Each year, more than 1.3 million American women — most between the ages of 45 and 55 — reach menopause, the biological milestone marking the end of menstruation. As the ovaries stop producing estrogen and progesterone, hormones essential not just for fertility but for nearly every system in the body, their absence triggers profound changes. Hot flashes, memory lapses, and insomnia can disrupt daily life, while more insidious effects, like bone loss and increased cardiovascular risk, emerge over time.
For decades, hormone replacement therapy (HRT) was the most effective treatment for severe symptoms. By 1999, more than a quarter of menopausal American women were taking hormones. But in 2002, a widely publicized study from the Women’s Health Initiative (WHI) linked HRT to a 26% rise in the incidence of breast cancer, and a 40% increase in strokes. Within months prescriptions plummeted, and millions of women were left to navigate menopause with few medical options. Only those whose quality of life was severely impacted by symptoms were prescribed short-term, low-dose HRT in a strict risk-benefit calculation.
In the years since, reviews of the WHI findings have revealed that the risks were overstated, and in some cases, misrepresented. Reanalysis of the data found an increase of only one case of breast cancer for every 1,000 women taking estrogen and progesterone. Additionally, women taking estrogen alone (an option for those with hysterectomies) had a 23% reduction in breast cancer risk, information lost in the panic over the WHI report.
Yet confusion lingers, leaving many women unsure about whether HRT is safe — or if they should be taking it at all.
To understand the benefits and risks associated with HRT, patients must first understand the symptoms and health risks of menopause. It’s important to know that menstrual cycles don’t stop overnight. The ovaries shut down gradually in a phase called perimenopause, which can last from two to eight years. As hormone levels drop, 90% of women develop a variety of uncomfortable symptoms, including irregular periods (from unpredictable staining to prolonged bleeding), hot flashes (a sudden sensation of heat lasting seconds to minutes), night sweats (usually sleep-disturbing and body-drenching), mood changes and trouble concentrating (due to interrupted sleep), and vaginal dryness (often causing painful sex or frequent bladder infections).
The loss of estrogen and progesterone also hastens age-related health problems like osteoporosis and coronary artery disease. Women lose nearly 50% of their bone mass within the first decade after menopause (post menopause), significantly increasing fragility fracture risk (hip, vertebra, and forearm). The incidence of heart disease nearly triples: It’s the number one killer of women in the United States, causing more than 300,000 deaths annually, 10 times as many as breast cancer. Menopause also slows metabolism and changes body fat distribution: A majority of women gain 5 to 7 pounds, primarily around the waist.
Today’s HRT is not the same as it was in 1999. Hormones are used in lower doses and in different forms, like patches, creams, gels, and sprays — not just pills. Because transdermal preparations are directly absorbed into the bloodstream, bypassing the liver, stroke risk is not increased. Older versions of progesterone linked to breast cancer are no longer prescribed. Breast cancer rates on combined HRT remain low, at about one additional case per 1,000 users.
Research has shown that women who take HRT within 10 years of their final period have significantly lower risks of heart disease, osteoporosis, and colon cancer than those who don’t take it; perimenopausal symptoms completely resolve, too. It remains controversial whether the benefits of starting HRT after age 60 outweigh the risks, but those who began before menopause can continue past the age of 65.
Because HRT can provide benefits beyond treating hot flashes, perimenopausal women should consult their health care providers to discuss choices well before their periods are gone for good. HRT is not currently recommended to those with a history of breast cancer.
There are also alternative treatments. Exercise, proper hydration and caffeine restriction may help ease some symptoms; vaginal lubricants like Astroglide can make sexual relations easier. Herbs such as black cohosh, St. John’s wort and dong quai may reduce hot flashes, but none should be taken without the approval of a health professional.
Certain non-hormonal prescription medications can also be effective, including antidepressants like venlafaxine (Effexor) or paroxetine (Paxil), neuroactive drugs like gabapentin and fezolinetant (Veozah), and antihypertensives like clonidine.
Custom-compounded bioidentical hormones are plant-derived, and reduce hot flashes in some women. But there is no evidence these products prevent disease, and their long-term safety is unclear.
Any woman with perimenopausal symptoms before the age of 40 should contact her health provider. Vaginal bleeding — even staining — after one year without menstruation is considered suspicious and requires medical attention.
Dr. Mary Jenkins, a contributor to the Herald and member of its board of directors, retired after nearly 40 years as a family practice physician in New York state.