Menopause and Hormone Replacement Therapy: What Women Should Know Now

For years, many women heard a simple message about hormone replacement therapy (HRT): avoid it. That message was passed down from mothers, grandmothers and even some doctors. Today, the guidance looks very different, and a lot of women are left wondering what is actually true.

Rebecca Burton Weprin, M.D., a board-certified obstetrician and gynecologist, has spent nearly 30 years helping women through this stage of life. She practices with Gynecological & Obstetrical Associates, part of Texas Health Physicians Group, and is on the medical staff at Texas Health Dallas. She wants women to know that menopause does not have to be something they simply endure.

"For most women, hormone replacement therapy is a viable option," Dr. Weprin said.

First, the basics

Menopause has one technical definition: no menstrual cycle for 12 months. In the United States, the average age is 52.

Perimenopause is the stretch of time that comes before. It can begin two to seven years before a woman's final period. During perimenopause, cycles may become irregular or unpredictable, premenstrual symptoms may feel stronger, and some women notice occasional hot flashes or night sweats.

Not everyone has the same experience. Dr. Weprin breaks it down this way: about 20% to 25% of women move through menopause with almost no symptoms and simply realize one day that they have not had a cycle in more than a year. Roughly half have some symptoms. The remaining 25% are highly symptomatic. That means their symptoms are frequent and strong enough to disrupt daily life, such as hot flashes, night sweats, sleep loss and brain fog that can be truly life altering.

Symptoms women may not connect to menopause

Hot flashes and night sweats are the symptoms most women expect. Others catch them by surprise. According to Dr. Weprin, menopause can also bring joint aches, dry eyes, brain fog, irritability, low mood and a noticeable shift in where the body carries weight.

That weight shift is one of the most common complaints she hears. As hormone levels change, many women start to gain belly fat and move toward a more male pattern of weight gain. Loss of muscle mass adds to the change, because less muscle means the body burns fewer calories. Strength training becomes important during these years.

Dr. Weprin also has a theory about mood. "A lot of the irritability and depression associated with menopause is really a reflection of poor sleep," she said. Lower estrogen can disrupt deep, restorative sleep, so the brain does not fully recover overnight. "If we fix the sleep, we may fix a lot of the other issues."

How hormone therapy works

The decision to start hormone therapy is guided first by symptoms. Women who are highly symptomatic are the clearest candidates.

There is a second set of reasons to consider it, and Dr. Weprin calls these the softer reasons. When started during the transition into menopause, hormone therapy can help maintain bone density, help preserve muscle mass and support long-term heart health.

Hormone therapy is estrogen, or estrogen combined with progesterone. Who needs what comes down to one question.

"You have to first ask, do I have a uterus or not," Dr. Weprin said. "Then you go down the tree from there."

Women who still have a uterus need both estrogen and progesterone. Women who have had a hysterectomy usually need estrogen alone. That single fact clears up a common source of confusion, since friends and online forums often leave women worrying they are being treated incorrectly.

Estrogen comes in several forms, including an oral tablet, a skin patch and a gel. Dr. Weprin often starts with the patch. It delivers estrogen through the skin and bypasses the liver, which lowers the risk of blood clots and inflammation. Progesterone is sometimes given as a separate capsule taken at bedtime, which can also help with sleep.

Vaginal estrogen deserves its own conversation

Vaginal dryness is treated differently from other symptoms. It responds to vaginal estrogen, which works locally rather than throughout the body.

Dr. Weprin considers vaginal estrogen safe for nearly everyone. "There is absolutely never a time that vaginal estrogen would not benefit you," she said.

The reason goes beyond comfort. The bladder has estrogen receptors, which are tiny docking spots on cells that estrogen connects to like a key in a lock. When estrogen reaches them, it helps keep both vaginal and bladder tissue healthy. That can significantly reduce recurrent urinary tract infections, a problem many older women live with for years.

The stakes are higher than most people realize. Dr. Weprin points out that sepsis from a urinary tract infection is a leading cause of death in women over the age of 80. Sepsis is the body's extreme response to an infection, when the reaction spreads and begins to harm the body's own organs. It can turn into an emergency quickly. "If you can use vaginal estrogen twice a week and essentially eliminate that risk, why would you not," she said.

