What Is HRT? A Guide to Hormone Therapy for Women

Key Takeaways:

• Hormone replacement therapy (HRT) treats symptoms of menopause like hot flashes, mood swings, and vaginal dryness.

• HRT may include estrogen and progesterone in a pill, patch, gel, or cream.  

• The benefits of HRT outweigh the risks for most people.

Hormone replacement therapy (HRT), also known as menopause hormone therapy, is a treatment for the uncomfortable symptoms of perimenopause and menopause. It works by supplementing the reproductive hormones that your body naturally produces less of as you approach menopause. 

In this guide, we’ll break down the basics of HRT, including how it works, the different types available, the benefits, and the risks of HRT — so you can feel informed, supported, and confident in whatever path you choose.

HRT works by supplementing hormones that your body isn’t making enough of. As you approach menopause, your ovaries stop producing estrogen the way they used to. This can have a significant impact on your quality of life, causing a host of challenging symptoms like hot flashes, mood swings, insomnia, and vaginal discomfort. 

Estrogen levels begin declining during perimenopause, the transitional period leading up to menopause. Perimenopause lasts, on average, about 4 years, but it can last up to a decade. Symptoms can persist throughout this time and can continue into postmenopause (you’ve officially reached menopause when you’ve gone 12 months without a period). 

HRT works by raising your overall estrogen levels enough to relieve your symptoms or by delivering a targeted dose where you need it most.  

There are different types of hormonal therapy for menopause available, including both systemic and localized treatments. Each is available in a variety of different forms, such as pills, patches, and gels. If HRT is right for you, your provider will consider your symptoms, health history, and preferences when recommending a prescription. 

Broadly, HRT falls into two categories: systemic and local. Let’s take a closer look below.

Systemic Hormone Therapy

With systemic HRT, supplemental hormones enter your bloodstream and circulate throughout your body. This type of HRT typically contains more estrogen than localized treatments like vaginal creams. And it’s used to treat a wider range of menopausal symptoms, including hot flashes, night sweats, mood changes, and genitourinary symptoms.

Forms of systemic hormone therapy for menopause include:

• Estrogen-only pills

• Combined estrogen and progesterone pills

• Estrogen-only patches

• Combined estrogen and progesterone skin patches (transdermal patches)

• Gels and sprays applied to the skin

Estrogen-Only Therapy

Your provider will only recommend estrogen-only therapy if you’ve had a hysterectomy. If you still have your uterus, it’s important to take a combination of estrogen and progesterone (or progestin, a synthetic progesterone) because of progesterone’s protective effects. 

Estrogen-only HRT pills, gels, and sprays are typically administered once per day. Estrogen patches are replaced once or twice a week. 

Combined Estrogen and Progesterone Therapy

Most women using systemic HRT for perimenopause and menopause use a combination therapy containing estrogen and progesterone. On its own, supplemental estrogen can cause the lining of your uterus to grow abnormally, increasing your risk of uterine (endometrial) cancer. 

Progesterone balances out the effects of estrogen and helps protect your uterine lining during HRT therapy.

Combination HRT therapies are most often available as pills and skin patches. But you can also combine treatments like topical gels and sprays with progesterone pills. 

HRT can be taken continuously or, for those who still get a period, in cycles that mimic your menstrual cycle.

Local (Low-Dose Vaginal) Estrogen Therapy

Local estrogen therapy is specifically designed to treat the vaginal and urinary symptoms of menopause — like dryness, itching, pain, and recurrent urinary tract infections. 

It delivers a low dose of estrogen directly to the vaginal tissue, with minimal absorption into the bloodstream. Low-dose vaginal estrogen comes in several forms, including:

• Vaginal cream

• Vaginal suppositories 

• Timed-release vaginal rings 

It’s important to understand that low-dose vaginal estrogen doesn’t circulate throughout the body, so it doesn't treat symptoms like hot flashes and mood changes. But it carries fewer risks than systemic HRT, which can make it a better fit for people with certain preexisting conditions and risk factors. 

