Patient education: Menopausal hormone therapy (Beyond the Basics)

INTRODUCTION — 

Menopause is defined as the time when monthly periods naturally stop. At this time, the ovaries stop releasing eggs and stop making the hormones estrogen and progesterone. Menopause usually occurs between the ages of 45 and 55; the average age is 51. After menopause, which is defined as one year without a menstrual period, it is no longer possible to get pregnant.

Menopause does not happen suddenly; most people first experience several years of changes in their menstrual periods (varying lengths of cycles followed by skipped periods before they stop completely. This is referred to as the "menopausal transition" or "perimenopause." During this time, declining levels of estrogen start to cause symptoms such as hot flashes, night sweats, mood changes, and sleep problems. In later years, many people also experience vaginal dryness. (See "Patient education: Menopause (Beyond the Basics)".)

Menopause is a normal part of life and does not always need to be treated. However, if you have bothersome symptoms, effective treatments are available, including hormone therapy and non-hormonal options. This article explains how estrogen works and discusses the risks and benefits of menopausal hormone therapy. Non-estrogen treatment options are discussed separately. (See "Patient education: Non-estrogen treatments for menopausal symptoms (Beyond the Basics)".)

WHAT IS MENOPAUSAL HORMONE THERAPY? — 

Menopausal hormone therapy is the term used to describe the two hormones, estrogen and progestin, that are given to relieve bothersome symptoms of menopause. Estrogen is the hormone that relieves the symptoms. People with a uterus must also take progestin (a progesterone-like hormone) to prevent uterine cancer. This is because estrogen alone can cause the lining of the uterus to overgrow (potentially leading to uterine cancer).

People who have had a hysterectomy do not have a uterus and cannot develop uterine cancer. If you no longer have a uterus, you will be treated with estrogen alone.

Types of estrogen — Estrogen is available in many different forms. For hot flashes, it can be taken as a transdermal patch (worn on the skin), an oral pill, or a "ring" or tablet that is inserted into the vagina. There are also gels and sprays that can be put on the skin.

The main type of estrogen that doctors use to treat menopause symptoms is estradiol. Estradiol is the estrogen that is identical to the one the ovary makes throughout reproductive life. The standard dose of oral estradiol is 1 mg daily by mouth. Lower doses such as 0.5 mg seem to have fewer side effects. Estradiol can also be given as a skin patch or a vaginal ring, spray, or gel.

Estrogen patch — Many experts now prefer prescribing the estradiol patch rather than estrogen pills (because it is associated with a lower risk of blood clots than estrogen pills). A combination estrogen and progestin patch is also available. Some patches need to be replaced every few days, while others are only replaced once a week.

Estrogen patches work as well as estrogen pills to increase bone density and treat menopausal symptoms. People with a uterus who use an estrogen patch must also take a progestin to decrease the risk of uterine cancer. (See 'Progesterone' below.)

Estrogen pill — Although estradiol is the preferred type of estrogen, there are other types that are sometimes used. All types of estrogen can help to relieve menopausal symptoms.

Combination pills that include both estrogen and progestin are available. (See 'Progesterone' below.)

Low-dose birth control pill — Very low-dose birth control pills are a good option for people in their 40s who have bothersome hot flashes, irregular bleeding, and who still need a reliable form of birth control. Caution should be used for people over 40 years who also have obesity because of the higher risk of blood clots. People over 40 years who have high blood pressure are at increased risk of stroke if they take birth control pills.

Birth control pills are generally not recommended for people who have completed menopause, because the dose of estrogen is higher than needed to relieve hot flashes. (See "Patient education: Hormonal methods of birth control (Beyond the Basics)" and "Patient education: Menopause (Beyond the Basics)", section on 'Birth control'.)

Vaginal estrogen — Vaginal dryness can also be treated with estrogen; doctors prescribe very low doses that treat the dryness but not hot flashes (because the dose is too low to get into the bloodstream). Vaginal estrogen comes in a cream, vaginal ring, or vaginal estrogen tablets. The low-dose vaginal estrogens do not require the use of a progestin pill. Vaginal estrogen used to treat dryness is discussed in a separate article. (See "Patient education: Vaginal dryness (Beyond the Basics)".)

If you have a history of breast cancer, talk to your health care provider or oncologist about the potential risks and benefits of vaginal estrogen. Some people (those treated with a medication called tamoxifen) may be better candidates for vaginal estrogen than others (those treated with a medication called an "aromatase inhibitor").

