Hormone Therapy post Menopause: What has changed? Balancing Benefits and Risks

Confident and radiant, these women embrace life post-menopause, exploring the benefits of hormone therapy with elegance and grace.

Hormone Therapy for Menopausal Symptoms: A Quick Guide

Hormone therapy (HT) is recommended by the American Academy of Family Physicians for women under 60 experiencing moderate to severe menopausal symptoms, as long as there are no contraindications. Each treatment plan should be tailored to individual needs, considering factors like symptom severity and health risks. For women over 60, a careful risk-benefit analysis is crucial before starting HT.

Key Benefits of Hormone Therapy

HT can effectively relieve hot flashes, reduce vaginal dryness and prevent osteoporosis. One meta anlysis of 4141 younger women (mean age 53.9+/- 3.5 years), HT improved survival odds significantly (39%). It could not prove or refute decreased risk of cancer or heart disease, which is a concern for many people, but did reduce death from other causes. Comparatively in older age group, ie those over 60, there was no change in survival with hormone therapy. (10).

This led to change in recommendations, with HT now being advocated for younger women within 10 years of menopause, particularly those with symptoms, as long as risk of heart disease or cancer is not too high. Non oral formulations, ie delivery through skin patches or vaginal suppositories are preferable to reduce excessive effect of these drugs, particularly for women at higher risk of heart disease or cancer. Non hormonal alternatives are also available for those whose risk is very high.

More trials are needed to understand if hormone therapy can actually reduce heart disease or cancer in younger perimenopausal women, before advocating it for reduction of chronic disease for all. Not all people agree to that, stating that overall survival is more important than cancer or heart disease free survival.

Does Hormone Therapy improve quality of Life?

There is strong evidence that hormone therapy (HT) improves quality of life in postmenopausal women, particularly those with bothersome symptoms (e.g., hot flashes, night sweats and vaginal dryness).

Clinical trials consistently show that HT leads to significant reductions in the frequency and severity of hot flashes, with associated improvements in menopause-related quality of life, sleep, and sexual function for symptomatic women.[11][12][13][14] Improvements are most pronounced in women with moderate to severe symptoms at baseline.[11][15]

However, the benefit is symptom-dependent: in women without hot flash, night sweat symptoms, HT does not improve overall quality of life or cognitive function.[11][15] For genitourinary symptoms, local estrogen therapy is highly effective and improves sexual function and vaginal health, further enhancing quality of life.[16][13]

Assessing Risks

Long-term studies show that HT does not increase overall mortality over 5–7 years. However, it’s essential to avoid HT in women with specific contraindications, as risks may rise with age or prolonged use. Non hormonal alternatives, are also available for those who prefer them.

Insights from Recent Research

Recent trials confirm that HT is effective for alleviating moderate to severe menopausal symptoms and improving bone health. Women who start HT close to menopause experience the most benefits, including reduced symptom severity and lower fracture risk.

Limitations of Hormone Therapy

HT is not recommended for preventing chronic conditions like heart disease or cancer as data is unclear at this time.

Personalized Hormone Therapy

The effectiveness and safety of HT depend on age, timing, type, and dosage. Women starting HT before 60 or within 10 years of menopause generally have a better benefit-risk ratio.

It’s essential to personalize HT, with ongoing assessments and shared decision-making, ensuring it’s only for those with bothersome symptoms and no contraindications.

Recent FDA Updates on Hormone Replacement Therapy

The FDA has begun removing the "black box" warning from many hormone-replacement therapies (HRT) for menopausal women. Here’s a summary:

✅ Key Changes

• The FDA has asked manufacturers to revise product labels, removing warnings about cardiovascular disease and breast cancer risks.

• This update follows a thorough review of scientific evidence, including new analyses from the Women’s Health Initiative.

• The FDA aims to encourage the use of therapies that can alleviate menopausal symptoms and improve long-term health.

Reasons for the Update

• Previous warnings were based on studies of older women and older hormone regimens.

• New findings suggest that starting HRT early in healthy women may have a different risk-benefit profile.

• The FDA determined that a universal warning was no longer appropriate, as it could impede effective care.

