When to Start Taking HRT (Hormone Replacement Therapy)

Key takeaways:

• The best time to start hormone replacement therapy (HRT) is usually during late perimenopause, but you can start whenever symptoms become bothersome.

• You can start HRT while you’re still getting your period (or anytime within 10 years of your last period).

• HRT can ease hot flashes, night sweats, and vaginal dryness, while also helping with mood, sleep, and bone health.

Menopause may be a natural part of aging, but it rarely feels that way. When the symptoms of perimenopause first appear, it takes most of us by surprise. Many women experience symptoms for months, even years, before making the connection — Oh, this is perimenopause. 

So, if you’re wondering whether it’s too soon to start hormone replacement therapy (HRT), you’re already ahead of the game. You’ve made the connection and you’re ready to figure out what’s next. 

We’re here to help. In this guide, we’ll dig into the benefits of HRT for menopause symptoms, talk about the best time to start HRT, and consider the risks of using it long term. And if you’re wondering whether it’s too late to start HRT, we’ve got answers for you, too.

You don’t have to wait until you reach menopause to start treating your symptoms. In fact, the most beneficial time to start HRT is usually during late perimenopause, when hormone fluctuations are causing the most troublesome symptoms. 

Perimenopause is the period of time leading up to menopause. Most women start perimenopause sometime between ages 45 and 55. Hormone levels, primarily estrogen, begin to decline during this time, which gives rise to menopause symptoms like hot flashes, night sweats, and mood swings. 

Treating Perimenopause Symptoms

Full-body symptoms, like hot flashes, typically peak during late perimenopause and early postmenopause, around age 50. Without treatment, symptoms can persist for years (the average is about seven years) before starting to improve. 

If you’ve started perimenopause, you may notice other symptoms such as:

• Night sweats

• Mood changes 

• Trouble sleeping

• Brain fog

• Irregular or heavy periods

• Vaginal dryness, itching, or irritation

• Urinary issues

Unlike full-body symptoms, localized symptoms like vaginal dryness, pain during sex, and recurrent urinary tract infections (UTIs) can continue well into the postmenopausal years. Without treatment, they also tend to get worse over time.  

Hormonal Birth Control vs. HRT During Perimenopause

If you’re already taking a combined oral contraceptive like the pill during perimenopause, it may be providing some benefits, like helping to regulate your cycle. Depending on your symptoms, your healthcare provider may recommend continuing treatment instead of starting HRT.

The estrogen and progestin in hormonal birth control pills can help manage certain mild perimenopause symptoms while also preventing pregnancy (which can still happen during perimenopause). You may switch to HRT around age 50 when you’re less likely to become pregnant or earlier if you’re experiencing severe symptoms like hot flashes and night sweats. 

You’ve entered menopause if it’s been at least 12 consecutive months since your last period. The average age of menopause onset in the United States is 52.

Many women can continue to experience symptoms during the early postmenopause years. For example, one study found that vasomotor symptoms could persist for almost 5 years after a woman’s final period.

Most experts recommend starting HRT before age 60 or within 10 years of menopause. Why? HRT is associated with an increased risk of heart disease and other issues when started later than that.

Women who experience premature menopause or early menopause can also start HRT. This is when the ovaries stop making estrogen and progesterone ahead of schedule, typically before age 40 or 45.

You can take HRT even if you’re still getting your period. Women in perimenopause still have a menstrual cycle, although periods are typically more irregular and vary in how long they last and how heavy the bleeding is.

However, when it comes to HRT and periods, you may notice some changes once you get started on the treatment.

Women experiencing symptoms while in perimenopause typically take sequential HRT. In sequential HRT, you take estrogen daily and progesterone for part of the month (usually 10 to 14 days).

At the end of your course of progesterone, you’ll typically have breakthrough vaginal bleeding that mimics a natural period.

Some women may take continuous HRT, which is when you take estrogen and progesterone every day. In that case, you might notice your periods are lighter, less frequent, or stop altogether.

Menopause hormone therapy works by replacing estrogen and progesterone. There are two types of HRT:

• Estrogen-only HRT

• Estrogen plus progesterone, also called combined HRT

Systemic HRT is usually taken in the form of a pill, skin patch, or gel. Systemic means the hormones enter your bloodstream and affect your whole body.

