What are the signs that you may need hormone replacement therapy?

If you’re in your 40s or 50s, chances are that you know someone who can’t say enough good things about hormone replacement therapy. Maybe they credit it with helping them sleep better, improving their mood, or just making them feel more like themselves again — no small thing when you’re muddling through menopause. It’s enough to make you wonder: Should you be on it too?

There is no hard-and-fast rule that all women should follow because menopause symptoms vary so widely. While some lucky souls glide through this natural transition with minimal discomfort, others find their daily lives significantly impacted by fluctuating hormone levels. So instead of doing a poll of your friends to decide if you should try it, learn to spot the signs you may need hormone replacement therapy that your body is sending you. Because life's too short to spend it constantly searching for the coolest spot on your pillow.

What is hormone replacement therapy (HRT)?

Hormone replacement therapy (HRT), also known as menopause hormone therapy (MHT), is a medical treatment that supplements the declining hormone levels due to menopause to relieve systems and promote long-term health. Think of it as reuniting with old friends who've been on an extended vacation.

During menopause, your ovaries stop producing as much estrogen and progesterone, which can lead to various uncomfortable menopause symptoms. “HRT works by supplementing these hormones to bring them back to more comfortable levels, helping alleviate symptoms that can range from mild annoyances to severe disruptions,” says Dr. Monica Christmas, M.D., the associate medical director at The Menopause Society, and director of the Menopause Program and Center for Women’s Integrated Health at the University of Chicago.

There are two main types of HRT: estrogen-only therapy (recommended for those who've had a hysterectomy) and combination therapy (which includes both estrogen and progesterone, for those who still have their uterus). To decide if HRT is a good fit for you, your provider will ask about your medical history, severity of symptoms, and risk factors for conditions like breast cancer or blood clots.

How does hormone replacement therapy work?

It’s actually pretty simple: Your body is producing lower levels of estrogen and progesterone than it used to, so HRT replaces them. Depending on exactly which symptoms you’re targeting, HRT can be delivered through various methods, including pills, patches, gels, sprays, vaginal rings, or creams.

The treatment is typically started at the lowest effective dose and adjusted based on how your symptoms are responding. Your healthcare provider will monitor your treatment regularly to ensure the benefits continue to outweigh any potential risks, which can vary depending on your personal health history and family medical background.

7 signs you may need hormone replacement therapy

These telltale symptoms of perimenopause and menopause might be your body's way of saying it needs some hormonal reinforcement. Each sign has varying degrees of intensity — what's mildly annoying for one person might be life-disrupting for another — which is why it's important to recognize when your symptoms cross the line from manageable to miserable. Here’s what to look for.

Hot flashes and night sweats

Say hello to perhaps the most recognized menopause symptom. Hot flashes, which are when declining estrogen affects your body’s temperature regulation system, affect more than 70% of people during menopause. This isn’t just feeling a little warm — it’s a sudden, intense wave of heat that can leave you soaked in sweat, even in air-conditioned rooms. The medical community has specific classifications for this vasomotor symptom (named that because they’re due to blood vessel activity). Mild hot flashes don’t interfere with usual activities, while moderate ones do interfere somewhat with your day-to-day life. Severe hot flashes? They're debilitating, forcing you to stop whatever you're doing — like when you're in the middle of a presentation and suddenly feel like you've been teleported to the surface of the sun.

When these episodes hit at night, they become night sweats. The impact extends beyond discomfort — it can create a cascade of issues including sleep deprivation, fatigue, and cognitive difficulties. There's also a correlation with cardiovascular disease 10 years down the road. A study from 2023 found that women under 60 who experience hot flashes have an increased risk of cardiovascular events compared with those who don’t have hot flashes. While it’s not entirely clear why, some experts think it is related to how estrogen changes affect blood vessels and the impact that has on blood pressure and cholesterol levels. There has also been some research suggesting a link between hot flashes and Alzheimer’s risk, with hot flashes indicating a potential marker for the disease.

If getting a good night’s sleep has become elusive — perhaps you're regularly changing night clothes or bedding due to night sweats — or if hot flashes are interrupting your work or social life, this is a clear sign that HRT might benefit you.

Sleep disturbances

Tossing and turning at night? You're not dreaming — menopause can wreak havoc on your sleep patterns. In a 2023 systematic review, between 46.5 percent and 54.7 percent of women reported having sleep disorders during the menopause transition, whether due to night sweats waking them up or general difficulty falling or staying asleep.

Poor sleep quality can create a domino effect, leading to daytime fatigue, difficulty concentrating, and a worse mood. "If you are having debilitating night sweats that wake you up a number of times at night, your disruptive sleep could then be making you have more brain fog the next day or making you more irritable,” says Christmas.

