Bloom Through Menopause

Chapter 7 of 12

Treatment OptionsYour Full Menu of Choices

14 min read18 sections

Few medicines have had a wilder ride than menopausal hormone therapy. Widely used, then feared almost overnight, and now being seriously rethought.

If you've heard conflicting things, that's why. Let's untangle the story, then walk through every option on the menu, hormonal and non-hormonal.

Not every woman will choose treatment. But every woman deserves a clear, informed conversation about it.

Hormone therapy in a nutshell#

Menopausal hormone therapy (MHT, often called HRT) tops up some of the hormones your ovaries no longer make: mainly estrogen, often with a progestogen. The Menopause Society calls it the most effective treatment for hot flashes and night sweats, and it also helps prevent bone loss and fractures and eases vaginal and urinary symptoms (more on its position statement below).

The plot twist: how hormone therapy got its bad name#

Before 2002, hormone therapy was common, and observational studies suggested users had less heart disease. To test that properly, a huge US trial was launched: the Women's Health Initiative (WHI).

In 2002, early results from one arm (estrogen plus a progestin) hit the headlines worldwide, linking hormone therapy to breast cancer. Prescriptions plummeted. But the full picture turned out to be far more nuanced:

  • The women were older. The average participant was 63, about 12 years past menopause, while menopause typically happens around 51.
  • The breast cancer risk was small in absolute terms. In the combined-therapy arm, breast cancer went from about 3 to about 4 cases per 1,000 women per year (WHI, JAMA 2002). The difference was borderline at first, but longer follow-up confirmed a small, real increase.
  • The estrogen-only arm looked different. After about 20 years of follow-up, women who took estrogen alone had about 22% fewer breast cancers and about 40% fewer breast cancer deaths than women on placebo (Chlebowski et al., 2020, summarised by AAFP).
  • Stroke: stroke risk rose by 35% to 40% across the whole WHI group, but for women aged 50 to 59, stroke rates were the same as placebo.

It's also worth knowing what the WHI was built to do: test whether hormone therapy prevents chronic disease, not whether it relieves symptoms. Most of the women taking part were already well past menopause.

From the researchThe US "black box" warning comes off#

For more than 20 years, US hormone therapy products carried the FDA's most serious "boxed" warning, based on those early WHI findings. In November 2025, the FDA began removing it. On 12 February 2026, it approved the first updated labels for six products, removing boxed warnings about heart disease, breast cancer and probable dementia. These covered combined therapy, estrogen-only therapy, progestogen for women using estrogen, and vaginal estrogen.

The FDA stated that randomised studies show women who start hormone therapy within 10 years of menopause, generally before 60, have lower death rates from any cause and fewer fractures. It also noted that in 2020, about 41 million US women were aged 45 to 64, but only around 2 million aged 46 to 65 had a hormone therapy prescription.

Timing is everything#

The biggest lesson since the WHI is the timing hypothesis. Think of estrogen like rust-proofing a car: it seems to work best on healthy metal, not on metal that's already rusting.

  • Started before 60, or within 10 years of menopause: a major Cochrane review found coronary heart disease risk roughly halved and deaths from any cause down about 30%. Blood clot risk was higher, but there was no extra stroke risk.
  • Started after 60, or more than 10 years after menopause: no effect on heart disease or death, with higher stroke and clot risk.
  • A Danish trial starting women at around 50 found a 52% lower combined risk of hospitalisation for heart failure, heart attack or death after 10 years.

Researchers have proposed an explanation, though it's still a theory: estrogen may help healthy arteries, but in women who already have artery disease, starting it may briefly raise the risk of a heart event. In a trial of women with existing heart disease, events were higher in the first year and lower by years four and five (HERS, JAMA 1998).

The AHA statement concludes that for most women in early menopause, the benefits of hormone therapy (including less diabetes, better insulin sensitivity and bone protection) appear to outweigh the risks. It notes specialist societies endorse it for recently menopausal women with appropriate reasons.

Breast cancer: the numbers behind the headlines#

For many women, breast cancer is the worry that stops them considering hormone therapy at all, so the details matter. Many breast cancers carry estrogen receptors, which means estrogen can fuel their growth, and the size of any extra risk from hormone therapy depends on the type used and for how long. Your own risk is one to discuss with your doctor.

