Menopausal Hormone Therapy 101

Menopause marks a profound and natural transition in a woman’s life. Though it is a normal biological process, the shifting balance of hormones can bring a wide range of physical and emotional changes. The average age of menopause is 51.4 years old, although symptoms often begin earlier, in perimenopause. Vasomotor symptoms such as hot flashes and night sweats are among the most common and often the primary focus of menopausal hormone therapy. However, many women also experience mood fluctuations–including anxiety and depression–along with cognitive symptoms such as brain fog and sleep disturbances. ^{1 2}

Physical changes are equally significant, with common concerns including weight gain, shifts in body composition and shape, joint and muscle aches, genitourinary symptoms including vaginal dryness, painful intercourse and urinary tract infections, decreased libido, and alterations in skin and hair health. Together, these symptoms can meaningfully affect quality of life and overall healthspan, making compassionate, evidence-based and personalized support essential during this stage of life^{. 3 4}

This article aims to provide a clear and approachable overview of menopausal therapy options, including hormonal and non-hormonal treatment. This resource is designed to give readers a foundation for understanding what treatments exist, how they work, and what factors influence their use. The information in this article is not meant to replace medical advice, but rather to empower you with knowledge so you can discuss your care with your qualified healthcare provider.

For those who are interested in going deeper, a more in-depth discussion will follow in our upcoming article. 

History and Evolution of Menopausal Hormone Therapy (MHT):

Menopausal hormone therapy (MHT) has been used for decades to manage symptoms of menopause and osteoporosis prevention, and was also used to reduce the risk of cardiovascular disease. Beginning in the 1940s, synthetic estrogen pills were used (in the form of conjugated equine estrogens (CEE)). ⁵  By the 1970s, risks of estrogen therapy to the uterus were recognized, including endometrial cancer and endometrial hyperplasia. As a result, synthetic progesterone was added to mitigate this risk. By the 1990s, 40% of menopausal women were on menopausal hormone therapy. 

In 2002, after the Women’s Health Initiative (WHI) study reported risks associated with estrogen and progestin therapy, including increased risk of blood clots, stroke, and breast cancer, the practice of prescribing hormone therapy fundamentally shifted. ⁶  Only 5% of menopausal women are taking menopausal hormone therapy today. Further research, as well as analysis of the original dataset and subsets have provided more nuanced insights, which is continuing to shift prescribing practices and our understanding of the impact of menopausal hormone therapy. ⁷ Moreover, newer formulations of hormones are being used today, and there is a question of how applicable this study is to the predominant choice of treatment today (more on this below). 

We recognize that factors such as age, time since menopause, personal health history, and the specific type of hormone therapy (type of hormones prescribed, mode of delivery and dose) all play pivotal roles in shaping an individual’s risk–benefit profile. For most healthy women under 60, and within 10 years since entering menopause, the benefits of hormone therapy often outweigh the potential risks. ⁸ Some of the criticisms of WHI are widely recognized today. Inclusion of women between the ages of 50 to 79 years old significantly impacted the risk factor profile and the measured effects of hormone therapy. In WHI, oral estrogen was used, which we now know increases the risk of blood clots and stroke. Similarly, synthetic progesterone was used, increasing the risk of breast cancer. Our current first choice for menopausal hormone therapy today typically includes transdermal estradiol (in the form of estrogen patch or cream) and oral micronized progesterone (progesterone that is identical to our body’s progesterone, rather than synthetic), which have a more favorable risk profile than the former hormonal therapies. Patient selection and hormone and delivery selection play significant roles in mitigating the risk and selecting women with greatest benefit from treatment. 

Today, decisions around treatment are highly personalized, guided by each woman’s medical history, risk factors, and goals. In partnership with knowledgeable physicians and menopause-trained providers, the approach has evolved toward finding the right therapy for the right person at the right time. ⁹

Current Guidelines for Menopausal Hormone Therapy

FDA Indications ¹⁰

Vasomotor symptoms (hot flashes and night sweats)

Genitourinary symptoms of menopause (often manifested by vaginal dryness and discomfort, painful intercourse, UTIs)

Prevention (not treatment) of osteoporosis

Treatment of premature hypoestrogenism (premature ovarian insufficiency, hypogonadism, bilateral oophorectomy – removal of ovaries prior to natural menopause)

Start within 10 years of menopause and before the age of 60 years old

Types of Menopausal Hormone Therapy 

Menopausal hormone therapy (MHT) is not a one-size-fits-all treatment, and it’s not appropriate for everyone. However, for many women, it can be an important tool for managing specific menopausal symptoms and supporting long-term health.

