Is Hormone Replacement Therapy Right For You?
Many women are conflicted when presented with the decision whether to start hormone replacement therapy (HRT). While menopausal symptoms, such as hot flashes, can be disruptive and negatively affect your quality of life, there are countless articles outlining the risks associated with hormone replacement therapy.
Making a decision can be daunting, and out-right confusing.
The truth is, there are multiple factors to take into consideration when deciding whether hormone therapy is appropriate. Deciding whether you should take hormones should be based on a conversation between you and your health care provider, weighing YOUR individual risks and benefits. Hormones are not a “one-size fits all” prescription. In fact, it needs to be individualized, taking into account your symptoms, your preferences and your risk factors.
Here is what needs to be taken into consideration before initiating hormone replacement therapy:
1. Your Symptoms
While the hallmark symptom of menopause is the hot flash, there are multiple symptoms associated with menopause. These include sleep disturbances, depression, joint aches, vaginal dryness and increased anxiety.
The decision to consider hormone replacement therapy is dependent on which symptoms you are experiencing, and the severity.
Hormone replacement therapy is indicated (and FDA-approved) for hot flashes, vaginal atrophy/dryness and to reduce bone loss.1 If you’re experiencing low mood but no hot flashes, HRT is likely not the appropriate treatment for you. If you’re experiencing just vaginal dryness, you may benefit from low dose estrogen therapy vs. a higher dose.
2. Your Age And When You Started Menopause
When you start hormone replacement therapy matters.
Our understanding of the risks associated with the timing of starting HRT is derived from the Women’s Health Initiative (WHI). The WHI was started in the early 1990’s, and is to date, the largest, long-term, randomized control trial evaluating hormone therapy in women aged 50 to 79 years.
Based on the data derived from the WHI, we consider the initiation of hormone replacement therapy to be the safest in women less than 60 years of age, who are within 10 years of starting menopause.1
The WHI found that for women who initiated hormone therapy more than 10 years from menopause onset, or who were older than 60 years, there was an increased risk of stroke or venous thromboembolism (blood clot). 1
Therefore, it’s important to initiate the conversation about HRT with your healthcare provider at the onset of menopausal symptoms. Don’t try to endure the hot flashes for 10 years!
3. Absolute Contraindications
– When HRT Is Not For You
There are a number of absolute contraindications to hormone replacement therapy. These include2:
- A history of breast cancer
- Coronary heart disease (CHD)
- A previous blood clot (venous thromboembolism (VTE)) or stroke
- Active liver disease
- Unexplained vaginal bleeding
- High-risk endometrial cancer
- Transient ischemic attack (TIA)
These should all be reviewed with your health care provider.
4. Calculating Your Risks
The two major risks we take into consideration before initiating hormone replacement therapy are cardiovascular disease (CVD) and breast cancer risks.3
To calculate CVD risks, I use a population-based risk calculator that takes into account your age, race, cholesterol levels, blood pressure, and whether you have diabetes or are a smoker. If you were considered to be at moderate risk, this would influence your health care providers chose of hormone therapy (i.e. topical vs. oral), and if you were at high risk, non-hormonal options would be advised.
Similarly, with breast cancer risk, I use a national breast cancer calculator to predict a women’s 5 year-risk; women with a moderate to high risk of breast cancer would be advised to try non-hormonal treatment options.
It’s important to have an in-depth conversation with your heath care provider about YOUR risks, so that you can make an informed decision.
5. Do You Have A Uterus?
Women who have a uterus, and who are on estrogen therapy must also be on oral progesterone. This is to prevent thickening of the lining of the uterus (endometrial hyperplasia). Estrogen causes the lining of the endometrium to thicken, and in the absence of progesterone, has the potential to progress into endometrial cancer.
Women who have had a hysterectomy can be on estrogen-only therapy.
6. Review The Benefits
Hormone replacement therapy can be highly effective in alleviating hot flashes and night sweats. As such, it can have a beneficial impact on sleep quality, as well as mood.3 This can make a huge difference in a women’s life and her ability to feel “normal” and resilient.
Estrogen therapy also helps to prevent osteoporosis, decrease joint pain, and reduce vaginal dryness, irritation, and recurrent UTI’s.
So What’s Next?
The decision to go on hormone replacement therapy must be an informed one. You need to know your risks, your options and the benefits.
In my practice, I spend an hour reviewing a women’s history, her symptoms and individual risk factors, mapping out the hormonal and non-hormonal options. We discuss prevention, longevity, in addition to symptom management. I want to ensure that each woman is informed and feels empowered with her decision.
To learn more about hormone replacement therapy, I highly recommend the following resources:
To read more about being proactive in menopause, and devising a plan tailored to you, download your free copy of my Proactive Menopause Plan.
If you’re interested in addressing your menopausal symptoms and discussing hormone replacement therapy, you can book a hormone assessment appointment.
- The, N. A. M. S. (2017). The 2017 hormone therapy position statement of The North American Menopause Society. Menopause (New York, NY), 24(7), 728-753.
- Stuenkel, C. A., Davis, S. R., Gompel, A., Lumsden, M. A., Murad, M. H., Pinkerton, J. V., & Santen, R. J. (2015). Treatment of symptoms of the menopause: an endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 100(11), 3975-4011.
- Martin, K., & Barbieri, R.(2020). Treatment of menopausal symptoms with hormone therapy. In J. A. Melin (Ed.), UpToDate. Retrieved June 9, 2020, from https://www.uptodate.com/contents/treatment-of-menopausal-symptoms-with-hormone-therapy