So what do the big studies say? Two major analyses give different-sized answers, and it's worth seeing both.

From the research, the larger estimate. The UK medicines regulator (MHRA), based on a 2019 worldwide analysis in The Lancet, estimates the extra breast cancer cases by age 69 for women using hormone therapy for 5 years from around menopause:

Type of hormone therapy (5 years) Extra cases per 1,000 women
Estrogen only About 5
Estrogen plus progestogen part of each month About 14
Estrogen plus daily progestogen About 20

The MHRA says these extra cases roughly double with 10 years of use, and some raised risk lingers for years after stopping.

From the research, the smaller estimate. A 2020 BMJ study of more than half a million UK women, summarised by NIHR, found lower risks:

  • No increased risk from any hormone therapy used for a year or less.
  • Estrogen-only therapy raised risk only marginally, and the extra risk disappeared after stopping.
  • For women in their 50s, about 26 in 10,000 non-users developed breast cancer each year, compared with 35 in 10,000 using combined therapy for under 5 years. That's 9 extra cases, or fewer than 1 in 1,000.
  • Risk rose with longer use (especially over 5 years) and with age, but fell after stopping.
  • The type of progestogen mattered: dydrogesterone was linked to the lowest risk and norethisterone to the highest.

Pills, patches, gels and rings#

How you take estrogen matters:

  • Tablets (oral): pass through the liver first, which can slightly raise clotting factors. Large observational studies link oral estrogen to more blood clots.
  • Patches, gels and sprays (transdermal): absorbed through the skin, and not linked to higher clot risk in those studies (NHS). That's why many doctors prefer them, especially for women with a personal or family history of clots.
  • Systemic vaginal ring: a higher-dose ring that treats vaginal symptoms and the whole body at once. It can be expensive and isn't available everywhere.
  • Pellets are also available.

No trials have directly compared routes for heart outcomes yet, so these findings come from observational data. Popular forms vary by country. In England, estradiol gel is now the most prescribed form (NHS prescribing data, via The Pharmacist), while in the US tablets have traditionally been most common (US Pharmacist).

Possible side effects#

Expect a settling-in period. Side effects often ease within a few weeks, so it's worth giving a new treatment about 3 months if you can, and finding the right form and dose may take some adjusting with your doctor (NHS):

  • Headaches are a recognised side effect. If you get migraines, tell your doctor so they can take it into account.
  • Irregular bleeding or spotting is common in the first few months and usually settles within 6 months. Tell your doctor if it lasts longer than that, gets heavier, or comes back after it had stopped.
  • Skin reactions to patch adhesive can happen. Sometimes it's the glue rather than the estrogen, so a gel or spray may suit you better.

Low-dose vaginal estrogen: the underused hero#

Vaginal creams, tablets and inserts treat dryness, painful sex and urinary symptoms right where they happen. Very little reaches the bloodstream, and the British Menopause Society says there's no significant absorption into the body and no added breast cancer risk (BMS consensus statement), although the product leaflet may still carry the same warnings as other hormone therapy.

She estimates well over half of women develop genitourinary symptoms, and believes almost every woman could eventually benefit. She considers vaginal estrogen safe for virtually everyone, including women with a history of breast cancer, though this should still be confirmed with your own doctor. She calls it the best treatment for repeat urinary infections after menopause, better than repeated antibiotics, and helpful for an overactive bladder. A vaginal DHEA product is another option, popular with breast cancer survivors.

Testosterone and libido#

For postmenopausal women with distressing low sexual desire (hypoactive sexual desire disorder), testosterone has good evidence of benefit, and it's the only use international experts currently support (Global Consensus Position Statement, 2019). It's sometimes promoted for energy, muscle, bone or brain fog, but the evidence doesn't show benefit for these. Approved products vary by country: Australia has a cream approved for women (healthdirect), the US doesn't, and where there's no women's product, guidelines prefer a carefully dosed approved product over compounded creams. Kept within the normal female range, the main side effects are mild acne or extra hair growth in some women. Blood levels are checked before starting, a few weeks in and then about every six months, and treatment is usually stopped if it hasn't helped by six months.