Hormone therapy isn’t right for all sleep issues, but if you've tried sleep hygiene improvements, meditation, and other non-hormonal solutions without success, and your sleep issues are clearly linked to other menopausal symptoms, HRT might be worth considering. “Am I putting somebody on hormone therapy just for sleep? No,” says Christmas. “But if we determine that maybe night sweats are the culprit, then it could help.”

Mood changes and irritability

The emotional roller coaster of menopause isn't just due to your feelings about aging — it's directly related to hormone fluctuations. Research shows that more than three out of 10 women will experience depression at some point in the menopause transition. You might find yourself:

• Experiencing sudden anger or irritability without clear triggers
• Feeling overwhelmed by situations you previously handled with ease
• Moving from happy to tears within minutes
• Dealing with anxiety levels that feel unfamiliar and unmanageable

These mood disturbances often stem from the dramatic ups and downs of hormone levels during perimenopause. These emotional changes can strain relationships and make daily tasks more challenging. While HRT isn't FDA approved specifically for mood changes, it can be worth discussing with your doctor if some of the mood problems are being brought on by sleeplessness from night sweats.

Vaginal dryness or discomfort

As estrogen levels drop, vaginal tissue becomes thinner, drier, and less elastic — a condition called vaginal atrophy. This can lead to discomfort during sex, increased susceptibility to urinary tract infections, and general vaginal irritation. Nearly 35% of participants in a study of 2435 women aged 57 to 69 years experienced vaginal dryness. These symptoms aren't just minor inconveniences — they can profoundly affect intimate relationships and overall quality of life.

While systemic HRT may be of some help, you can also go with a more localized treatment. "Low-dose vaginal estrogen therapy can be extremely helpful for minimizing those symptoms," says Christmas. You can administer vaginal estrogen with a cream, tablet, or ring.

Low sex drive

A decline in libido is a common but often under-discussed symptom of menopause, with sexual functioning declining most in late perimenopause and the first year of postmenopause. This may be due to both physical and psychological factors.

The physical component includes:

• Decreased blood flow to genital tissues
• Vaginal dryness making intercourse uncomfortable
• Lower testosterone levels affecting arousal
• Fatigue from other menopausal symptoms

The psychological component involves:

• Body image concerns
• Relationship stress
• Performance anxiety
• Depression or anxiety related to this life transition

When to worry? It depends. If the decrease has begun to affect your relationships or sense of well-being, that may be a sign that HRT could help. Local estrogen therapy, applied to the vaginal area to help with the dryness and irritation, may take care of some of the physical factors. Or you can talk to your provider about HRT with testosterone, which may help with low sexual desire in both perimenopausal and postmenopausal women.

Urinary problems

Estrogen plays a crucial role in maintaining the health of urinary tract tissues. As estrogen levels drop significantly during menopause, the urethral and vaginal tissues may become thinner, and the following symptoms can occur:

• Increased frequency or urgency to pee
• Stress incontinence (leaking when coughing, sneezing, or exercising)
• More frequent urinary tract infections
• Nighttime bathroom trips disrupting sleep

A 2025 review indicated that approximately 30% of postmenopausal women may experience urinary incontinence (unintentional urine leakage). These issues can significantly impact quality of life, leading some women to limit social activities or change their exercise habits.

While HRT is not a first-line treatment for urinary problems, if your doctor determines your bladder symptoms are primarily related to urogenital atrophy (a.k.a. issues with your vulva, vagina, and bladder) local estrogen treatments — such as vaginal creams or rings — can offer relief.

Hair loss

While not typically mentioned as frequently as hot flashes or mood swings, many people experience hair thinning or loss during menopause. This can be related to changing hormone levels, particularly the decrease in estrogen, which affects hair growth cycles.

If you're noticing your hair becoming thinner, brittle, or falling out more than usual, alongside other menopausal symptoms, this could be another sign pointing toward hormone imbalance. Even then, though, HRT may not be the first recommended treatment. There’s some evidence that hormonal therapy (or oral contraceptive pills) may be able to help with hair loss, but more research is needed before it becomes a first-line treatment.

The bottom line

Menopause symptoms can significantly impact quality of life for many women. Hormone replacement therapy — taking estrogen and progesterone to raise declining hormone levels due to menopause — is one way you can find some relief. HRT can help with hot flashes, night sweats, vaginal dryness, and more. The key is recognizing when symptoms move beyond manageable inconveniences to issues that affect your daily functioning, relationships, and overall well-being. If you're experiencing multiple symptoms that interfere with your quality of life, it's time to talk with your healthcare provider about whether hormone replacement therapy might be right for you.