Hormone Therapy
Hormone Therapy (Estrogen and Progesterone)
WHAT IS ESTROGEN?
Estrogen is a hormone made by the ovaries. It helps prepare the body for pregnancy every month. Women make less estrogen during perimenopause and almost completely stop making it once they are postmenopausal. This decrease in estrogen may explain some of the symptoms women have during the menopause transition.
Taking estrogen to replace some of what is no longer made by the body can offer relief from some symptoms during perimenopause. Women with a uterus need to take a progesterone with the estrogen. This is because estrogen makes the uterine lining grow. Adding progesterone stops this growth and prevents the estrogen from causing uterine cancer.
Estrogen comes in many forms. These include pills, a skin patch, gels and sprays applied to the arms or thighs, and vaginal rings, vaginal tablets, and vaginal creams.
The estrogen in most pills, patches, gels and sprays (estradiol) is manufactured in laboratories with a base of soybeans or yams. Conjugated equine estrogen comes from from the urine of pregnant horses and contains conjugated equine estrogen.
Some women prefer “bioidentical” or “natural hormones.” Bioidentical means they are the same as those made by the body (estradiol and micronized progesterone). There is no difference in how the synthetic and natural hormones work.
WHAT IS PROGESTERONE?
Progesterone is a hormone made by the ovaries. It helps prepare the body for pregnancy every month. Women make less progesterone during perimenopause and stop making it almost completely once they are postmenopausal. This decrease in progesterone may explain some of the symptoms women have during the menopause transition.
Taking progesterone to replace some of what is no longer made by the body can offer relief from some symptoms during perimenopause, like heavy uterine bleeding. Women with a uterus need to take progesterone if they take estrogen. This is because estrogen makes the uterine lining grow. Adding progesterone stops this growth and prevents the estrogen from causing uterine cancer.
Progesterone comes in many forms. These include pills, a skin patch combined with estrogen, injections, IUDs and vaginal gels.
The progesterone in some pills and gels (called progestins) is manufactured in laboratories using soybeans or yams. Other types of progesterone are synthesized and have different names.
Some women prefer “bioidentical” or “natural hormones.” Bioidentical means they are the same as those made by the body (estradiol and micronized progesterone). There is no difference in how the synthetic and natural hormones work.
OUR BOTTOM LINE, DOES IT HELP?
YES.
Estrogen pills, patches, gels, and mists can be effective at treating some symptoms during the menopause transition. Hormone therapy helps relieve some hot flashes and night sweats, but does not eliminate them. It may also help with sleep problems, mood changes, pain with sex, and overall quality of life. However, there is a small risk of heart attack, stroke, and blood clots in the veins of women who use hormone therapy (either combined estrogen and progestin or estrogen alone).
Progesterone pills, patches, injections, IUDs and vaginal gels can be effective at treating heavy or irregular uterine bleeding during the menopause transition. Progesterone therapy helps relieve some hot flashes and night sweats, but does not eliminate them. It may also help with sleep problems.
Women with a history of or who are at risk for blood clots, breast cancer, heart disease, or stroke should NOT take estrogen therapy.
Talk this over with your health care provider. You will need to decide what options are best for you depending on your symptoms and your values about trying different therapies.
Because of the risks, the North American Menopause Society recommends trying non-medical ways to cope with symptoms before trying medicines like hormone therapy. We agree. See if a non-medical solution works well enough for your symptoms before trying estrogen, progesterone, or both.
HOT FLASHES AND NIGHT SWEATS
Estrogen therapy decreases the frequency of hot flashes and night sweats. Your health care provider may prescribe a “standard” or a “low” dose estrogen pill or patch. On average, women who take standard dose estrogen have 3 fewer hot flashes/night sweats a day. About 70% of women will have no noticeable hot flashes/night sweats. When women take low dose estrogen, they have about 1-2 fewer hot flashes/night sweats per day. Your health care provider can tell you if your prescription is a standard or low dose, or you can check this chart (link to chart in the health care provider info below).
Although the higher dose works a little better at reducing hot flashes, it is also riskier. (See risks below.)
Estrogen therapy decreases the severity of hot flashes and night sweats.
Estrogen therapy decreases how much hot flashes and night sweats interfere with daily life.
Progesterone therapy decreases the frequency of hot flashes and night sweats. Your health care provider may prescribe the progesterone at night time to assist with sleep. Although the higher dose works a little better at reducing hot flashes, it is also riskier. (See risks below.)
SLEEP PROBLEMS & INSOMNIA
Estrogen and progesterone can help prevent waking up at night because of hot flashes (also called night sweats) and may help you sleep better. Estrogen and progesterone therapy do not prevent insomnia that is not caused by night sweats.
PAIN WITH SEX
Estrogen pills and the estrogen patch can reduce vaginal dryness and pain during sex and improve overall sexual function. However, products applied directly to the vagina work just as well, and may be better. and are less risky. Research also shows that vaginal lubricants without estrogen can be helpful. Plant or silicone-based lubricants work as well as vaginal estrogen (creams, pills, or ring). Therefore, if your main complaint is vaginal dryness or pain during sex, start with a vaginal lubricant to see if that decreases discomfort or pain.
