarily a hard-and-fast-rule for when to stop HRT. Based on new research, it may be safe for many women to continue to use HRT after age 65 if they continue to have symptoms like hot flashes. The dose and form of HRT matter in this conversation, as well as individual health history and risks, so have an open conversation about this with your clinician. 

The above is for systemic HRT; the approach to vaginal estrogen is different and it’s considered safe to use as long as you need it. This medication can be an important part of maintaining vaginal health for the long-haul, and stopping it will bring back symptoms like vaginal dryness. 

Keep in mind that it may be up to you to initiate the HRT conversation with your provider. Robbins recommends asking yourself how you’re feeling right now and what are health concerns for your future. For example, she points out, if you’re at a higher risk for osteoporosis, you’ll want to mention that since HRT can help protect bones. Every woman is different, so make sure you talk to a clinician who is educated in menopause treatment, like those at Weight Watchers Med+ Menopause, to see if HRT is a good fit for you.

Think about the kinds of side effects you noticed during PMS, and those are the most common side effects of HRT. These include:

• Temporary breast soreness

• Fluid retention

• Headaches

• Vaginal spotting or bleeding. This should go away within six months of starting HRT, but always call your doctor about spotting, especially if you are postmenopausal.

If you experience any of these and they’re bothering you, your clinician can adjust the dose or form of HRT you’re taking. “When I start a patient on hormone therapy, I explain that there may be an adjustment period where they have some side effects, but these usually are temporary and even out,” says Kahan. “I usually recommend giving it six weeks and then checking in.”

There are some long-term, more serious side effects, but the medical community’s understanding of the possible risks and benefits of HRT and how to use it have changed. “Many women have been hesitant to go on hormone therapy because there was a lot of bad info on the risks that are now debunked,” says Robbins. Here’s what happened: The 2002 Women’s Health Initiative stated that HRT increased the risk of breast cancer and cardiovascular disease. Years later, it was found that the results of that study should not be applied to all women and all forms of hormone therapy. But research shows that the headlines from 2002 may continue to scare many women off of HRT. That doesn’t mean that there are no concerns — for some people, certain forms of HRT may slightly raise your risk of breast cancer — but it underscores the importance of having a trusted healthcare provider with whom you can discuss your personal risk and potential benefits. 

Some forms of estrogen can also raise your risk for blood clots. If you already have risk factors for blood clots, talk to your clinician about a transdermal (patch) form of HRT.  Research indicates that the patch may have a lower risk of blood clots compared to oral forms. 

Due to risks, there are certain groups of people who may not be the best candidates for HRT, including those with a history of breast or endometrial cancer, stroke, heart attack, blood clots, or liver disease, or are pregnant. This is why it’s so important you have a knowledgeable provider who can look carefully at your health history when deciding if HRT is a good fit or not.

The cost of hormone treatment varies depending on your insurance plan, the type of provider you see, and what kind of medication you’re taking. Here’s what to consider, depending on your situation:

• You are seeing a provider under your insurance: You’re responsible for co-pay or co-insurance, and meeting your deductible. 

• You are going to a self-pay practice provider/out-of-network: You’ll pay out-of-pocket for any medical appointments.

• You’re signed up with a virtual provider: “The good thing about caring for hormonal health is that it can be done via telehealth providers,” says Robbins. These options, including Weight Watchers Med+ Menopause, can improve access and be more convenient if you don’t have menopause-educated clinicians in your area. 

When it comes to medication, there are many FDA-approved estrogen and progesterone medications, and these are typically covered by insurance, says Robbins. Again, rules differ among insurers, so it’s best to call first to understand your benefits and prospective costs.

HRT is an effective and generally safe treatment for some symptoms of menopause, such as hot flashes, night sweats, and vaginal dryness. With many different options, it’s worth having a conversation with your clinician if symptoms are bothersome and affecting your quality of life. Much of the decision to go on HRT rests on evaluating your individual risks and benefits. Having a thorough conversation with a clinician who knows about menopause is the best first step in feeling better and improving your health during this time of change.