The most common reason for prescribing MHT is to relieve vasomotor symptoms (VMS)—hot flashes and night sweats, that can disrupt sleep, reduce energy levels, and reduce the overall quality of life. Beyond symptom relief, hormone therapy can also help reduce bone loss and reduce the risk of osteoporosis, though it is not used as a treatment for this condition.^{11 12}

In certain circumstances, MHT may be prescribed to address premature hypoestrogenism, a condition in which the body produces insufficient estrogen at a younger age. This can result from natural causes such as primary ovarian insufficiency (POI) or from medical interventions such as surgical removal of the ovaries (bilateral oophorectomy) or other forms of hypogonadism. In these cases, the goal of hormone therapy is to help restore physiological hormone levels to support bone, cardiovascular, and cognitive health. ^{13  14   15}

MHT can also be highly effective for genitourinary syndrome of menopause (GSM)—a group of symptoms that may include vaginal dryness, irritation, painful intercourse, and urinary changes. In these situations, local forms of estrogen therapy can offer targeted relief with minimal systemic absorption.^{16  17}

The goal of hormone therapy is to relieve symptoms–while using the lowest effective dose for the shortest duration needed to achieve therapeutic benefit. That being said, for women who started MHT in the appropriate window of time, as noted above, and who are symptomatic off of MHT, it may be appropriate to continue MHT with ongoing appropriate screening and risk-benefit discussions. The approach is highly individualized, balancing efficacy and safety to optimize both quality of life and long-term health. ¹⁸

There are several categories and delivery methods of hormone therapy to consider. 

Estrogen (oral, transdermal, vaginal)

Estrogen is the central hormone for treating vasomotor symptoms and it is also effective for genitourinary syndrome of menopause (GSM). Estrogen is available in oral tablets, transdermal patches/gels/sprays, and vaginal products (creams, tablets, rings). Conjugated equine estrogens (CEE), micronized 17β-estradiol, esterified estrogens, and newer estrogens such as estetrol are among the formulations in clinical use. Micronized 17β-estradiol is the principal bioidentical, FDA-approved estradiol formulation. Low-dose local (vaginal) estrogen is highly effective for vaginal dryness and has minimal systemic absorption when used only for local symptoms (although systemic symptoms, even from local formulations, can occur).¹⁹ Systemic estrogen (oral or transdermal) is used when vasomotor symptoms or bone-preservation are also goals. Initiation and choice of route are individualized based on symptom pattern, comorbidities, and timing relative to menopause.²⁰

Different forms of estrogen have different pros and cons.

• Pills (oral estrogen): When estrogen is taken by mouth, it first goes through the liver. This can affect cholesterol, liver proteins, and blood clotting factors. Oral estrogen can increase the risk of blood clots and stroke.
  
• Patches, gels, or sprays (transdermal estrogen): These deliver estrogen directly through the skin, so they don’t pass through the liver first. This usually means steadier hormone levels and fewer effects on clotting or certain proteins such as sex hormone binding globulin and C-reactive protein, marker of inflammation.
  
• Vaginal creams, tablets, or rings: These work locally and are especially helpful for genitourinary symptoms of menopause (GSM) such as vaginal dryness, discomfort, or urinary tract issues. They provide very low overall hormone exposure. ²¹

Those individuals who still have a uterus need progesterone or progestin when they are treated with systemic estrogen, in order to protect the lining of the uterus from developing cancer. Ongoing check-ins with your healthcare provider help track symptom relief, side effects, safety, and provide the opportunity to adjust the dose or mode of delivery if needed. ^{22  23}

Vaginal DHEA 

Dehydroepiandrosterone (DHEA) is a hormone made by the adrenal glands and is a precursor to estrogen and testosterone. During menopause, DHEA levels decline, which, along with low estradiol, can contribute to vaginal dryness, irritation, and discomfort with intimacy.

