Hormone replacement therapy: Uses, Types, Risk, side effects and benefits, Limitations and Alternatives

Updated: June 16, 2022

Hormone replacement therapy is used to help balance estrogen and progesterone in women around the time of menopause.
It is also known as hormone therapy (HT) or menopausal hormone therapy (MHT). HRT can help relieve sweating, hot flashes, vaginal dryness and other symptoms of menopause. It can also reduce the risk of osteoporosis which is more common after the menopause. Some types of HRT contain both progesterone and estrogen, some only estrogen, and sometimes testosterone is used.
Hormone replacement therapy is an effective way to relieve symptoms of perimenopause and menopause. This is beneficial in women over the age of 35 those who feel run down, prone to weight gain and out of other options when it comes to managing symptoms of menopause.

Uses of Hormone replacement therapy:

Progesterone and estrogen are important hormones in reproductive system of a woman. Estrogen stimulates the release of eggs, and progesterone prepares the womb for egg implantation. The supply of eggs diminishes over time as you get older. As the number of eggs falls, estrogen production also decreases. Most women will start to experience these changes in hormone levels during their late 40s. This can lead to hot flashes and other problems. The risk of osteoporosis increases after menopause.
Apart from the natural aging process, menopause can occur by a hysterectomy that includes removal of the ovaries, or cancer treatment. Smoking is also another risk factor of menopause. Fluctuation in hormone levels can cause severe discomfort and some health risks which can be reduced by HRT. These include:

• changes in body temperature, hot flashes and night sweats
• moodiness, emotional instability like irritability and anxiety
• thinning hair on both your head and body. This occurs in most men and women, although usually more noticeably in men.
• sleep problems
• Lowered sex drive and signs like vaginal dryness
• bone thinning, or osteoporosis
• urinary problems
• lower fertility
• gradually ending of menstrual cycles. Irregular periods can continue for several years.
• concentration and memory difficulties
• smaller breasts and an accumulation of fat in the abdomen
• Exhaustion and having less energy, even chronic fatigue along with muscle weakness occurs for some people
• Dryer skin

These symptoms can be experienced in perimenopause, menopause and postmenopause. When a woman will continue to menstruate, although there is changes in hormonal levels,it is called perimenopause. It can last from 3 to 10 years. But average duration is 4 years.
When the last period occurs, at an average age of 51 years, the woman is in menopause and the period will completely stop.
One full year after the last period, menopause ends, and the woman enters the postmenopausal stage. Symptoms normally decline within 2 to 5 years, but it can take 10 years or more.
Although age contributes to hormonal imbalance, nutrient deficiencies, a lack of sleep and high amounts of emotional stress can all disturb hormonal balance and raise inflammation well before menopause even takes place. Therefore many a times, if the root problems causing hormonal imbalances such as poor diet, sedentary lifestyle, anxiety, etc., are properly addressed, then the unwanted symptoms can be resolved without the use of hormone therapy.

Types of Hormone replacement therapy:

HRT can come as pills, creams, gel, patches, or in a vaginal ring. Usually HRT use different combinations and delivery of the hormones. These include:

Estrogen-only HRT:

This is suitable for women who have had a hysterectomy where their uterus, or womb, and ovaries have been removed and do not need progesterone.
This is not suitable for you if you haven't had your uterus removed. In this case estrogen along with progesterone or progestin will be prescribed by your doctor.
As estrogen alone, when not balanced by progesterone, can stimulate growth of the lining of the uterus which can increase the risk of uterine cancer, it is not suitable for those women who are still having their periods. If you have had your uterus removed,  you don't need to take progestin.

Cyclical, or sequential HRT:

Women who are still menstruating but have perimenopausal-like symptoms can use this. Cycles may be monthly, with an estrogen plus progestogen dose at the end of the menstrual cycle for 14 days, or a daily dose of estrogen and progestogen for 14 days every 13 weeks.

Continuous HRT:

This is used during postmenopause where the patient takes a continuous combination of estrogen and progestogen.

Local estrogen:

Local estrogen such as vaginal tablets, creams, or rings can help reduce urogenital problems, including dry vagina and irritations. The lowest possible dosage is prescribed at the beginning to treat symptoms which can be increased at a later stage. It may take a few weeks to feel the effects of treatment and there may be also be some side effects at first. You can normally begin HRT as soon as you start experiencing menopausal symptoms with the recommendation of your doctor. Usually there is no need to have any tests first.
If the initial dose doesn't work after trying it for three months, the doctor may suggest changing your dose or changing the type of HRT you are taking.
If you are younger than age 45, you need enough estrogen to provide protection against the long term health effects of estrogen deficiency. If you are still experiencing menopausal symptoms that significantly effecting your quality of life, your doctor may recommend longer term treatment.
The duration of treatment can be decided by the doctor. Once the menopausal symptoms pass, HRT can be stopped. Gradually decreasing your HRT dose is usually recommended because it is less likely to cause your symptoms to come back in the short term.
If you have particularly severe symptoms or symptoms that persist for several months after you stop HRT should be evaluated by the doctor. You may need to start HRT again.

