Introduction
Few treatments in women’s health have been discussed as widely, or misunderstood as often, as menopausal hormone therapy. Much of what women believe about it was shaped by headlines from years past, by well-meaning advice from friends, or by marketing that promises a gentler and more natural alternative. As a result, many women who could benefit from an informed conversation about their options never have one.
Ask Dr. Lili was created to make that conversation easier. Each column takes a real question from a reader and answers it with the evidence and clinical perspective Dr. Lili brings to her patients at Healthy Skin Centre in New Westminster. This month’s question comes from a reader who, like many women in her early fifties, is weighing relief from her symptoms against everything she has heard about the risks.
The Question
Dear Dr. Lili,
I’m 51 and my periods have become unpredictable. I wake up drenched at night, I’m tired at work, and I don’t feel quite like myself. A friend says hormone replacement therapy changed her life, but I remember hearing that it causes breast cancer. I’m also seeing advertisements for “bioidentical” hormones that claim to be safer.
How do I know what to believe, and whether hormone therapy is right for me?
Mariah, New Westminster
Dr. Lili’s Answer
Dear Mariah,
You are asking the question I hear from women almost every day. Many have spent years managing hot flashes, poor sleep and other symptoms because they were told HRT for menopause was dangerous. Others have been promised that a product labelled “natural” or “bioidentical” has no risks. Neither message gives women the full picture.
You deserve a clear discussion of what hormone therapy can do, what its risks are, and how those risks apply to you. This is one of the conversations I hope to make easier through my work on menopause, including my book.
What Is HRT for Menopause?
Hormone replacement therapy, or HRT, is now often called menopausal hormone therapy (MHT). MHT describes the treatment more accurately: we are treating symptoms and we are not trying to restore the hormone levels you had at 25.
Systemic MHT provides estrogen to treat symptoms such as hot flashes and night sweats. If you have a uterus, you also need a progestogen to protect the uterine lining from the effects of systemic estrogen. If you have had a hysterectomy, estrogen can usually be prescribed on its own.
Estrogen, the foundation of most HRT treatments for menopause, comes in several forms, including patches, gels and pills. The choice depends on your symptoms, medical history and preferences. The benefit of a patch or gel is that it delivers estrogen through the skin and carries a lower risk of blood clots than estrogen taken by mouth. This is why I always recommend this first.
What Are the Benefits of HRT for Menopause?
MHT is the most effective treatment we have for bothersome hot flashes and night sweats. When those symptoms improve, women often tell me they are sleeping better and coping better during the day. MHT also helps prevent bone loss while it is being taken. For women younger than 60 or within 10 years of menopause who have no contraindications, the benefits of MHT generally outweigh the risks.
Vaginal dryness and discomfort deserve attention too. Some women benefit from systemic MHT, but others need low-dose vaginal estrogen, either alongside it or on its own. Vaginal estrogen acts mainly in the local tissues and is a different treatment decision from taking systemic hormones.
What About Anxiety, Skin and Hair?
I see women who arrive wanting help with night sweats and then mention that their mood feels less steady, their skin seems drier, or their hair is thinning. These changes matter. But I would be careful about promising that estrogen will fix every one of these problems.
I’m often asked about HRT for menopause anxiety. If poor sleep and frequent hot flashes are contributing to irritability or difficulty concentrating, treating those symptoms may help you feel better. Anxiety or depression can also need assessment and treatment in their own right.
Estrogen influences the skin and hair follicle, but skin aging and hair loss have many causes. MHT is not prescribed solely as a skin or hair treatment, and it cannot replace an assessment of sudden or significant hair shedding. At Healthy Skin Centre, I look at the whole woman before recommending treatment for her skin or hair.
Is Bioidentical Hormone Therapy Safer?
“Bioidentical” means a hormone has the same molecular structure as a hormone made by the body. It does not mean that the product is automatically safer, and it does not mean it must be custom compounded. Regulated estradiol and micronized progesterone are examples of bioidentical hormones available by prescription.
Custom-compounded hormone preparations are often marketed as “more natural” or precisely tailored to your body. Their safety, effectiveness and consistency have not been assessed to the same standard as regulated products.
What Are the Risks?
MHT is not risk-free. Breast tenderness, bloating or spotting may occur, particularly when starting or adjusting treatment. Some effects settle; persistent or unexpected bleeding needs assessment.
The more serious risks depend on factors including your age, time since menopause, personal health history, whether you have a uterus, and the hormones and delivery method used. I do not give every woman the same prescription, or the same answer about safety.
Timing matters as well: beginning systemic therapy after age 60 or more than 10 years after menopause can carry a less favourable balance of benefits and risks.
Who Should Be Particularly Cautious?
A history of breast or uterine cancer, unexplained vaginal bleeding, blood clots, stroke, cardiovascular disease or significant liver disease calls for careful assessment and may make systemic MHT inappropriate. There are also effective nonhormonal ways to treat menopause symptoms, so a woman who cannot take MHT still has options.
So, Is MHT Right for You?
Mariah, I would start by asking what is disrupting your life most, then review your medical history and discuss your treatment choices. You need information that applies to your health, your symptoms and your goals.
And you do not need to keep suffering through hot flashes and sleepless nights alone.
Have a Question for Dr. Lili?
Ask Dr. Lili is a place for real questions and evidence-based answers about menopause, skin, hair and healthy aging. If you have a question for a future column, send it through our Contact Us page. Questions may be edited for length or clarity, and identifying details will not be published.
If menopause symptoms are affecting your daily life, you can also learn more about Healthy Menopause at Healthy Skin Centre in New Westminster, BC.
Ask Dr. Lili provides general health information for educational purposes and is not a substitute for individualized medical advice.