By Kelli Miller
WebMD Health News

Reviewed by Arefa Cassoobhoy, MD, MPH

March 31, 2015 — If you’re in menopause, you might wonder if hormone replacement therapy (HRT) can help or harm your health. Research on the pros and cons of HRT has been on a rollercoaster-like path for decades. Some studies say it’s good for you. Others warn it isn’t. New research cites even more risks.

Is it safe or not? Two women’s health experts answer common questions.

Why the HRT confusion?

“When hormone therapy first came out, it was highly promoted, like it was the fountain of youth,” says Lynn Pattimakiel, MD, who works at the Center for Specialized Women’s Health at the Cleveland Clinic.

In the 1980s, research showed it could ward off osteoporosis and maybe heart disease. Such things are common after menopause.

But in 2002, a big study released by the Women’s Health Initiative said HRT made a woman more likely to have heart attacks, strokes, and blood clots. Other reports from the program said it raised the risk of breast cancer. This triggered a lot of fear and worry.

“Women stopped taking the hormones when the trial results were released,” says JoAnn Pinkerton, MD, director of the Midlife Division at the University of Virginia.

Five years later, a new look at the data offered better news. The risks varied by age and how long you’ve been in menopause. “They found that if you are under 60 or within 10 years of menopause,” there’s a lower risk of death, Pinkerton says. The average age of menopause is 52.

Today, researchers continue to report on HRT’s long-term benefits and risks. Among the latest findings:

• Short-term use (3-5 years) may slightly raise the risk for ovarian cancer.

• HRT can boost a woman’s heart health when taken within the first 10 years of menopause, provided they don’t already have concerns for heart disease. But it can raise the risk for heart disease in older women. Earlier studies also said this was true.

• Previous studies show that HRT can raise breast cancer risk for women who take combined estrogen-progestin therapy. The same risk was not found in women who took estrogen alone.

Is HRT ever OK?

Yes, for the right woman, the risks are relatively low, experts say.

“HRT is a valuable option for treating many young, newly post-menopausal women who have severe symptoms that disrupt their quality of life,” Pattimakiel says. These symptoms include hot flashes, sleep problems, and vaginal dryness. Other symptoms that might spur women to discuss HRT with their doctor are unstable moods, painful sex, or urinary tract infections they get again and again.

About 1 in 4 women have such symptoms, which may make them sweat so much it disrupts their day. Hot flashes can start before menopause (a phase doctors call perimenopause), and they can last up to 10-15 years. “They peak within the first 4 years around menopause,” Pinkerton says.

Women over 70 are more likely to have some of the dangerous side effects seen in the large women’s health study. “We would not start HRT at that age,” Pinkerton says.

How long can I take it?

“There’s no time when you have to stop,” she says.” You need to [talk to your doctor] about the risk and benefits and what you need it for.”

The FDA recommends using it for the shortest amount of time possible. On average, a woman takes HRT for 3-5 years.

What happens if I stop it?

Chances are your symptoms will return. They could be as bad as when you started menopause. Sometimes, they are less severe. “We really can’t predict it,” Pattimakiel says. Studies say it doesn’t make a difference if you stop treatment abruptly or slowly.

If you do decide to quit, she suggests you do it at a stable time, not a stressful one.

Always talk to your doctor before stopping a medication. If you have symptoms that won’t go away, be sure to tell your gynecologist.

How can I lower my risks?

Ask your doctor about the different types of HRT. Some only contain estrogen. Some are combined with progesterone. If you still have your uterus, you need HRT that includes both. Progesterone protects against uterine cancer. But doctors “think it’s that combo that may increase the risk of breast cancer,” Pinkerton says.

Also, HRT might not be right for you if you have or had:

• Blood clots
• Heart disease
• Stroke
• Breast cancer or any estrogen-dependent cancer
• Family history of heart disease or certain cancers

Does it matter if I take a pill or a cream?

There are many ways to take HRT. It might be a pill, cream, spray, skin patch, or another form. Using these on your skin rather than taking a pill lowers your risk of blood clots, because it doesn’t go through your liver.

“If you’re young and healthy, it probably doesn’t matter how you take it,” Pinkerton says. “As you age, there may be a benefit to [a skin form].”

What about “bioidentical hormones”?

These are chemically the same as the hormones your body makes. FDA-approved bioidenticals can be prescribed by your doctor. Bioidentical doesn’t mean “natural,” even though some compound pharmacies may use this term for such treatments. They are made from soy or other plants and are changed to act like human hormones.

Such pharmacies may offer compounded menopause treatments after doing saliva tests. But experts worry about safety. And the FDA has said there may be little evidence to prove they work.

“We don’t recommend a compounding pharmacy because we can’t guarantee the quality. There is no one that is really monitoring it,” Pattimakiel says. “You may be getting a certain dose at one time and another in the next batch.” Another concern is the possibility of contamination.

Can I completely avoid menopause symptoms?

“Yes, if you have great genetics,” laughs Pinkerton.

Remember, not every woman has severe menopause symptoms. Most have just mild ones.

SOURCES: Lynn Pattimakiel, MD, internist, the Center for Specialized Women’s Health, Cleveland Clinic. JoAnn Pinkerton, MD, professor of obstetrics and gynecology; director of the Midlife Health Center at the University of Virginia, Charlottesville, VA ; member, Board of Trustees for the North American Menopause Society. Womenshealth.gov: “Menopausal hormone therapy (MHT).” Collaborative Group on Epidemiological Studies of Ovarian Cancer, The Lancet, published online Feb. 12, 2015. News release, Royal College of Obstetricians and Gynaecologists. News release, National Institutes of Health. Women’s Health Initiative web site. National Institutes of Health: “Facts About Menopausal Hormonal Therapy.” Centers for Disease Control and Prevention: ” Hormone Replacement Therapy: Knowledge and Use in the United States.” Bluming, A. Cancer Journal, March-April 2009. Schierbeck, L. British Medical Journal, 2012. News release, Cochrane Library. ENDO 2015: The Endocrine Society Annual Meeting. U.S. Food and Drug Administration: “Compounded Menopausal Hormone Therapy Questions and Answers.”

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