This low-dose, localized treatment is also safer for long-term use, making it a common choice for people who’ve already reached menopause. While symptoms like hot flashes tend to improve after menopause, vaginal symptoms tend to continue or get worse without treatment.  

The benefits of Hormone therapy for perimenopause and menopause are clear — it can significantly improve your quality of life and reduce the burden of symptoms. Studies show that HRT helps treat the following symptoms:

• Hot flashes and night sweats

• Vaginal dryness and irritation

• Pain during sexual activity

• Mood changes 

• Insomnia and sleep disruptions

• Leaking urine, urinary urgency, and pain during urination

• Recurring urinary tract infections

• Sexual problems caused by reduced lubrication, blood flow, and sensation

HRT may also offer longer-term protective health benefits. Studies suggest that HRT may:

• Lower your risk of osteoporosis and related fractures

• Help prevent heart disease when started before age 60 or within 10 years of menopause

• Reduce your risk of type 2 diabetes and improve insulin sensitivity 

• Support muscle strength and preserve lean body mass

• Improve skin elasticity and collagen production

• Reduce joint pain and stiffness

The risks of HRT are relatively low for most healthy women, but there are risks associated with treatment. Risks can vary based on your age, health history, and the type of HRT you use, so it’s important to discuss the pros and cons of HRT with a healthcare provider. 

Is HRT Safe?

Research has linked HRT to a slightly increased risk of:

• Breast cancer. For most women, the relative risk is low and comparable to risk factors like obesity and low physical activity. But risk level can vary based on the type of HRT you use and how many years you use it for. 

• Heart disease. For healthy women younger than 60 or within 10 years of the start of menopause, the cardiovascular benefits of HRT typically outweigh the risk. 

• Stroke. HRT pills (but not patches, gel, or spray) have been associated with a slightly increased risk of stroke, but the risk is very low for people under 60.  

• Blood clots. HRT pills (but not patches, gel, or spray) can slightly increase your risk of blood clots, but the risk is very low. 

• Uterine (endometrial) cancer. Risks are elevated in people with a uterus who use systemic estrogen-only therapy without the protective effects of progesterone.  

• Gallbladder issues. The risk of gallstones and gallbladder disease is increased with HRT. 

Certain risk factors can impact the safety of HRT therapy. For example, research suggests that starting treatment earlier — ideally within 10 years of menopause or before age 60 — is when HRT benefits are greatest and risks are fewest. 

HRT may not be suitable for you if you are pregnant or if you have a history of:

• Breast, ovarian, or uterine cancer

• Blood clots or stroke

• Liver disease

• Unmanaged high blood pressure

• Heart disease 

HRT Safety

A menopause-friendly healthcare provider can help you weigh the risks and benefits of HRT and help find a treatment plan that's right for you. 

Here are a few HRT safety tips:

• Find a provider trained in menopause treatment. Unfortunately, many healthcare providers have little experience with menopause care. Find a provider who understands what you’re going through and how to help. 

• Tell your provider about your health history and medications. Make sure your provider knows about any potential risk factors and any other prescriptions or supplements you’re taking.

• Get personalized treatment options. Choose the lowest effective dose for the shortest time needed to relieve your symptoms.

• Check in regularly with your provider. Let your provider know how things are going, talk to them about dose adjustments if side effects are bothering you, and keep them updated about any changes to your health. 

Many people tolerate hormone replacement therapy well, but like any medication, it comes with a risk of side effects — especially when you first start. 

The good news is that side effects typically improve in a few weeks as your body adjusts to the treatment.

