Is Hormone Therapy for Menopause Safe?

Key Takeaways

• The use of hormone therapy to relieve menopause symptoms like hot flashes and night sweats is not correlated to a greater risk of death, researchers say.
• Hormone therapy can reduce bone loss and prevent fractures.
• The new report should reassure women confused by preliminary findings linking hormone therapy with a range of illnesses.

If you're not sure whether it's safe to use hormone therapy as a treatment for menopause symptoms like hot flashes and night sweats, there's a reason you're uncertain. Even healthcare providers are exasperated about the mixed messages from the scientific community about whether hormone therapy poses any dangers.

Now a new analysis of data from a two-decades-long investigation called the Women's Health Initiative adds to the evidence that hormone therapy is safe.

The analysis, published May 1 in JAMA , found that hormone therapy didn't increase the chance of death from all causes in any age group when compared with placebo.

Although there was an increased risk of heart attack reported in initial trial results from more than 20 years ago, the long-term data showed no statistically significant difference between those who took hormone therapy and those who didn't.

Stroke risk among young hormone users was relatively low - less than one extra case per 1,000 women using estrogen-progestin therapy and no excess risk with estrogen alone.

The risk of breast cancer depended on the type of hormone therapy. Women who used estrogen alone (available only for those who've had a hysterectomy) saw a 20 percent reduction in breast cancer risk over the follow-up period. But the relative risk of breast cancer increased about 20 percent with longer use of combination hormone therapy that included both estrogen and progestin, though the absolute risk was low.

The new analysis found that fracture risk among hormone users was 33 percent lower across all age groups compared with placebo. Hormone therapy is FDA-approved and currently used for reduction of bone loss and prevention of fracture.

Investigators also found that the risk-benefit ratio for women who took hormone therapy was more favorable for women aged 60 or younger, which further confirms previous research.

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Experts hope that these latest findings will clear up any remaining doubts and help people better understand the benefits and risks of hormone therapy.

We asked Stephanie Faubion, MD , the director of the Center for Women's Health at Mayo Clinic and the medical director of the Menopause Society (TMS) , to dig deeper into the issue of hormone therapy and put to bed any lingering confusion.

Editor's note: This interview has been edited for length and clarity.

Everyday Health: What should women know about these new long-term findings from the Women's Health Initiative?

Dr. Stephanie Faubion: I think women should know that hormone therapy remains the most effective treatment for menopause symptoms and is still significantly underutilized.

Women can be reassured that for the majority of those who are under age 60 and within 10 years of menopause onset that the benefits of hormone therapy for management of menopause symptoms (or prevention of bone loss) typically outweigh the risks.

EH: Tell me about that evidence showing hormone therapy to be safe for treating menopause symptoms.

SF: Multiple studies have shown that hormone therapy is effective in treating hot flashes [known medically as vasomotor symptoms of menopause ].

Even in the Women's Health Initiative study, which was not designed to look at vasomotor symptoms, when you look at the women in that study who are in their fifties - the population we are most likely to treat for vasomotor symptoms - the benefits tend to outweigh the risk for those women.

EH: When women unnecessarily worry about hormone therapy, they may turn to nonhormonal treatments like antidepressants, anticonvulsants, and dietary supplements. But there isn't any data on the long-term risks of these treatments, is there?

SF: That's exactly right. We have no idea what the long-term effects are of using an antidepressant like an SSRI [selective serotonin reuptake inhibitor] for symptom management, but I can guarantee you there are some, because no medication is without adverse effects. Also, other drugs, such as gabapentin [used to prevent seizures and relieve nerve pain], can cause weight gain - sometimes substantial weight gain.

There are even reports of women using cannabis , and there's no data on safety or efficacy there.

There's a lot of false advertising for supplements and other products that claim there are benefits when they really haven't been proven, and that they're safer than FDA-approved hormones, and that's simply not true.

EH: So what is the Menopause Society's position on hormone therapy?

SF: There are three indications for use of menopausal hormone therapy. One, for vasomotor symptoms - that includes hot flashes and night sweats; two, for genitourinary syndrome of menopause, which may include vaginal dryness, painful urination, or painful sex; three, to help prevent bone loss and reduce fracture risk.

Each woman should work with her healthcare professional to find the most effective formulation, dose, and route of administration. For example, there's some observational evidence that would suggest that a transdermal route of administration (for example, a patch or a cream) is safer than an oral route.

All estrogens are not the same; all progestogens are not the same. In addition, we give them through different routes of delivery, like oral or a patch or a vaginal ring.

And we give them in different doses. So now more than ever, we can start to individualize therapy for women based on their symptoms, past medical history, and family history.

And all this needs to be assessed on a regular basis. I have my patients return once a year, or sooner if any symptoms change or if anything's new about their personal or family history. We don't just put somebody on hormone therapy and say, "You're on it forever."

We also don't recommend you stop taking it in three or five years or at a certain age. It's really based on a woman's ongoing need for hormone therapy, and what's new with her health. Some women elect to continue with hormone therapy longer, perhaps because their symptoms persist and nothing else is adequate to manage them.

EH: Let's talk about hot flashes and night sweats. They can be a lot more debilitating than people realize, right?

SF: Women are missing work, changing jobs, turning down opportunities for advancement at work because of these symptoms. These are not trivial. They're impacting women's lives, their relationships, and their ability to function.

Symptoms are often long in duration - the average length of time is seven to nine years, and 1 in 3 women will have symptoms even longer. When women have moderate to severe symptoms for this long, waiting it out probably isn't a great option.

EH: What's your overall message to women about hormone therapy for hot flashes?

SF: Women should know that hormone therapy is safe and effective. They can seek a clinician who is certified in menopause management by the Menopause Society at Menopause.org . There is no need to suffer!

Editorial Sources and Fact-Checking

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Sources

1. Manson J et al. The Women's Health Initiative Randomized Trials and Clinical Practice. JAMA . May 1, 2024.
2. Faubion S et al. The 2022 Hormone Therapy Position Statement of the North American Menopause Society. Menopause . July 2022.