Hormone Replacement Therapy (HRT): Types, Benefits and Risks
The short answer
Hormone replacement therapy (HRT) replaces some of the estrogen, and usually progesterone, that the ovaries stop making at menopause. It is the most effective treatment for hot flashes and night sweats; in a Cochrane review, oral HRT cut weekly hot flash frequency by about 75% compared with placebo. For healthy women under 60 or within 10 years of menopause, The Menopause Society says the benefits generally outweigh the risks.
What does hormone replacement therapy actually do?
Across perimenopause, the ovaries release estrogen and progesterone less predictably, and after the final period they make very little. Many tissues respond to that change, including the brain's temperature-control center, the vagina and bladder, bones, skin and sleep. Menopausal hormone therapy (MHT), still widely called HRT, gives back a measured dose of estrogen so those tissues are not running on so little.
The goal is not to restore the hormone levels of a 25-year-old. It is to use the dose that controls symptoms and protects bone, at a level of risk that makes sense for you. The Menopause Society's 2022 position statement describes hormone therapy as the most effective treatment for hot flashes and night sweats (vasomotor symptoms) and for genitourinary syndrome of menopause, and notes that it prevents bone loss and fracture (Menopause Society 2022).
That matters because hot flashes are not always brief. In the SWAN study, women with frequent hot flashes or night sweats had them for a median of 7.4 years in total, and for longer when they started early in perimenopause (Avis 2015). For more on that timeline, see how long hot flashes last.
By the numbers
Hormone therapy by the numbers
What are the main types of HRT?
Estrogen-only vs. estrogen plus progestogen
Estrogen is the part of HRT that relieves symptoms. If you still have a uterus, estrogen on its own makes the uterine lining grow, which raises the risk of endometrial hyperplasia and cancer. So women with a uterus also take a progestogen: either body-identical progesterone or a synthetic progestin. Women who have had a hysterectomy usually take estrogen alone (see estrogen after hysterectomy).
Systemic vs. local (vaginal) therapy
Systemic therapy (pills, patches, gels, sprays, creams and rings designed to raise blood levels) treats whole-body symptoms such as hot flashes, night sweats and sleep disruption. Low-dose vaginal estrogen (cream, tablet, insert or ring) treats dryness, pain with sex and some urinary symptoms with very little absorption into the bloodstream. Many women need only one; some use both. Our guide to local vs. systemic HRT goes deeper.
Delivery methods
| Form | How it works | Points to know |
|---|---|---|
| Oral tablet | Swallowed; processed by the liver first | Familiar and inexpensive; oral estrogen carries a higher clot risk than skin-based estrogen |
| Patch, gel or spray | Absorbed through the skin | Bypasses first-pass liver metabolism; not linked to higher clot risk in large observational data |
| Compounded cream | Pharmacy-made cream rubbed into the skin | Allows custom strengths and combinations; not FDA-approved, with less consistent dosing data |
| Vaginal estrogen | Applied inside the vagina | Treats local symptoms; does not relieve hot flashes |
| Pellets | Implanted under the skin every few months | Cannot be removed or adjusted once placed; mostly compounded |
If pellets are on your list, ask how the dose would be adjusted or reversed if side effects occur, since a pellet can't be removed once placed.
What are the proven benefits of HRT?
- Hot flashes and night sweats. A Cochrane review of placebo-controlled trials found oral HRT reduced weekly hot flash frequency by about 75% and also reduced their severity (MacLennan 2004).
- Sleep. When night sweats ease, sleep often improves too, though insomnia has many causes and may need its own treatment.
- Vaginal and urinary symptoms. Estrogen restores vaginal tissue thickness, moisture and pH. Low-dose vaginal estrogen is the usual first choice when these are the only symptoms.
- Bone. HRT prevents bone loss and reduced fractures in the Women's Health Initiative (WHI) trials (Manson 2013).
- Mood. Estrogen can help mood swings tied to perimenopause, but it is not a treatment for clinical depression on its own.
HRT is not recommended solely to prevent heart disease or dementia, and it is not a weight-loss treatment.
What are the risks of hormone replacement therapy?
Most of the fear around HRT dates to the first WHI reports in 2002, which studied women with an average age of 63 using one oral estrogen (conjugated equine estrogens) with or without one synthetic progestin. Later analyses showed that risk depends heavily on age, time since menopause, type and route of hormone, and how long you use it (Manson 2013). In November 2025 the FDA removed the class-wide boxed warning from menopausal hormone therapy labels, reflecting that evidence (Buchanan 2026). The risks did not disappear; they are just better understood.
- Blood clots. In UK data covering more than 80,000 women with clots, oral HRT was linked to higher risk (adjusted odds ratio 1.58), while transdermal estrogen was not linked to a higher risk (Vinogradova 2019).
- Breast cancer. A worldwide meta-analysis found every type of systemic HRT was associated with some excess breast cancer risk that rose with duration, more for estrogen plus progestogen than estrogen alone; low-dose vaginal estrogen was not (Collaborative Group 2019). In long-term WHI follow-up, estrogen alone in women after hysterectomy was associated with lower breast cancer incidence, while the combined regimen was associated with higher incidence (Chlebowski 2020).
- Stroke and heart disease. Absolute risks are low in women in their 50s and rise for those who start more than 10 years after menopause or after 60.
- Endometrial cancer. This is a real risk with estrogen alone in women with a uterus, which is why a progestogen is added. Report any unexpected bleeding.
- Common side effects. Breast tenderness, spotting, bloating, headache or mood changes, often settling within a few months or with a dose change. See HRT side effects.