Progesterone — Postmenopausal females with a uterus who are treated with estrogen alone have an increased risk of developing uterine cancer and hyperplasia (a precursor to uterine cancer). Taking a second hormone, either progesterone or similar hormones, minimizes this risk. (See "Patient education: Endometrial cancer diagnosis, staging, and surgical treatment (Beyond the Basics)".)

●Progesterone – Experts recommend natural progesterone for most people. It is called micronized progesterone. There are also other types of progesterone-like hormones that are synthetic (called progestins). Medroxyprogesterone acetate, norethindrone, and norgestrel are also available.

Micronized progesterone has no negative effect on lipids and is a good choice for people with high cholesterol levels. In addition, natural progesterone might have other advantages when compared with medroxyprogesterone acetate.

●Intrauterine progestin – An intrauterine device (IUD) is a form of birth control; one type, the levonorgestrel IUD (brand names: Mirena, Liletta, Kyleena, Skyla), releases progestin to prevent pregnancy. In some countries, these types of IUDs (using a lower dose of levonorgestrel) are used in menopausal females taking estrogen to minimize the risk of developing uterine cancer. The IUD is not currently approved in the United States for use after menopause; however, if you already have one when you enter perimenopause, your doctor may suggest that you keep it in until after menopause is complete.

Compounded "bioidentical" products — Many people have turned to compounded "bioidentical" hormone therapy as an alternative to conventional hormones for treating symptoms of menopause. "Bioidentical" means that the hormones used for therapy are identical in molecular structure to the hormones produced by the ovaries. "Compounded" means the preparation is mixed in a special compounding pharmacy in order to create a customized dose of hormones in the form of pills, creams, or vaginal suppositories.

The quality of these custom compounded products is not regulated by the US Food and Drug Administration (FDA), and the dose of hormones can vary from batch to batch. For these reasons, expert groups caution against using them. However, in 2019, an estrogen-progestin pill that is also bioidentical became available; this preparation is not compounded and is approved by the FDA, meaning that it has documented safety and efficacy. This might be a good option for people who prefer not to use more conventional hormone therapies. It has also not been found to cause undesirable side effects such as weight gain or high blood pressure.

RISKS AND BENEFITS OF HORMONE THERAPY — 

The Women's Health Initiative (WHI) was a large study designed to find out if hormone therapy would reduce the risk of heart attacks (coronary heart disease [CHD]) after menopause. The study found that combined estrogen-progestin therapy was safe in younger postmenopausal females ages 50 to 59 years, with no increased risk of heart attacks or death, and very small increases in risk of breast cancer and blood clots. However, in older females, especially those over age 70 years, estrogen-progestin treatment was associated with an increased risk of heart attacks, strokes, and blood clots.

Modern hormone regimens that use hormones identical to those the ovary produces (estradiol and progesterone) are thought to be considerably safer than those used in the WHI.

The results of the estrogen-only study were different. People who took estrogen alone had a small increase in the risk of stroke and blood clots, but there was no increased risk of heart attacks. There was a decreased risk of breast cancer with estrogen alone.

Heart attacks — The risk of having a heart attack related to use of hormone therapy appears to depend on your age. There is no increased risk of heart attacks related to hormone therapy in people who:

●Went through menopause less than 10 years before starting hormones

or

●Were age 50 to 59 years when they took hormone therapy

Other studies since the WHI also report that hormone therapy does not increase heart attack risk in younger people; some suggest it might even lower the risk slightly. In the WHI, people who went through menopause more than 10 years ago or over age 60 years were at increased risk of having a heart attack related to hormone therapy.

Breast cancer — The Menopause Society concludes that typical use of menopausal hormone therapy does not appreciably increase the risk of breast cancer. In the WHI, the absolute excess risk was very low in young people taking combined therapy, and there was a reduction in risk in those on estrogen alone.

Osteoporotic fracture — The risk of breaking a bone at the hip or spine because of osteoporosis is lower in people who take estrogen-progestin or estrogen alone. However, hormone therapy is not recommended to prevent or treat osteoporosis, because there are bone medicines (called bisphosphonates or denosumab) that are very effective and have fewer serious risks. (See "Patient education: Osteoporosis prevention and treatment (Beyond the Basics)".)

Dementia — Among the older females studied in the WHI, there was no improvement in memory or thinking with either estrogen alone or with combined estrogen-progestin but there was an increase in the risk of developing dementia in older females who started hormones at a late age. No increase in dementia risk was seen in the younger menopausal females in the WHI or in other studies.