Risks, side effects and benefits of HRT:

HRT can cause side effects as other medications. However, these side effects will usually disappear within three months of starting treatment which include:

• headaches
• nausea
• breast tenderness
• indigestion
• abdominal pain
• vaginal bleeding

There is an increased risk of certain serious problems, such as blood clots and breast cancer from some type of HRT. The risk of breast cancer rises if HRT is used for over 5 years. However, the risk of stroke or blood-clotting problems is not so high for women aged 50 to 59 years.
Women often gain weight around menopause, but this is not necessarily due to HRT. Other possible reasons for weight gain around this time include a lack of physical activity, a redistribution of fat as hormone levels change, and an increase in appetite resulting from low estrogen level. Maintaining a healthy diet and getting plenty of exercise can help reduce weight gain.
These risks may vary, depending on age. For example, women who begin hormone therapy more than 10 or 20 years from the onset of menopause or at age 60 or older are at greater risk of the above conditions. But if hormone therapy is started before the age of 60 or within 10 years of menopause, the benefits appear to outweigh the risks.
The risks of hormone therapy may also vary depending on whether estrogen is given alone or with progestin, the dose and type of estrogen, and other health factors such as your risks of heart and blood vessel (cardiovascular) disease, cancer risks, and family medical history.
Women who experience early menopause, particularly those who had their ovaries removed and don't take estrogen therapy until at least age 45, have a higher risk of:

• Osteoporosis
• Heart disease
• Earlier death
• Symptoms of Parkinson's disease
• Anxiety or depression

The protective benefits of hormone therapy usually outweigh the risks for women who reach menopause prematurely. Your age, type of menopause and time since menopause play significant roles in the risks associated with hormone therapy.   
The benefits of HRT may outweigh the risks. But speak to your doctor who understands the individual's risks, if you have any concerns about taking HRT.
The benefits of HRT include:

• improving muscle function
• Because declining levels of hormones like progesterone, DHEA and testosterone are responsible for your low levels of energy, HRT can help improve motivation, better sleep and alertness.
• reducing the risk of heart failure and heart attack
• lower mortality in younger, postmenopausal women
• effective in preventing skin aging, if used cautiously in some women
• As estrogen and testosterone have benefits for preventing bone loss, there is a reduced hip fracture risk when estrogen and progesterone levels are restored. However, the prevention of bone loss or rebuild of lost bones by HRT have not been proven.
• oral use of HRT is highly effective in alleviating hot flashes and night sweats, two of the most common symptoms associated with menopause and sleep disturbances.

HRT can also increases estrogen level. This results in decreased vaginal pH and increased blood flow, epithelial thickness, secretions. Therefore, menopause or postmenopausal women who are affected by vaginal atrophy, causing symptoms like vaginal dryness, pain during sex, itching, irritation, burning and discharge can get relief. Although HRT can protect against some changes that occur in women, it cannot prevent all aspects of aging.

Limitations of HRT:

HRT can be taken by most of the women if they are experiencing symptoms associated with the menopause.
But HRT may not be suitable if you:

• have a history of breast cancer, ovarian cancer or womb cancer
• have a history of blood clots
• stroke
• heart disease
• have untreated high blood pressure. In this case, your blood pressure will need to be controlled before you can start HRT
• have liver disease
• severe migraines
• are pregnant. It is still possible to get pregnant while on HRT, so you should use contraception until two years after your last period if you are under 50 or for one year after the age of 50

In these circumstances, alternatives to HRT may be recommended instead.

Alternatives to HRT:

Alternative ways of controlling your menopausal symptoms are there if you are unable to take HRT or decide not to take it. These include:

• lifestyle measures, such as exercising regularly, eating a healthy diet, cutting down on coffee, alcohol and spicy foods, stopping smoking, wearing loose clothing, sleeping in a well ventilated, cool room and adding a fan to the bedroom or cooling gel pad or pillows.
• tibolone, a medication that is similar to combination of oestrogen and progestogen. But this may not be as effective and is only suitable for women who had their last period more than a year ago.
• Some antidepressants can help with hot flushes and night sweats, although they can also cause unpleasant side effects such as agitation and dizziness.
• clonidine is a non-hormonal medicine that may help reduce hot flushes and night sweats in some women.
• Several remedies such as bioidentical hormones are claimed to help with menopausal symptoms, but these aren't recommended because the safety and effectiveness are not proved.
• Herbal or supplement treatment are also not recommended by Food and Drug Administration (FDA). However, consuming ginseng, block cohosh, red clover, soya beans and Kava help with menopausal symptoms to some extent.