Hormone Replacement Therapy: What Women Need to Know

Navigating menopause can feel overwhelming, but understanding your options is key. Phelps Health Obstetrician and Gynecologist (OB/GYN) Jenny Pennycook, MD, FACOG, cuts through the confusion to shed light on hormone replacement therapy. She also offers essential advice for women considering trendy treatments.

What is hormone replacement therapy?

Hormone replacement therapy (or HRT) is an FDA-approved treatment to relieve the symptoms of menopause (when periods stop) and perimenopause (the months or years leading up to menopause). During this transition, the ovaries make varying amounts of hormones, which can lead to symptoms including:

• Bone loss
• Brain fog
• Hot flashes and night sweats
• Mood swings or depression
• Sleep problems/fatigue
• Vaginal dryness

HRT treats these symptoms by stabilizing levels of the reproductive hormones estrogen and progesterone, restoring hormonal balance.

What are the different types of HRT?

There are two main types of HRT.

• Estrogen therapy: Available in pill, skin patch, ring, gel, cream or spray form. For women who have had a hysterectomy (surgery to remove the uterus), a provider will typically recommend an estrogen-only therapy.
• Combination therapy (estrogen-progesterone therapy or EPT): Typically comes in a pill, skin patch or intrauterine device (IUD). Progesterone may reduce the risk of uterine cancer in women who still have their uterus.

Is HRT safe?

The Scare

In 2002, a Women’s Health Initiative (WHI) trial raised questions about the safety of hormone therapy. Increased risks (cardiac events and breast cancer) appeared to outweigh the preventive benefits (reduced fractures and colon cancers). The study’s negative results garnered widespread publicity, causing panic among users and prompting new guidance for doctors prescribing HRT. The result? Ninety percent (90%) of women using the HRT ended treatment at the time. Note: The study focused on women in their late 50s and 60s, who had taken a hormone pill for 5-plus years.

A Fresh Look

Like most things, the truth is somewhere in the middle. In later years, reanalysis of the WHI trial and new studies showed that HRT benefits younger or early postmenopausal women, by improving heart health and mortality. However, public opinion on HRT remains mixed.

Besides minimizing my hormonal symptoms, does HRT have other benefits?

Years of research have also shown positive HRT benefits, including:

• Decreased risk for diabetes and insulin resistance
• Decreased colon cancer risk
• Decreased fracture risk

Who is a good candidate?

In recent years, hormone panels (or tests) have become trendy. While these tests can be helpful, bloodwork only shows a snapshot in time. During perimenopause, women’s hormone levels constantly fluctuate with their cycle. And what’s considered a “normal” level for one woman may not be “normal” for another.

Because of this, women should first listen to their bodies. If hormonal symptoms are interfering with quality of life, women should consider talking with their women’s health provider about HRT.

How can women minimize the risks of HRT?

• Start HRT before age 60 or within 10 years of menopause. Studies show your risk for HRT complications is higher if you begin therapy more than 10 years after menopause symptoms begin. Taking HRT in your 40s or 50s is typically not associated with an increased risk of cardiovascular (heart) disease.
• Take progesterone if you still have a uterus.
• Work with your provider to find an HRT that best minimizes your risk.
• Live a healthy lifestyle.
• Get regular women’s health exams and mammograms.

Who should not take HRT?

Women may not be a good candidate if they:

• Have or had breast, ovarian or uterine cancer
• Have had blood clots or are at high risk for them
• Have a history of stroke, heart attack or increased risk for cardiovascular disease

In these cases, women should discuss the risks and benefits with their provider.

What are the potential side effects of using HRT?

• Light bleeding
• Breast tenderness
• Mood swings

Typically, these symptoms go away in 3-4 months. If symptoms are bothersome, women should ask their provider about adjusting the dosage or the type of HRT to reduce side effects.

Can I go to a med spa for HRT?

The medical spa market has boomed in recent years. Advertised as a mix between a medical clinic and a spa, med (or medi) spas offer traditional spa services alongside promises of younger-looking skin, hormone therapy and more. With offerings once exclusive to doctors, these facilities promise the best of both worlds. When it comes to med spas, proceed with caution.

What are the risks of med spas?

• Safety and oversight: In a 2023 med spa review, a supervising doctor was not on-site at 81.8% of the facilities. In addition, the level of expertise required for med spa employees varies greatly from state to state.
• Hormone testing: Med spas often offer hormone testing, through blood, salivary or urinary tests. According to the American College of Obstetricians and Gynecologists, salivary tests have not proven to be accurate. Estrogen levels are extremely low in saliva, making it challenging to measure. Currently, there are no FDA-approved salivary or urinary hormone measurement tests. Consumers should be aware that these tests can often be expensive, unnecessary and unreliable.
• Compounded bioidentical hormone therapy: Med spas may administer compounded therapy, compounds with identical chemical structure to hormones produced in the body (such as estrogen and progesterone). However, compounded medicines don’t undergo the strict manufacturing and purity standards of their FDA counterparts, introducing more room for human error. Additionally, insurance doesn’t cover (sometimes costly) compounded therapy. Women can get bioidentical hormone therapy from their healthcare provider, though. With a prescription, patients can know that these treatments are FDA approved, rigorously tested for quality and covered by insurance.
• A dangerous mix: Compounded hormone creams, for example, may conveniently combine estrogen, progesterone and testosterone, but they carry risks. In cream form, estrogen is easily absorbed, while progesterone may not be absorbed enough to protect the uterus. A Cleveland Clinic study found a link between the use of custom-compounded hormones and uterine cancer in traditionally low-risk women.
• Pellet hormone therapy: Hormone pellets are implants under the skin that release bioidentical hormones. The absorption is inconsistent, and the effects can last up to 6 months. These pellets are also compounded and not FDA-approved or regulated.