Important Considerations

• The removal of the warning does not mean HRT is without risks; caution remains for women using systemic estrogen-alone products.

• Decisions about HRT should still be personalized, factoring in age and health conditions.

• Some experts caution that the FDA’s approach may require further scrutiny.

In summary, while hormone therapy offers significant benefits for managing menopausal symptoms, careful consideration and personalized assessment are essential for safety and effectiveness.

References

1. Managing Menopausal Symptoms: Common Questions and Answers. Jennifer G. Chang MD, Meghan N. Lewis MD, Maggie C. Wertz MD. American Academy of Family Physicians (2023).

2. The Women’s Health Initiative Randomized Trials and Clinical Practice: A Review. Manson JE, Crandall CJ, Rossouw JE, et al. JAMA. 2024;331(20):1748-1760. doi:10.1001/jama.2024.6542.

3. The 2022 Hormone Therapy Position Statement of the North American Menopause Society. Menopause (New York, N.Y.). 2022;29(7):767-794. doi:10.1097/GME.0000000000002028.

4. Menopausal Hormone Therapy and Women's Health: An Umbrella Review. Zhang GQ, Chen JL, Luo Y, et al. PLoS Medicine. 2021;18(8):e1003731. doi:10.1371/journal.pmed.1003731.

5. Hormone Therapy in the Postmenopausal Years: Considering Benefits and Risks in Clinical Practice. Genazzani AR, Monteleone P, Giannini A, Simoncini T. Human Reproduction Update. 2021;27(6):1115-1150. doi:10.1093/humupd/dmab026.

6. Hormone Therapy in Menopause: Concepts, Controversies, and Approach to Treatment. Flores VA, Pal L, Manson JE. Endocrine Reviews. 2021;42(6):720-752. doi:10.1210/endrev/bnab011.

7. Hormone Therapy for the Primary Prevention of Chronic Conditions in Postmenopausal Women: US Preventive Services Task Force Recommendation Statement. Grossman DC, Curry SJ, Owens DK, et al. JAMA. 2017;318(22):2224-2233. doi:10.1001/jama.2017.18261.

8. Hormone Therapy for the Primary Prevention of Chronic Conditions in Postmenopausal Persons: US Preventive Services Task Force Recommendation Statement. US Preventive Services Task Force, Mangione CM, Barry MJ, et al. JAMA. 2022;328(17):1740-1746. doi:10.1001/jama.2022.18625.

9. Management of Menopausal Symptoms: A Review. Crandall CJ, Mehta JM, Manson JE. JAMA. 2023;329(5):405-420. doi:10.1001/jama.2022.24140.

10.Mortality associated woth hormone therapy in younger and older women- a meta analysis. Salpeter S, Walsh J, Greyber E, Ormiston T, Salpeter E. J Gen Intern Med. 2004 July; 19 (7): 791-804.

11. An Empowerment Model for Managing Menopause. Hickey M, LaCroix AZ, Doust J, et al. Lancet (London, England). 2024;403(10430):947-957. doi:10.1016/S0140-6736(23)02799-X.

12. Hormone-Replacement Therapy: Current Thinking. Lobo RA. Nature Reviews. Endocrinology. 2017;13(4):220-231. doi:10.1038/nrendo.2016.164.

13. Management of Menopausal Symptoms: A Review. Crandall CJ, Mehta JM, Manson JE. JAMA. 2023;329(5):405-420. doi:10.1001/jama.2022.24140.

14. Reconsidering Hormone Replacement Therapy: Current Insights on Utilisation in Premenopausal and Menopausal Women: An Overview. Yanachkova V, Vasileva-Slaveva M, Kostov S, Yordanov A. Journal of Clinical Medicine. 2025;14(20):7156. doi:10.3390/jcm14207156.

15. Estrogen and Progestogen Therapy in Postmenopausal Women. Fertility and Sterility. 2006;86(5 Suppl 1):S75-88. doi:10.1016/j.fertnstert.2006.07.1476.

16. Hormone Therapy for Postmenopausal Women. Pinkerton JV. The New England Journal of Medicine. 2020;382(5):446-455. doi:10.1056/NEJMcp1714787.