By the numbers
Blood clot risk depends on how you take estrogen
Who should not take HRT?
Is HRT safe for women under 60?
For women younger than 60 or within 10 years of menopause onset who have no contraindications, The Menopause Society concludes the benefit-risk ratio is favorable for treating bothersome hot flashes and preventing bone loss. For women who start more than 10 years after menopause or after 60, the balance appears less favorable because absolute risks of heart disease, stroke, clots and dementia are higher (Menopause Society 2022). Staying on HRT past 60 can still be reasonable for persistent symptoms, with a yearly review.
Bioidentical, FDA-approved or compounded: what's the difference?
"Bioidentical" means the hormone has the same structure as the one your body makes: estradiol and progesterone. Many FDA-approved products are bioidentical, including estradiol patches, gels and tablets, oral micronized progesterone, and an oral capsule that combines estradiol and progesterone.
Compounded hormones are mixed by a pharmacy for an individual prescription. That can allow strengths or combinations not sold commercially, such as estradiol and progesterone in a single cream. But compounded products are not FDA-approved: the FDA does not review them for safety, effectiveness or dose consistency, and they do not carry the same labeling. A National Academies review found insufficient evidence to support their routine use (NASEM 2020). ACOG advises that compounded hormone therapy should not be prescribed routinely when FDA-approved formulations exist, and that saliva or blood hormone testing is not recommended for dosing it (ACOG 2023). The Menopause Society shares these concerns. Compounded does not mean safer; the same estrogen risks apply. More detail is in bioidentical vs. synthetic hormones.
What are the alternatives to HRT?
If you cannot or prefer not to take hormones, The Menopause Society's 2023 nonhormone statement recommends cognitive behavioral therapy, clinical hypnosis, certain SSRI/SNRI antidepressants, gabapentin, fezolinetant and oxybutynin, with weight loss supported by more limited evidence. It does not recommend most supplements and herbal remedies, soy products or paced breathing for hot flashes (Menopause Society 2023). For vaginal dryness alone, moisturizers, lubricants and low-dose vaginal estrogen come first.
How do you start HRT?
Step by step
How to start HRT
- Track your symptomsFor a couple of weeks: what they are, how often, and what they affect.
- Gather your historyLast period, cancers, clots, migraines, heart disease, medications, and close relatives' breast or ovarian cancer.
- Talk with a licensed clinicianAn OB-GYN, primary care clinician, a menopause specialist in person, or a telehealth service. Blood hormone tests are usually not needed to diagnose menopause after 45; your symptoms and cycle history matter more.
- Agree on a planThe type, dose and route, when to check in (often around 3 months), and what side effects or bleeding to report.
- Stay up to date on screeningIncluding mammograms and cervical screening, and review the plan at least yearly.
Amie offers one route here: Amie HRT+, a compounded cream combining estradiol and progesterone, with the strength chosen by a licensed clinician after an online review of your health history. Like all compounded hormones, it is not FDA-approved, and the clinician decides whether it, an FDA-approved product, or a referral for in-person care is the better fit for you. FDA-approved patches, gels and oral progesterone are widely available through insurance and your own doctor, and are a sound choice for many women.
The bottom line
Common questions
Who is a good candidate for hormone replacement therapy?
Women with bothersome hot flashes, night sweats or other menopause symptoms who are under 60 or within 10 years of their last period and have no contraindications have the most favorable balance of benefit and risk. A licensed clinician reviews your personal and family history before prescribing.
Does HRT cause breast cancer?
Combined estrogen-plus-progestogen therapy is linked to a small increase in breast cancer risk that grows with longer use. Estrogen-only therapy, used after hysterectomy, did not raise breast cancer risk in the Women's Health Initiative trial. Vaginal estrogen at low doses was not linked to excess risk.
Do I need progesterone with estrogen?
If you still have a uterus, yes. Estrogen alone thickens the uterine lining and raises the risk of endometrial cancer, so a progestogen such as progesterone is added to protect it. Women who have had a hysterectomy usually take estrogen alone.
Is compounded HRT FDA-approved?
No. Compounded hormone products are prepared by pharmacies for individual prescriptions and are not reviewed by the FDA for safety, effectiveness or consistent dosing. Several FDA-approved estradiol and progesterone products are available and are recommended first by ACOG when they meet your needs.
How long can I stay on HRT?
There is no fixed cutoff. Current guidance supports continuing for as long as the benefits outweigh the risks for you, with a yearly review with your clinician, especially after age 60 or if symptoms persist.
Sources
- The 2022 hormone therapy position statement of The North American Menopause Society. Menopause 2022
- MacLennan AH et al. Oral oestrogen and combined oestrogen/progestogen therapy versus placebo for hot flushes. Cochrane 2004
- Avis NE et al. Duration of menopausal vasomotor symptoms (SWAN). JAMA Intern Med 2015
- Manson JE et al. Hormone therapy and health outcomes in the Women's Health Initiative trials. JAMA 2013
- Chlebowski RT et al. Hormone therapy and breast cancer in long-term WHI follow-up. JAMA 2020
- Collaborative Group on Hormonal Factors in Breast Cancer. Lancet 2019
- Vinogradova Y et al. HRT and risk of venous thromboembolism. BMJ 2019
- ACOG Clinical Consensus No. 6: Compounded Bioidentical Menopausal Hormone Therapy (2023)
- National Academies. The Clinical Utility of Compounded Bioidentical Hormone Therapy (2020)
- The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause 2023
- Buchanan LA et al. The FDA boxed warning on menopausal hormone therapy. Menopause 2026
Amie prescribes in all 50 states. Find online hrt in your state.