She also mentions two FDA-approved libido medicines, one injected before sex and one taken daily, which can be expensive.

Sexual wellness: find the real cause#

Sexual concerns usually fall into a few types, and each has different causes and fixes (ISSM):

  1. Relationship problems: medication can't fix these, so the relationship comes first.
  2. Arousal problems: lower blood flow after menopause can play a part. Treatment options for women are more limited than for men, so it's worth asking a specialist.
  3. Orgasm problems: orgasms may be weaker or slower, a topic that rarely gets the attention it deserves.
  4. Pain: thinning, fragile tissue can make sex painful; vaginal estrogen can help.
  5. Low desire: often the most common. Testosterone or the approved medicines above may help.

How long can you stay on it?#

There's no set age when you must stop. The British Menopause Society says arbitrary limits shouldn't be placed on how long HRT is used (BMS), and The Menopause Society says it doesn't need to be routinely stopped at 60 or 65 (2022 statement). Keep reviewing it with your doctor, because some risks, such as breast cancer, rise with longer use.

Starting after 60?#

Still worth a conversation, but it needs a careful one-to-one assessment. For women who start at 60 or over, or more than 10 years after menopause, the balance may be less favourable, because the absolute risks of heart disease, stroke, clots and dementia are higher (The Menopause Society 2022, via MDedge). Some doctors also use heart tests, such as a coronary calcium scan, to help decide, though guidelines don't require them. Low-dose vaginal estrogen is a separate case and can be used at any age.

Who shouldn't use hormone therapy (or should wait)#

  • Unexplained or abnormal vaginal bleeding that hasn't been checked
  • A hormone-sensitive cancer currently present
  • An active blood clot being treated
  • Severe liver disease (mild fatty liver usually isn't a barrier)

Premature or early menopause: a special case#

Women who reach menopause before 40, or have their ovaries removed early, face higher risks of heart disease, diabetes, stroke and earlier death if left untreated. Guidelines endorse hormone therapy for these women until at least the average age of menopause. Younger women usually need higher doses than those used around the usual age of menopause, to bring levels closer to what their ovaries would naturally make (bpac^nz).

Non-hormonal and complementary options#

  • Supplements: The Menopause Society's 2023 review doesn't recommend herbal or dietary supplements for hot flashes, including soy, evening primrose oil and wild yam, because the evidence is weak or mixed (2023 nonhormone therapy statement). Supplements aren't tightly regulated, so their contents can vary, and some have caused side effects such as liver problems. Check with your doctor or pharmacist before trying one, especially if you take other medicines.
  • CBT: can help with symptoms and mood (see the brain section).
  • Acupuncture: may ease symptoms, though it doesn't treat the cause and can be costly.
  • Progesterone at bedtime: if your hormone therapy includes oral micronised progesterone, it's usually taken at night because it can make you drowsy. Small studies suggest it may help some women fall asleep faster, but it isn't an approved sleep treatment on its own (Cheung et al., 2021).

From the researchNew non-hormonal prescription medicines#

A new class of medicines targets the brain pathway behind hot flashes, an option for women who can't or prefer not to take hormones.

Availability and approval vary by country, so ask your doctor what's available where you live.

Other medicines worth knowing about#

  • GLP-1 weight medicines (such as Ozempic or Mounjaro): one small Mayo Clinic study found postmenopausal women on semaglutide lost more weight if they also used hormone therapy (about 16% vs 12% after a year), an early finding that still needs confirming (Healio). Because fast weight loss can include muscle and bone, experts advise enough protein and regular strength training while on these medicines (joint obesity medicine advisory, 2025). In women with PCOS they can make periods more regular and raise the chance of pregnancy, so use reliable contraception; Mounjaro can also make the pill less effective for a few weeks after starting or increasing the dose (TGA).
  • Thyroid medicine: starting estrogen can change your thyroid needs, so levels should be rechecked about six weeks later.

Finding menopause-informed care#

Many doctors get little menopause training: in one US survey, only about a third of gynaecology training programmes had a menopause curriculum (The Menopause Society). So finding an experienced clinician can take some effort.