This article is part of WHA’s new perimenopause and menopause series. You can learn more about knowing and coping with the first signs of perimenopause, the 34 most common symptoms, menopause weight management and more.

Hormone replacement therapy (HRT) is an available treatment option for many people dealing with perimenopause symptoms when the effects of low estrogen can be disruptive, especially in the early years of perimenopause.

Unfortunately, HRT has gotten a bad rap over the years. This has mostly been debunked thanks to newer studies on its safety and efficacy—more on that below. Today, HRT is an effective treatment option for several of the 30-plus symptoms associated with perimenopause and a reminder that no person has to grin and bear it through this time.

What is hormone replacement therapy?

Hormone replacement therapy is a treatment that replenishes hormones to alleviate symptoms of perimenopause and menopause. It can also be used for other hormonal imbalances. There are two primary types of HRT for menopause: estrogen therapy and combination therapy (estrogen and progesterone). If you still have a uterus, you will need progesterone or other medication to protect against uterine cancer.

HRT initially became available to large numbers of people in the 1960s and was used to relieve hot flashes. A study in 2002 by the Women’s Health Initiative raised concerns about the long-term safety of hormone treatments in older people, specifically around age 63. HRT is now used primarily during the years of perimenopause (broadly speaking, in the 40s) when symptoms of estrogen loss tend to be the most intense and risk factors are much lower than in later years.

There are different types of hormonal menopause therapies, including administration routes and formulations, as well as different hormonal makeups.

Some of hormone replacement therapy options for peri/menopause include:

  • Estrogen or combination pills taken orally
  • Patches, sprays or gel that deliver hormones through the skin
  • A ring inserted into the vagina that releases hormones locally or throughout the body
  • Creams or tablets inserted vaginally

These methods all fall into two treatment camps: systemic or local. Systemic (pills, patch, spray, gel) means the treatment gets into the bloodstream and goes where it’s needed. Local (vaginal cream, vaginal tablet, ring) means the treatment is applied to the specific area it’s intended to help.

Treatment is administered either continuously (every day) or cyclically (every couple weeks). Your provider will likely start you on the lowest possible dose to improve your symptoms and then go from there.

Is hormone replacement therapy safe?

Given the misinformation and sometimes lack of information about hormone replacement therapy, there’s understandably some wariness around its use. However, hormone therapy guidelines have evolved over the past 20 years and continue to as more research is completed. So, what the generation before us was told and may have told us is not necessarily what holds true today.

Fear around HRT is also understandably perpetuated because many people think the effects of HRT will be the same as effects felt from previous experience with contraception. While someone may worry they’ll experience those same side effects when beginning HRT, in reality, menopausal hormone options are quite different from the types found in hormonal birth control, and the effects can be different, too.

Does hormone replacement therapy work for everyone?

Generally speaking, someone who is symptomatic and in perimenopause, or within the first 10 years of menopause (one year without a period), is a good candidate for hormone replacement therapy. Of course, a thorough review of your medical history is really important since what’s best for one person isn’t necessarily what’s best for you.

Treatment is entirely individual based on symptom control. Some might respond to treatment in days, while others may need weeks. Some are on HRT for a few years, others for a decade or more.

HRT is frequently both therapeutic and diagnostic. Meaning, it can help alleviate symptoms and find related symptoms that benefit from treatment. It’s the most efficacious treatment for symptoms related to perimenopause out of all the existing treatment options we have for perimenopause. And many will have relief for the majority of their symptoms.

Benefits and risks of hormone replacement therapy for menopause

The benefits and risks of hormone replacement therapy are highly individual, largely based on your medical history, existing symptoms, the type of hormone therapy you use and for how long. But here are some potential benefits and side effects of its use.

Benefits of hormone replacement therapy

We know the primary benefits of HRT are relief of perimenopausal symptoms and prevention of osteoporosis. We know less about HRT’s long-term benefits, including its effect on cognitive functioning and cardiovascular disease prevention.

Whether you use a systemic or local treatment, the symptoms HRT most often directly improves are:

  • Vaginal dryness
  • Night sweats
  • Hot flashes
  • Changes in mood
  • Insomnia
  • Breast tenderness
  • Headaches
  • Joint pain
  • Dizziness
  • Body odor
  • Hair loss

There are also tangential benefits. For example, decreased libido may not be directly solved by HRT, but hormone treatment could improve fatigue and mood changes, in turn improving libido. And to answer a common question: using HRT for menopausal weight gain is not effective, but it doesn’t cause you to gain weight either.

Side effects of hormone replacement therapy

There is a lot of confusion about HRT and breast cancer risk. Studies have actually shown a decreased risk of breast cancer in those using estrogen alone (for those with hysterectomies). For those using combined estrogen and progestogen, it’s around a 3 in 1,000 increased risk when used for more than five years, but this is specifically with older hormonal formulations. With newer formulations, based on observational studies, that risk is likely lower. Your provider can walk you through risks specific to your own medical history.

In terms of broader side effects, they differ from person to person and usually improve within the first couple weeks of use (for example, breast tenderness and/or headaches). It’s important to speak with your provider about any side effects you experience so you can determine the next steps together.

How long can you stay on hormone replacement therapy?

There is no set timeframe for people to use hormone replacement therapy, or age to discontinue. Treatment varies based on your symptoms and their severity, and your preference for how long you want to be on HRT. You may also stop systemic treatment but continue on local treatment for longer, depending on symptoms.

You and your provider should continue to revisit the treatment plan every year, or sooner if symptoms change.

How can I treat menopause without HRT?

If hormone replacement therapy isn’t right for you, but you’re looking for help with perimenopause symptoms, your provider can talk you through different options. Lifestyle changes, medications and over-the-counter treatments may all be possibilities.

If you have any questions or concerns about HRT risks or are interested in seeing if it could be the right choice for you, have a conversation with your provider–or one who specializes in menopause if yours does not. HRT is nuanced and you should work with someone who can help you understand that. But it’s also effective and safe for most people looking for relief from perimenopause and menopause symptoms.