Why timing matters

One of the biggest shifts in recent years is the understanding that starting earlier can matter. Many of the protective benefits come from maintaining hormone balance during a woman's 50s, as she moves through the transition.

That creates a real difference based on where a woman is. Someone who is a few years past menopause is often close enough to the transition to still gain meaningful benefits. Someone who has been in menopause for 15 years or more may have missed the window for some of them. Vaginal estrogen, however, remains helpful at any age.

Is it safe? What about the risks?

For most healthy women, Dr. Weprin says the risks are small. About 98% tolerate hormone therapy well. A small number may experience nausea or headaches.

Personal and family history still matter. Any estrogen carries a slightly higher risk of stroke and blood clots, and that risk is higher with oral estrogen than with a patch or gel. A woman who has had a blood clot, or who has a family history of clotting disorders, needs a careful conversation with her doctor before starting.

This is also why Dr. Weprin encourages women to work with an OB-GYN for prescribing. If a dose needs fine-tuning, or if bleeding or another complication comes up, an OB-GYN can manage that piece too.

One myth worth retiring: hormone therapy does not cause weight gain. If anything, starting it during the transition may help prevent the belly-centered weight shift that comes with falling hormone levels.

What to expect if you start

Relief often comes quickly. Many women with hot flashes and night sweats feel a difference within two to three weeks, though the full biological effect takes about 10 to 12 weeks.

There is no fixed end point. Some women stay on hormone therapy only through the most symptomatic phase, which usually lasts three to five years. Others continue longer. The choice is personal, and it can be revisited over time unless a medical event, such as a stroke, changes the picture.

Follow-up is straightforward. Women who start out highly symptomatic are often seen again in four to six months to make sure the dose is right. After that, a yearly visit is typical.

Finding the right provider

Many women who ask about hormone therapy hear that their doctor is not comfortable prescribing it. Dr. Weprin says that is not a reflection on the patient. For roughly two decades, hormone therapy was rarely taught, so a generation of physicians never trained in it.

"If you feel it's just not in your gynecologist's wheelhouse, it's okay to find someone who is," she said.

Women looking for a clinician with extra training can search the practitioner directory at The Menopause Society, formerly the North American Menopause Society. The society certifies providers who complete additional coursework and pass a competency exam.

For further reading, Dr. Weprin's first recommendation is "Estrogen Matters" by Avrum Bluming, M.D., and Carol Tavris, Ph.D. She also suggests "The New Menopause" by Mary Claire Haver, M.D. Both are written for a general audience.

The bottom line

Menopause is not a problem to quietly wait out. From bone and heart health to sleep, mood and quality of life, there are real options, and the right choice looks different for every woman.

The best next step is a conversation. Women who have questions about menopause, perimenopause or hormone therapy can talk with their OB-GYN about whether it is right for them.

Hot Takes on Hormone Replacement Therapy: 8 Things to Know Symptoms lead the way. Hormone therapy mainly treats symptoms like hot flashes, night sweats and sleep loss. The more disruptive they are, the more likely it is to help. Timing matters. Starting during the transition into menopause, often in the early 50s, offers the most long-term benefit for bone, muscle and heart health. Know your anatomy. Women with a uterus need estrogen and progesterone. Women who have had a hysterectomy usually need estrogen alone. The patch is often first. A skin patch or gel bypasses the liver, which lowers the risk of blood clots. Vaginal estrogen is nearly always safe. It helps keep bladder and vaginal tissue healthy and can cut down on repeat urinary tract infections at any age. It does not cause weight gain. In fact, it may help prevent the belly-fat shift that comes with falling hormones. VERY IMPORTANT NOTE: “Women who have had breast cancer are often not candidates for HRT,” Dr. Weprin said. “This needs to be discussed with their cancer physicians. There are no other types of cancer that preclude HRT use.” Find the right provider. If your OB-GYN is not comfortable prescribing it, search for a certified menopause practitioner at The Menopause Society.

Want to know if HRT is right for you?

Texas Health can help. With OB-GYNs and primary care providers across North Texas, we can help you find the care you need. Find an OB-GYN online at texashealth.org, or call 1-877-THR-WELL (847-9355).