When applied as a vaginal insert or cream, DHEA works locally, supporting vaginal tissue health, elasticity, and natural lubrication, without significantly affecting hormone levels in the rest of the body. It is most often used to treat genitourinary syndrome of menopause (GSM). ²⁴

Vaginal DHEA is an option for women  with vaginal dryness and/or painful intercourse. (Note that moisturizers or lubricants are non-hormonal treatment options). At approved doses (such as prasterone 6.5 mg daily), vaginal DHEA is well tolerated and has minimal systemic absorption. Side effects are usually mild, such as local irritation or discharge. Periodic check-ins with your healthcare provider are recommended to monitor progress and adjust treatment if needed. ²⁵

Selective Estrogen Receptor Modulators (SERMs)

SERMs  are compounds that act like estrogen in some parts of the body and estrogen inhibitors in others. This “selective” action allows SERMs to provide certain estrogen benefits, such as bone protection, without stimulating tissues like the breast or uterus.

SERMs can be used alone or in combination with estrogen, depending on the treatment goal. They are not the same as traditional hormone therapy but are used for prevention and treatment of osteoporosis, reduction of breast cancer risk, and treatment of genitourinary symptoms.

Common SERMs and Their Uses:

• Bazedoxifene (BZA) – Often combined with conjugated estrogens (as Duavee®) to treat hot flashes and protect from bone loss in postmenopausal women with a uterus. The BZA component replaces the need for progesterone by protecting the uterine lining from estrogen’s effects.
  
• Ospemifene – Used to treat painful intercourse and vaginal dryness associated with genitourinary syndrome of menopause (GSM). It works on vaginal tissue to restore thickness and elasticity without the use of vaginal estrogen.
  
• Raloxifene – Helps prevent and treat osteoporosis in postmenopausal women and may lower the risk of invasive breast cancer. It does not relieve hot flashes and can sometimes worsen them.
  
• Tamoxifen – Commonly used in breast cancer prevention and treatment. It blocks estrogen in breast tissue but can act like estrogen in the uterus and bones.
  
• Toremifene – Similar to tamoxifen, primarily used in treating estrogen receptor–positive breast cancer in postmenopausal women.

While SERMs offer important benefits, they can increase the risk of blood clots, hot flashes, leg cramps and swelling. Bazedoxifene and ospemifene tend to have fewer uterine side effects than older SERMs like tamoxifen. Regular follow-up with your provider is important to assess safety and effectiveness, particularly for those with a personal or family history of clotting disorders or cancer. ^{26, 27}

Progesterone

Progesterone is a naturally occurring steroid hormone produced by the ovaries. Among its many functions, it plays important roles in reproduction, pregnancy and it balances the effects of estrogen on the uterus. For women in menopause who have their uterus, progesterone is prescribed along with estrogen to reduce the risk of endometrial (uterine) cancer.

The preferred form is micronized progesterone, which is chemically identical to the body’s own hormone. It is taken by mouth, usually at bedtime, since it can have a calming, sleep-promoting effect. Micronized progesterone is the only FDA-approved bioidentical progesterone available. (It should be avoided by individuals with peanut allergies as some preparations use peanut oil as a vehicle.) ²⁸

Vaginal progesterone can be used off-label in menopause when the oral form is not tolerated, to protect the uterine lining in women using estrogen. 

Synthetic forms, called progestins, act similarly to progesterone but differ in structure and effects. Some, such as those in hormonal IUDs, also protect the uterine lining and can be suitable for women seeking both contraception (e.g., those in perimenopause) and endometrial protection. ²⁹

Progesterone is generally well tolerated, but may cause fatigue, or even grogginess or mood changes. Regular follow-up is crucial to assess efficacy but also the effect on the uterine lining in some cases. 

Bioidentical Hormones 

Bioidentical hormones are hormones that are chemically identical to those naturally produced by the body, such as estradiol, estriol, progesterone, testosterone, and DHEA. These hormones can be made in standardized, FDA-approved formulations or as custom-compounded preparations made in specialized pharmacies.

While the term bioidentical simply refers to a hormone’s molecular structure, it has become a popular marketing term often used to imply that compounded products are more “natural” or “safer” than conventional hormone therapies. However, there is no scientific evidence supporting that compounded bioidentical hormones are safer, more effective, or better tolerated than FDA-approved bioidentical hormones.

