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Hormone replacement therapy replaces the estrogen your ovaries stop producing at menopause. It is the most effective treatment available for hot flashes and night sweats, it prevents the bone loss that accelerates after the final period, and for the right woman at the right time it is a straightforward decision.

It is also the treatment most surrounded by outdated fear and overconfident marketing in equal measure. This page is about assessing whether it is right for you specifically.

Who benefits

The strongest case for hormone therapy is a woman who is:

Under 60, or within 10 years of her final period. This is the window in which benefits most reliably outweigh risks. Starting many years after menopause changes that balance.
Having symptoms that affect her life — hot flashes, night sweats, disrupted sleep, or the vaginal and urinary changes of menopause.
At elevated risk of osteoporosis, or already losing bone density.
In early menopause or primary ovarian insufficiency. If your periods stopped before 45, and particularly before 40, hormone therapy is generally recommended at least until the average age of natural menopause. This is replacement of what your body should still be making, and the risk calculation is different from that of a 55-year-old.
Following surgical removal of both ovaries before natural menopause. See oophorectomy.

Who should not take systemic hormone therapy

A history of breast cancer or estrogen-sensitive cancer
A history of blood clots, deep vein thrombosis or pulmonary embolism
A history of stroke or heart attack, or active coronary disease
Unexplained vaginal bleeding — this must be investigated first, not treated through
Active liver disease
Pregnancy

Some of these are absolute and some depend on detail. A strong family history of breast cancer, well-controlled hypertension, migraine with aura, or a treated clotting event years ago are all reasons for a careful individual discussion rather than an automatic no. Bring the details.

Low-dose vaginal estrogen is a separate question. Absorption into the bloodstream is minimal, and it is appropriate for many women who cannot take systemic hormones. If dryness and painful sex are your main problem, this may be the whole answer.

Forms, and what the differences mean

Transdermal estrogen — patch, gel or spray. Absorbed through the skin, bypassing the liver, and associated with a lower clot risk than oral estrogen. Usually the preferred route, particularly if you have any cardiovascular or clotting risk factors.
Oral estrogen — convenient and effective, with a higher clot risk than transdermal.
A progestogen, taken alongside estrogen if you still have a uterus. Estrogen without it thickens the uterine lining and raises the risk of endometrial cancer. This is not optional. Micronised progesterone is commonly used. A hormonal IUD can supply the uterine protection in some situations.
Vaginal estrogen — cream, tablet or ring, for local symptoms only.
Testosterone — not FDA-approved for women in the United States, and prescribed off-label in specific circumstances, principally for low sexual desire that persists after estrogen has been optimised. Testosterone therapy for men is a separate topic: see testosterone therapy for men.

Compounded and pellet hormone therapy: what you should know

Pellets and custom-compounded creams are heavily marketed as bioidentical, natural, and individually tailored. Two facts belong in that conversation.

Compounded bioidentical hormone preparations are not FDA-approved. The National Academies of Sciences, Engineering, and Medicine reviewed them and found insufficient evidence of safety and effectiveness, recommending they be restricted to patients who genuinely cannot use an approved product — for example because of an allergy to an ingredient in every commercial preparation. Batch-to-batch dose consistency is not assured.

FDA-approved hormone therapy is also bioidentical. Estradiol patches, gels and micronised progesterone are molecularly identical to what the ovary makes. Bioidentical is not a synonym for compounded, and the marketing depends on people not knowing that.

A pellet cannot be removed or dose-adjusted once implanted, and pellet regimens often produce hormone levels well above the physiological range. If you are considering pellets, ask what the alternative approved option would be and why it is not being offered first. We will have that conversation honestly.

What happens at the visit

History. Symptoms and how much they affect you, menstrual history, personal and family history of breast cancer, clots, stroke and heart disease, and your current medications.
Examination. Blood pressure, weight, and a clinical breast exam.
Testing where it changes the decision. Thyroid function, and other blood work by history. Hormone levels are generally not needed to diagnose menopause after 45. Levels are checked in early menopause, in unusual presentations, and sometimes to monitor absorption — not to fine-tune a dose against a target number.
Up-to-date screening. Mammography and cervical screening current before starting.
A discussion of risk in absolute terms, not relative percentages, so the numbers mean something.

Monitoring

A review at three months to check symptom response and side effects, then at least annually. Breast tenderness, bloating and irregular spotting are common in the first months and usually settle. Report any bleeding that starts after a settled period on therapy, any new severe headache, calf pain and swelling, chest pain, breathlessness, or a new breast lump.

There is no fixed maximum duration. The old instruction to stop at five years regardless has been abandoned; continuation is reviewed periodically against your symptoms and your changing risk, and some women stay on therapy for many years with good reason. See menopause management for the non-hormonal options.

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Medical disclaimer

This page is general health information, not medical advice for any individual, and not a recommendation of any particular product or brand. Whether hormone therapy is appropriate for you depends on your age, time since menopause, medical and family history, and must be decided with a physician. Seek urgent care for chest pain, breathlessness, calf pain and swelling, sudden severe headache, or new vaginal bleeding while on hormone therapy.