Possible side effects of HRT therapy include:

• Headaches

• Breast pain or tenderness

• Changes in your menstrual cycle (like spotting between periods or heavier vaginal bleeding)

• Digestive issues like diarrhea and nausea

• Mood changes, including low mood, anxiety, or depression

• Muscle cramps

• Fatigue and dizziness

• Skin issues, including acne or rash

• Hair loss

While some people report anecdotally gaining weight on HRT, it’s often difficult to separate the effects of treatment from the natural changes that occur during perimenopause and menopause, such as shifts in metabolism, sleep, and body composition.

Some early studies suggest that lifestyle factors, in addition to hormones, tend to play a bigger role in weight gain at this stage of life. One study found that HRT could even help prevent some of the body fat distribution changes that can happen after menopause. 

Hormone therapy for menopause isn’t the right approach for everyone. If HRT isn’t an option for you, there are effective ways to manage menopause symptoms without estrogen or progesterone.

Lifestyle changes like eating a balanced diet, exercising regularly, managing stress, and maintaining a healthy body weight can help. If you’re having trouble managing your weight, you may want to explore weight loss medications.

Mental health support through talk therapy can help build coping mechanisms for mood swings, sleep issues, and emotional changes.

There are also non-hormonal medication options, such as:

• Antidepressants. Originally designed to treat depression and anxiety, SSRIs or SNRIs may also help reduce hot flashes and support mood stability.

• Gabapentin. Typically used for nerve pain, gabapentin may reduce hot flashes and improve sleep.

• Clonidine. The blood pressure medication clonidine may ease hot flashes (though side effects like dry mouth or dizziness are possible).

• Fezolinetant (Veozah). FDA-approved to treat hot flashes, fezolinetant is a non-hormonal medication used to treat menopause-related hot flashes and night sweats.

• Oxybutynin can treat overactive bladder and has also been shown to help with vasomotor symptoms like night sweats.

HRT alternatives that may help treat vaginal and urinary symptoms include:

• Ospemifene is a non-hormonal pill that improves vaginal dryness and reduces pain during sex.

• Vaginal moisturizers and lubricants can relieve dryness and irritation, but be sure to look for fragrance-free, pH-balanced options.

• Low-dose birth control pills can help regulate menstrual cycles and prevent pregnancy if you’re in perimenopause. 

Hormone replacement therapy for menopause and perimenopause is a safe and effective treatment for most people. It is available in a variety of forms, including pills, patches, and creams that can be used systemically or locally. Like all medications, there are risks involved, so it’s important to weigh the pros and cons with a menopause-friendly healthcare provider. 

What is HRT used for? 

Hormone replacement therapy (HRT) is typically used to treat the symptoms of perimenopause and menopause. It can also be used to treat:

• Early menopause 

• Primary ovarian insufficiency 

• Surgical menopause 

• Low estrogen due to medical treatments like chemotherapy and radiation

• Low estrogen caused by other conditions

What are bioidentical hormones?

Bioidentical hormones are chemically and structurally similar to the hormones your body naturally produces. But the term is loosely defined and often causes confusion for both patients and providers. 

Bioidentical hormones for menopause include estradiol, which is actually the same hormone used in traditional, FDA-approved estrogen therapy. Other types of bioidentical hormones, like certain progesterone therapies, have not been FDA-approved and are instead produced by compounding pharmacies.

The term “bioidentical hormones” is often used alongside terms like “natural” and “plant-based” in marketing materials to imply that these hormones are safer than traditional HRT. But there is no scientific evidence to suggest that bioidentical hormones are safer or cause fewer side effects than traditional HRT.  

How often do you take HRT?

How often you take HRT will depend on the type of treatment you're using and your treatment plan. Estrogen-only therapy is typically taken daily (or applied weekly if you use a patch). If you’re using a combined treatment, your treatment plan may be cyclic or continuous. 

Cyclic HRT (also called sequential HRT) mimics your regular menstrual cycle and is best suited for people who still get a period. It involves daily estrogen, with progesterone added to the mix for about 2 weeks out of the month. Continuous HRT is usually for those who are postmenopausal and prefer to avoid monthly bleeding.