Major medical organizations– including The Menopause Society (formerly NAMS) and the American College of Obstetricians and Gynecologists (ACOG) – advise against the routine use of compounded bioidentical hormones. Compounded products are not regulated for purity, potency, or consistency, and the quality and dosing may be pharmacy-dependent.

By contrast, FDA-approved bioidentical hormones are closely monitored for quality, purity, and safety, and their doses and delivery methods have been studied in clinical trials. These forms are considered the gold standard when bioidentical hormone therapy is indicated.

Bioidentical hormones can play an important role in hormone therapy when prescribed in standardized, FDA-approved forms and used under medical supervision. Compounded preparations may be appropriate in certain cases such as allergies or sensitivities to certain ingredients, or in-between doses, that are unavailable in FDA-approved products. As with anything, it is important to make informed decisions and have consistent medical oversight whether you are taking an FDA-approved, or compounded formulation. ^{30 31}

Testosterone 

Although often thought of as a “male hormone,” testosterone also plays an important role in women’s health– supporting energy, mood, and sexual desire. After menopause, testosterone levels naturally decline, which can contribute to low sexual desire, reduced arousal, and decreased satisfaction.

Research shows that when used in very low doses, about one-tenth of those used for men, testosterone can modestly improve sexual function and overall well-being in postmenopausal women with hypoactive sexual desire disorder (HSDD). Benefits may include increased sexual interest, improved arousal and responsiveness, and a greater sense of sexual satisfaction. Meta-analyses indicate that physiologic (low-dose) testosterone therapy is generally safe and well tolerated, with no severe adverse effects reported in short- to medium-term studies. However, higher doses can cause unwanted effects such as acne, hair growth, voice changes, or mood changes. The long-term safety of testosterone therapy in women has not yet been established.  ³²

Because there are no FDA-approved testosterone formulations for postmenopausal women in the US, treatment typically involves the careful use of compounded or off-label use of FDA-approved products for men at low-doses, which may not be covered by insurance. Serum testosterone levels are not used to diagnose HSDD, but they should be checked at baseline and monitored to ensure safe, physiologic dosing.

When prescribed thoughtfully and monitored closely, low-dose testosterone therapy may help restore sexual desire and improve quality of life for select postmenopausal women. Ongoing follow-up with a clinician experienced in hormone therapy is essential to maintain safety and balance, and other causes of low libido should be considered and discussed. ³³

Non-Hormonal Therapies

Hormone therapy is not the right choice for every woman. For those with a history of breast cancer, blood clots, stroke, cardiovascular disease, certain autoimmune disorders, or other medical conditions, the risk vs benefit of menopausal therapy should be carefully considered. For those with a contraindication to MHT, or preference for other modalities, non-hormonal approaches can be effective alternatives for managing menopausal symptoms.

Several prescription medications have been shown in clinical studies to reduce vasomotor symptoms (VMS) such as hot flashes and night sweats. These include specific selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) (such as paroxetine or venlafaxine), as well as gabapentin and clonidine. These therapies may also improve sleep quality and overall comfort during menopause. Fezolinetant (Veozah), a selective neurokinin 3 receptor antagonist, is another non-hormonal treatment approved for treating vasomotor symptoms of menopause that is generally well tolerated. 

For genitourinary symptoms such as vaginal dryness, irritation, or pain with intercourse, vaginal moisturizers and lubricants, or vaginal estrogen therapy, when used consistently can provide effective relief and improve comfort. 

Lifestyle and behavioral approaches are equally essential in supporting overall well-being and symptom reduction. ³⁴

  Evidence supports:

• A balanced, anti-inflammatory diet rich in fruits, vegetables, whole grains, lean protein, and omega-3 fats.
• Weight loss has been shown to improve VMS in perimenopause and early postmenopause, however evidence is limited. 
• Regular physical activity including both aerobic exercise and strength training, which supports mood, cardiovascular health, and  bone strength. ^{35, 36, 37}
• Blood sugar balance, as glucose fluctuations can worsen hot flashes, mood swings, and fatigue. Eating protein- and fiber-rich meals, avoiding long gaps between meals, and minimizing refined carbohydrates and added sugars can help stabilize energy and reduce vasomotor symptoms. ^{38 39}
• Stress-management practices—like mindfulness, yoga, and paced breathing—can help build emotional resilience and reduce the intensity of symptoms. ⁴⁰
  Cognitive Behavioral Therapy (CBT), which has been shown in randomized controlled trials to reduce hot flash bother and improve sleep quality.⁴¹
• Limiting tobacco and caffeine use can reduce the frequency and severity of vasomotor symptoms (VMS) in some menopausal women, as both are well-established triggers. While alcohol may worsen symptoms in some women, alcohol consumption in moderation is reasonable if it is not a personal trigger.⁴² Note that alcohol consumption increases the risk of breast cancer. 
• Acupuncture provides only modest relief of vasomotor symptoms in menopause, including reductions in hot flashes. Its effectiveness is significantly less than that of menopausal hormone therapy, which remains the most effective treatment for VMS. Meta-analyses and systematic reviews show acupuncture is less effective than MHT for reducing hot flash frequency and improving quality of life. The benefit of acupuncture or placebo is minimal, suggesting much of its effect may be nonspecific or placebo-related. Acupuncture may be most appropriate for women who cannot or prefer not to use hormone therapy, such as those with contraindications to estrogen or personal preference for non-pharmacologic options. ⁴³

Together, these non-hormonal and lifestyle-based strategies form a comprehensive, evidence-based framework for women seeking to manage menopausal symptoms while supporting long-term health and quality of life. 

Risks, Benefits, and Monitoring

The decision to begin MHT involves weighing potential risks against benefits and making an informed decision with the guidance from a trusted healthcare provider who is knowledgeable in treating menopause symptoms. Factors such as family history, cardiovascular health, bone density, and hormone-sensitive cancer risk (such as breast or uterine cancer) all influence treatment recommendations. Transdermal estradiol therapies are considered safer for women at risk of blood clots compared to oral estrogen. Regular follow-up with a healthcare provider is essential to monitor outcomes, reassess risks, and adjust treatment as needed.

Hormone therapy is not meant to be a lifelong prescription for everyone. The duration of therapy depends on patient age, health risks, symptom severity, quality of life, and patient preference. Some women may use hormone therapy for just a few years, while others may continue longer under careful medical supervision and ongoing screening (such as cardiovascular and breast cancer screening).

In our medical practice, prior to initiating menopausal hormone therapy, we engage in a comprehensive discussion with our patients regarding not only their symptoms, but their overall quality of life, goals and values, and risks and benefits of available treatment modalities. We use risk assessment tools and tests to estimate the risk of cardiovascular disease and breast cancer risk. After a detailed discussion about personalized risks vs benefits, we encourage shared, informed decision making, to ensure every patient feels empowered to make a decision in alignment with their values and goals, as well as the objective data we have available

Moving Forward

Menopause is a highly individualized experience, and there is no single approach that works for everyone. For some women, menopausal hormone therapy provides profound relief and restores quality of life. For others, non-hormonal or lifestyle strategies are more appropriate. The key is working closely with a healthcare provider to consider personal health history, current symptoms, and long-term goals.

By understanding both the history and current approaches to hormone therapy, women can make empowered choices about managing menopause. With the right combination of medical, non-pharmacological, and lifestyle tools, it is possible to navigate this life stage with confidence and improved well-being.

In future articles, we’ll be exploring complementary strategies to support women through menopause, including evidence-informed guidance on supplemental support, nutrition, and lifestyle approaches. We’ll also take a deeper look into the risks versus benefits of hormone therapy, helping to clarify misconceptions and highlight how individualized care can optimize both safety and effectiveness. These upcoming discussions aim to provide a well-rounded perspective to empower women with informed, practical tools for their health journey.

We encourage any woman experiencing menopausal symptoms to speak to their doctor about symptom management and available treatment options. 

Our team is here to guide and support you every step of the way. We’re committed to providing the personalized care you deserve, helping you move forward with confidence and strength. You have the power to take charge of your health during perimenopause – and we’re here to help you do just that.  To learn more about our medical, nutrition and health coaching services, contact us at 646.627.8000, fill out a New Patient Inquiry Form, or email Bridget@drbojana.com. 

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