Progesterone does not help with pain with sex.
VAGINAL PAIN OR DRYNESS (NOT DURING SEX)
Estrogen pills and the estrogen patch can reduce vaginal dryness and pain.
Progesterone will not help with vaginal pain or dryness.
MOOD, ANXIETY & DEPRESSION
Estrogen therapy may help improve the mild anxiety and depression that some women have during the menopause transition. But this use is not approved by the FDA. Some women need to be treated with both estrogen therapy and an antidepressant to have more control over their moods. If your main concern is mood, anxiety, or depression, a better choice may be a combination of psychotherapy (talk therapy) and an antidepressant medication. Two types of antidepressants can also help decrease the frequency of hot flashes and night sweats.
DRY EYES
Estrogen therapy may help with dry eye syndrome.
PALPITATIONS
Estrogen therapy may help with menopause related palpitations
WEIGHT GAIN
While estrogen therapy would not be prescribed for weight loss, using it may help women gain less weight and maintain muscle mass.
ACHES AND PAINS
Estrogen therapy is not effective for aches and pains.
BLADDER CONTROL PROBLEMS
Estrogen therapy does not decrease urinary incontinence.
BRAIN FOG / COGNITIVE ISSUES
Estrogen therapy is not recommended to prevent the onset of dementia or cognitive impairment. In women aged 65 and older, estrogen therapy with or without a progestin increases the risk of dementia and cognitive decline, and can make verbal memory worse over time.
Studies of younger women (early 50s) using estrogen therapy find no effect on memory or other aspects of cognition by the time they reach their late 50s and mid-60s.
WHO SHOULD NOT USE MENOPAUSAL HORMONE THERAPY?
Women with a history of or at risk for blood clots, breast cancer, heart disease, or stroke should NOT take estrogen therapy.
Women with a history of or at risk for blood clots, breast cancer, heart disease, or stroke should NOT take progesterone therapy without consulting their provider.
POTENTIAL RISKS & SIDE EFFECTS
The risks are dangerous but unlikely. There is a small risk of heart attack, stroke, and blood clots in the veins of women who use menopausal hormone therapy (either combined estrogen and progesterone or estrogen alone).
Estrogen treatment can also increase the risk of gallstones.
The combination of estrogen and progesterone (but not estrogen alone) can increase the risk of breast cancer. In addition, the small risk of heart attack, stroke, and blood clots in the veins of women who use estrogen therapy is slightly increased when progesterone is added.
Ways to reduce the risks:
- Consider using the estradiol patch instead of taking pills. The patch has a lower risk of stroke and blood clots than estrogen pills.
- Start with a low estrogen dose to see if it works for you, before trying the standard dose. The risks of low dose hormone therapy are smaller than the risks for standard dose. The current recommendation from the U.S. Food and Drug Administration (FDA) is to increase dosage only if you need it to relieve symptoms.
- Consider using micronized progesterone rather than synthetic progesterones. Breast cancer risk may be lower with micronized progesterone.
- Minimize the number of years you use menopausal hormone therapy, and especially consider stopping it after 5 years. In some women, menopausal symptoms such as hot flashes lessen or stop a few years after menopause. Your health care provider may suggest trying to stop therapy every few years to see if your symptoms are gone.
There is no evidence that synthetic estrogens are riskier than bioidentical hormones. But, for women who prefer these “natural hormones”, FDA-approved bioidentical hormones (estradiol) are available. The Food and Drug Administration ensures the quality of products.
Some women use a compounding pharmacy to make hormones for them. The quality may vary, and doses can vary from pill to pill. Compounded hormones are not monitored by the FDA and we do not recommend using them.
You will need to decide what options are best for you depending on your symptoms and your values about trying different therapies.
QUALITY OF LIFE EXPECTATIONS
Estrogen therapy may improve quality of life for women with bothersome menopausal symptoms. This is true over a range of doses and preparations.
IF I WANT TO TRY THIS TREATMENT WHAT ARE MY NEXT STEPS?
Estrogen therapy is effective in providing some relief from many menopause symptoms, but it also has risks you may not want to take. Talk this over with your health care provider. You will need to decide what options are best for you depending on your symptoms and your values about trying different therapies..
The standard dose of estrogen (oral conjugated estrogen, oral estradiol, transdermal) reduces hot flashes by 3 or more per day, and eliminates hot flashes in about 7 out of 10 women while they are taking it. When women take lower doses of estrogen, it reduces their hot flashes by 1-2 per day.
| Standard dose* | Low dose* | |
| Oral conjugated estrogen | 0.625 mg once a day | 0.3 mg once a day |
| Oral estradiol | 1.0 mg once a day | 0.5 mg once a day |
| Transdermal estradiol – Skin patch | 0.05 mg once a day | 0.025 mg once a day |
Because of the risks of heart attack, stroke, and blood clots, the U.S. Food and Drug Administration (FDA) recommends starting with a low dose and then increasing as needed. Women should take it for a maximum of five years. Women with a history of or at risk for blood clots, breast cancer, heart disease, or stroke should not take hormone therapy.
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Last reviewed April, 2021
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