There are also local types of HRT, specifically vaginal estrogen. This uses a low dose of estrogen in the form of a cream, suppository, or vaginal ring. This is a great, low-risk solution if your symptoms are limited to vaginal and urinary problems, but it won’t help with full-body symptoms like hot flashes. 

Before you get started on hormone replacement therapy, you’re probably curious about its various risks and benefits. Let’s discuss these now.

Benefits of HRT

HRT has several proven benefits for women experiencing symptoms of menopause. These include:

• Fewer vasomotor symptoms. Both estrogen-only HRT and combined HRT can reduce the frequency of vasomotor symptoms like hot flushes and night sweats by up to 75 percent.

• Less vaginal dryness. As with local HRT, systemic hormone replacement therapy helps improve vaginal dryness, irritation, and pain.

• Improved mood. Research suggests that HRT may help with mood changes, like symptoms of anxiety and depression. 

• Better sleep. Systemic HRT helps with sleep problems like insomnia, difficulty falling asleep, and trouble staying asleep. 

• Reduced bone loss. HRT can slow menopause-related bone loss, which means it may lower your risk of osteoporosis and fractures.

Possible Risks and Drawbacks of HRT

Hormone replacement therapy is also associated with some risks and side effects.

Side effects of HRT can include things like:

• Breast tenderness

• Headaches

• Changes in your period

• Mood changes

These are typically temporary and go away in a few weeks.

By the way, if you’re concerned about weight gain while taking HRT, don’t worry. There’s currently no evidence that taking HRT leads to significant weight gain.

The health risks associated with HRT use can vary depending on the type of HRT you’re using. According to the American College of Obstetricians and Gynecologists (ACOG), systemic HRT might come with a slightly increased risk of:

• Blood clots and stroke

• Heart attack 

• Breast cancer

• Endometrial cancer (for estrogen-only systemic HRT in women with a uterus)

• Gallbladder disease 

Hormone replacement therapy may not be recommended for women with certain health conditions. These include:

• A history of blood clots, stroke, or heart attack

• A history of breast or endometrial cancer

• Unexplained vaginal bleeding

• Untreated high blood pressure (hypertension)

• Certain types of liver disease

While taking HRT, your healthcare provider may want to follow up with you more frequently if you:

• Have cardiovascular disease risk factors like high blood pressure, high cholesterol, or diabetes

• Smoke cigarettes

• Have gallbladder disease

If you can’t or choose not to do HRT based on the possible risks, non-hormonal treatment options are available. Talk to your medical provider about which ones would be a good fit for you.

There’s no hard-and-fast rule for how long you take HRT.

According to the Menopause Society, most women are on hormone replacement therapy for 4 to 5 years. Some may also choose to switch to a lower dose of HRT or change to a non-pill form.

Women with premature or early menopause typically take HRT until at least the average age of menopause (around 50 to 52).

When you and your healthcare provider decide it’s time to stop HRT, you’ll typically slowly taper down your dose over a period of 3 to 6 months.

When you stop taking HRT, it’s possible some of your symptoms may return.

For example, roughly half of women experience a return of vasomotor symptoms after discontinuing HRT. Other symptoms may return as well, such as those related to mood and vaginal lubrication.

Another thing to be aware of is that bone loss will also start again after stopping HRT. That means you’ll have to work with a medical professional to take additional steps to prevent osteoporosis.

As we come to the end of our discussion on when to start taking HRT, let’s review some of the main points:

• You can start HRT when you have menopause symptoms. This can be either before menopause (during perimenopause) or after.

• It’s generally recommended that women start taking HRT within 10 years of menopause due to the risk of heart disease.

• It’s possible to start HRT if you’re still having periods. 

• There are no established recommendations for how long to take HRT, but most women stop after a few years. Some symptoms may return after stopping.

At the end of the day, the decision of when to start HRT comes down to an open discussion with your provider. A healthcare professional can take into account your age, symptoms, and medical history to come up with a treatment plan tailor-made for you.