Some experts think that estrogen treatment might be helpful for preventing dementia if you take it in the earliest years after menopause (although this is not proven); taking it many years after menopause seems to be harmful.

Depression — Many people experience anxiety and/or depression during the transition to the menopause. Some studies show that estrogen treatment helps improve mood and decrease depression. However, some people need to be treated with both estrogen and an antidepressant to feel better. Once a person has completed menopause and their hormones are stable, they usually begin to feel better. (See "Patient education: Depression in adults (Beyond the Basics)".)

Sleep problems — Many people have sleep problems during the menopausal transition. Sometimes this is because they have hot flashes at night that interfere with sleep (night sweats). However, people can have trouble sleeping even if they don't have hot flashes. This can be due to disorders like restless leg syndrome and sleep apnea. Estrogen treatment is very effective for improving sleep in people with night sweats.

WHO SHOULD TAKE HORMONE THERAPY? — 

The most common reason for taking systemic hormone therapy is to treat bothersome menopausal symptoms, such as hot flashes or vaginal dryness. Most experts agree that hormone therapy is safe for healthy people who have menopausal symptoms and are within the first 10 years of the onset of menopause.

When should hormone therapy stop? — Some experts recommend that you taper and stop hormone therapy after approximately five years to avoid any increased risk of breast cancer. However, this can often be a challenge because the average duration of hot flashes is 7 to 10 years, but they can last longer. Some experts take a more liberal approach, and continue hormone therapy beyond age 60 or even 65 years in some people. It's important to talk with your doctor about the risks and benefits in order to make the decision that is right for you.

If you are using a patch, your doctor or nurse can give you a lower-dose patch to help you taper the dose. If you are taking pills, one way to do this is to skip one pill per week at first, then continue to gradually decrease the number of pills per week until you are no longer taking any.

If menopausal symptoms return as you lower your dose of hormones, you can try hormone therapy alternatives. Some people have to go back on hormone therapy for a while. (See "Patient education: Non-estrogen treatments for menopausal symptoms (Beyond the Basics)".)

Low-dose vaginal hormone therapy is used to treat vaginal dryness, vaginal burning, and frequent urinary tract infections caused by menopause. Low-dose vaginal therapy can be taken at any age because it is not associated with medical complications.

Who should avoid hormones? — Hormone therapy is not recommended for people with the following:

●Current or past history of breast cancer

●Coronary heart disease

●Liver disease

●Abnormal bleeding that has not been evaluated

●A previous blood clot, heart attack, or stroke

●High risk for these complications

If you have symptoms that bother you but are not a candidate for hormone therapy, talk to your doctor about your options. (See "Patient education: Non-estrogen treatments for menopausal symptoms (Beyond the Basics)".)

Females with breast cancer — People with breast cancer often experience early menopause due to breast cancer treatments. In these people, estrogen or hormone therapy (by mouth or patch) is not recommended. The hormones could increase the chance of the cancer coming back.

Alternatives to hormone therapy are available and are often effective in relieving bothersome menopausal symptoms. These alternatives are discussed in detail in a separate article. (See "Patient education: Non-estrogen treatments for menopausal symptoms (Beyond the Basics)".)

WHERE TO GET MORE INFORMATION — 

Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Menopause (The Basics)
Patient education: Sex problems in females (The Basics)
Patient education: Vaginal dryness (The Basics)
Patient education: Perimenopause (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Menopause (Beyond the Basics)
Patient education: Non-estrogen treatments for menopausal symptoms (Beyond the Basics)
Patient education: Hormonal methods of birth control (Beyond the Basics)
Patient education: Vaginal dryness (Beyond the Basics)
Patient education: Endometrial cancer diagnosis, staging, and surgical treatment (Beyond the Basics)
Patient education: Gallstones (Beyond the Basics)
Patient education: Osteoporosis prevention and treatment (Beyond the Basics)
Patient education: Screening for colorectal cancer (Beyond the Basics)
Patient education: Depression in adults (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis
Estrogen and cognitive function
Menopausal hot flashes
Menopausal hormone therapy and cardiovascular risk
Menopausal hormone therapy and the risk of breast cancer
Menopausal hormone therapy in the prevention and treatment of osteoporosis
Menopausal hormone therapy: Benefits and risks
Preparations for menopausal hormone therapy
Treatment of menopausal symptoms with hormone therapy
Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment