Menopause is having a moment, UCHealth’s Dr. Nanette Santoro likes to say. Conversations about hot flashes, night sweats and hormone therapy are everywhere, thanks to celebrity podcasts and endless social media posts, along with new government rules and research findings.

And the biggest menopause news centers on hormone therapy medications.

Leaders at the U.S. Food and Drug Administration (FDA) recently announced that menopausal hormone therapy medications no longer require a “black-box” warning. That type of warning is the most serious safety alert for medications, and for more than two decades, many women have been afraid to use hormone therapy because they worried that the medication would increase their risk of getting breast cancer and heart disease.

So, what is the truth about hormone therapy and cancer risk? How safe are hormone therapy medications? Do they help with challenging menopause symptoms? And what are the signs that you may need hormone therapy?

To answer common questions about menopause and hormone therapy, we consulted with Santoro, who is also the E. Stewart Taylor Professor of obstetrics and gynecology at the University of Colorado Anschutz School of Medicine.

The good news is that most women can safely take hormone therapy and find relief from hot flashes and other issues they may be experiencing, Santoro said.

“There’s no need for women to suffer in silence with their symptoms,” she said.

“Menopause is having a moment, and I think it’s a good moment,” Santoro told medical providers during an education session about menopause and hormone therapy at UCHealth University of Colorado Hospital. “It’s good to bring attention to the condition. It’s universal for women.”

What is menopause, and when does the transition to menopause usually happen?

Menopause refers to the stage of life when a woman no longer has menstrual cycles. Santoro emphasized that this is “a natural life passage.”

For many women, the symptoms associated with menopause – hot flashes, night sweats, mood changes, vaginal dryness and others – begin during perimenopause, up to 10 years before they have their last period. During perimenopause, a woman’s levels of the hormones estrogen and progesterone begin to fluctuate and decline as her monthly periods become irregular.

Some women will notice they skipped a period, or their cycle becomes less predictable. This is the early transition to menopause.

When a woman’s periods start to last longer, or if a woman has gone two months or more without a period, she’s getting closer to menopause. By the time a woman is 49, she’s 95% likely to have her final period within four years, Santoro said.

A woman enters menopause when she’s gone one year without a period. Women also can go into menopause earlier if surgeons remove their ovaries or if they need chemotherapy or radiation treatments for ovarian or pelvic cancer.

What is menopausal hormone therapy, and why do women use it?

Hormone therapy provides the body with estrogen and sometimes progesterone. Hormone therapy treats many of the symptoms of menopause, especially the dreaded hot flashes.

Is hormone therapy, or HT, the same as menopausal hormone therapy?

Yes. For years, doctors and patients called hormone therapy hormone replacement therapy, or HRT, but most providers now avoid using the word “replacement.”

“It (the word replacement) implies that women without estrogen are deficient,” Santoro said. “It also is used to create a fear-based narrative that sells hormones to women by putting them into a state of panic that they are losing something priceless when their ovaries produce less estrogen.”

These days, instead of using the term HRT, many doctors now call the medications hormone therapy, menopausal hormone therapy or female hormone therapy,

And it’s important to know that about 25% of women shouldn’t take hormone therapy, Santoro said.

Who should not use menopausal hormone therapy?

• Women who have estrogen-dependent cancers, including breast, ovarian and uterine cancer.
• Women who have a strong family history of estrogen-dependent cancers.
• Women with liver disease.
• Women with blood-clotting disorders.
• Women who are at high risk of having a stroke.
• Women who smoke.

Fortunately, many of these women can take new non-hormonal, FDA-approved medications to treat hot flashes, Santoro said.

Why is hormone therapy considered safe for most women?

Most healthy women under age 60 or those who are within 10 years of the onset of menopause can safely use hormone therapy for the most bothersome symptoms, Santoro said.

Concerns about the safety of hormone therapy – and possible increased risks of breast cancer – date to 2002, when researchers doing a large study called the Women’s Health Initiative released their findings about hormone therapy. The findings indicated that women taking hormones were at a higher risk of developing breast cancer.

Unfortunately, the findings turned out to be incorrect. Here’s why the initial interpretation of the Women’s Health Initiative study was incorrect, according to Santoro:

• The increase in breast cancer rates was statistically insignificant.
• The average age of women in the study was 63, a decade older than the average age when women start menopausal symptoms.
• The study participants received a type of hormone therapy that doctors no longer use.

But the damage already had been done.

Health experts from an arm of the National Institutes of Health took the extraordinary step of halting the Women’s Health initiative study early. Intense media coverage followed and sparked fear, causing millions of women to avoid hormone therapy.

Hormone therapy and breast cancer risk: What the research shows

One finding about hormone therapy and the risk of breast cancer has held up over time, Santoro said.

There is a small but statistically significant increase in the risk of breast cancer for women who have not had hysterectomies (and thus, still have a uterus) and are taking estrogen plus progestin, a synthetic form of progesterone. But researchers also showed that women who had hysterectomies and took estrogen alone had a decreased risk of breast cancer compared to women who took no hormones. That finding received far less publicity and remains under-appreciated, Santoro said.

Subsequent studies of the same women who participated in the original study also showed no differences in mortality between hormone users and non-users when they started hormones between the ages of 50 and 60. Doctors do not recommend hormone therapy for women age 70 and over because they face increased risk of heart disease, stroke and breast cancer, among other risks. Researchers don’t know whether the types of hormone combinations that doctors currently give women (naturally occurring estradiol and progesterone) would have resulted in different outcomes, she said.

The risk of breast cancer associated with hormone therapy use was consistent with prior studies, and the increased risk was small. Researchers, doctors and women have tended to overlook this finding, Santoro said.

Here are the facts about hormone therapy and increased risk of breast cancer:

• For every 10,000 women, ages 50 to 79, statisticians would expect about 600 people to get breast cancer even if they never used hormone therapy.
• If 10,000 women in that same group — ages 50 to 79 — took estrogen plus progestin hormone therapy, about 608 would get breast cancer compared with the baseline of 600.
• So, the increased risk of getting breast cancer after using hormone therapy is small for most women, Santoro said.

That’s why Santoro encourages women to talk with their medical providers so they can evaluate their individual risks and make informed decisions about whether hormone therapy is right for them.

Are there increased risks of cardiovascular disease for women who use hormone therapy?

In 2002, the Women’s Health Initiative researchers also warned that hormone therapy could cause heart disease, blood clots and stroke. But subsequent studies from the Women’s Health Initiative team and others have not shown increased risks for heart disease over time.

Researchers have determined that the risk of blood clots is greater in women who take estrogen in a pill, which was the predominant way doctors prescribed it during the early 2000s. Medical experts now believe that using non-oral estrogen (usually an estradiol patch) minimizes the risk of blood clots, although more research is needed, Santoro said.

She said the risk of getting a blood clot or heart disease from hormone therapy is very low for most women in their 50s who are within 10 years of menopause. The risk of stroke is slightly higher for people using hormone therapy. Women who have had a previous blood clot, have high blood pressure or are at high risk of suffering a stroke should discuss their risks and concerns with their doctor, Santoro said.

How do you take hormone therapy? Do women get injections or take pills?

No. Hormone therapy medications are not injections. Women typically use estrogen patches or gel, and pills are also available. Women apply hormone patches like an adhesive bandage, making them easy to use. Patches are safer than pills for most women because they bypass the liver and have a slightly lower risk of causing blood clots. Women who have vaginal dryness as their sole menopausal symptom can apply estrogen in a cream form.

Is there a shortage of estrogen patches right now?

Yes. Experts with the American Society of Health-System Pharmacists are reporting shortages of some estradiol patches. Doctors and drug makers say that the shortages may be linked to increased demand for hormone therapy now that FDA officials no longer are requiring safety warnings for the patches.

Does hormone therapy slow aging?

No. Contrary to posts you might see on TikTok or Instagram, hormone therapy has never been proven to prevent aging or other conditions that come with aging, including heart disease or dementia, though researchers are continuing to study many possible connections with hormone therapy and various health impacts, Santoro said.

What does hormone therapy help with?

“We are talking about symptom treatment,” Santoro said. “We are not talking about disease prevention.”

For most women, hormone therapy can provide relief from hot flashes, restless nights, vaginal dryness and more, Santoro said.

“No one needs to suffer with menopausal symptoms,” she said. “Many treatments are available and effective, and we often wait too long to use them.”

What are the signs that I might need hormone therapy?

For most women, hormone therapy can help with the most common symptoms of perimenopause and menopause.

These common symptoms of menopause include:

• Hot flashes
• Sudores nocturnos
• Vaginal dryness
• Poor sleep
• Mood changes, including anxiety and depression

The symptoms are most severe before a woman’s final menstrual period and the official transition to menopause, Santoro said.

“So, waiting until someone’s menopausal to treat her for symptoms is waiting too long,” Santoro said.

At what age should I start hormone therapy treatment? 

It’s important for women and their doctors to understand the menopause timeline, recognize the symptoms and plan for when it might be the right time to start hormone therapy.

While menopause is defined as the end of menstrual cycles, symptoms often begin years earlier, and the best age to start hormone therapy is not the same for each woman. Those who have early or premature menopause, sometimes in their early 40s or even late 30s, should talk with their doctor about their symptoms and the potential benefits of hormone therapy.

“On average, late 40s and early-to-mid-50s is really the prime time when hormones have the most benefit with the least risk,” Santoro said.

Can I try hormone therapy for a short period or stop taking it at any time? 

If your menstrual cycles are still predictable but you’re starting to have some menopausal symptoms, Santoro recommends giving hormone therapy a try.

“One way to sort out ‘Is it menopause? Is it not menopause?’ is to try hormones,” Santoro said.  “I often will tell my patients, ‘Just date them. You’re not getting married here.’”

As long as a patient has no obvious medical risks that would bar her from using hormone therapy, there is little harm in a 3-month trial to see if menopausal symptoms decrease. Women can even stop the hormones and restart them again to be sure it was the hormones that helped alleviate their symptoms.

What medical conditions can mimic menopause symptoms?

Other conditions can cause symptoms that are similar to symptoms that women experience during menopause. Especially if women are dealing with fatigue, women should check with their doctors because they could be dealing with fibromyalgia, chronic fatigue syndrome and autoimmune disorders.

Santoro warned against assuming that hormones are the root cause of all symptoms.

“If the hormones don’t seem to be helping, it’s time to look for other causes,” she said. “Lots of things are happening to women in midlife.”

How long can I stay on hormone therapy?

Women under age 60 who are within 10 years of menopause can stay on hormones for as long as they are experiencing symptoms, Santoro said.

After age 60, the risks of heart disease, blood clots and stroke begin to increase, she said.

“And, periodically, everybody needs to be re-evaluated for risks and benefits,” she said.

Are hot flashes and night sweats normal menopause symptoms or a sign of something else? 

Hot flashes and night sweats can be an indicator of your future risk of heart disease, Santoro said.

Researchers have learned that women who have few or no hot flashes have lower risk of heart attacks and other cardiovascular health problems. Women who have early onset of hot flashes, or who had more than six days of hot flashes in the previous two weeks, have a higher rate of heart disease 20 years later, Santoro said.

“Hot flashes are a clue to us to pay attention to that person’s risk factors, because she may be someone who is at higher risk for heart disease,” she said.

Using hormone therapy for hot flashes probably won’t lower your risk of future heart disease, she said. Rather, “it’s tagging someone who’s at high risk.”

What are the best hormone treatments?

When you take a hormone patch or pill, doctors call this systemic estrogen therapy because your body absorbs the hormone. Systemic estrogen therapy is good at treating hot flashes and night sweats and can also help prevent bone loss and osteoporosis.

Pharmacists provide vaginal estrogen as a pill, cream or vaginal ring. It is the treatment of choice to relieve menopause-related vaginal dryness and some urinary symptoms.

Santoro recommends starting with a non-pill type of hormone therapy.

She suggests first trying a patch that contains estradiol, which is a form of estrogen, or one that combines estrogen and progestin.

“There’s almost always a way to find something that’s comfortable for a patient,” Santoro said.

What are the benefits of hormone therapy?

Hormone therapy works well to control menopause symptoms, including hot flashes, night sweats, mood swings and more. Estrogen therapy can help prevent bone loss and lower the risk of osteoporosis.

Common menopause and hormone therapy myths

Santoro said there are common myths about hormone therapy that have gained traction on social media.

Here are the facts about hormone therapy:

• Hormone therapy will not prevent certain health conditions or aging.

“Hormones are not a magical tool to prevent aging, despite what you may be seeing in the media,” she said.

Hormone therapy has not been proven to prevent heart disease or dementia, despite claims on social media, she said.

• Hormone therapy will not help with adrenal fatigue.

Adrenal fatigue is a non-medical term for symptoms that some people claim are the result of underperforming adrenal glands. These glands sit on top of each kidney and release different kinds of hormones, including cortisol and adrenaline.

“Adrenal fatigue is not really a thing, and it is not associated with menopause,” Santoro said. “There’s no sudden drop in adrenal hormones with menopause. In fact, there’s a small increase in adrenal hormones in the late menopause transition.”

• Menopause does not cause a drop in testosterone that contributes to loss of libido.

Testosterone in women remains the same during menopause and may increase, Santoro said.

“So, changes in libido that are linked to hormones are a little bit hard to justify,” she said. “The loss of libido that may happen at this age is more closely associated with age than it is with menopause.”

• Women who have had a hysterectomy do not need to take progesterone to avoid endometrial cancer.

A woman who has had a hysterectomy has a very low risk of endometrial cancer, so adding progesterone only “adds another hormone that may add risks, and it does not have any proven benefits,” she said.

Are hormone therapy treatments unsafe for particular people? 

Your doctor might tell you hormone therapy isn’t right for you if you:

• Have or had certain types of cancer, including breast or uterine cancer and some types of ovarian cancer
• Have had a blood clot
• Have had a stroke or heart attack or have a risk of cardiovascular disease
• Have gallbladder or liver disease
• Are over age 60 and/or had your last menstrual period more than 10 years ago

Does hormone therapy have side effects?

Hormone therapy can cause side effects, so talk with your doctor if you have concerning side effects.

Possible side effects of hormone therapy:

• Alopecia
• Breast pain and tenderness
• Vaginal bleeding (this is less of a concern during the first six months of treatment)
• Cefaleas
• Náuseas
• Aumento de peso
• Cansancio
• Humor

What is the difference between hormone therapy and compounded bioidentical hormones?

Bioidentical hormones are hormones that are chemically the same as the hormones in your body. FDA regulators have approved a number of bioidentical hormone preparations that contain the same hormones as naturally occurring estradiol and progesterone.

Pharmacists in compounding pharmacies make compounded bioidentical hormones. FDA officials do not regulate these for safety and efficacy as a treatment for menopause, do not hold them to the same standard for ‘proof of claim’ and do not require risk disclosures. Compounded bioidentical hormones are not risk free, as some advertisements might suggest. Experts from the National Academy of Medicine recently reviewed the topic and advise against the use of compounded bioidentical hormones.

What if I can’t take hormones, or I want to try a nonhormonal treatment?

FDA officials recently approved Fezolinetant as a new nonhormonal treatment that helps with hot flashes. Doctors can prescribe other nonhormonal drugs to help with symptoms, including Venlafaxine, Citalopram, Gabapentin and Clonidine. Most of these are older drugs that doctors prescribe for other conditions, such as depression, nerve pain and blood pressure, but researchers found that women’s hot flashes got better while on these medications.

Doctors also recommend lifestyle changes that are good for your health anyway, including eating a healthy diet, maintaining good sleep habits and reducing stress.

Should women consider taking testosterone?

Testosterone for women has become a popular topic on social media. But do women need it?

Santoro says, “For the most part, no.”

She said there is no such thing as testosterone deficiency syndrome in women. And menopause does not cause a drop in testosterone, as it does with estrogen.

“There is a wildly lucrative business selling the mystique of testosterone to women,” she said.

But Santoro encourages women to be highly skeptical about claims that they should be using testosterone.

Clinical trials show testosterone does not increase muscle mass or improve fatigue or moods, she said.

(In contrast, weightlifting and strength training are healthy for people of all ages, especially older women who are concerned about bone density.)

Doctors prescribe testosterone for some women with hypoactive sexual desire disorder, or reduced desire for sex.

Santoro advises against using testosterone pellets, which also have become popular on social media. FDA regulators classify them as a dietary supplement.

“I see many pellet survivors in my practice and sometimes it takes a year or more for their hormone levels to come down,” she said.

Can I take hormone therapy if I’m over the age of 60?

Santoro said she’s seeing a growing number of patients over age 60 who are interested in hormone therapy. If women do not have menopause symptoms, there is no reason for them to start taking hormones.

What’s the best advice about hormone therapy for women over the age of 70?

After age 70, women on hormones face a higher risk of blood clots, stroke, and heart disease, and hormone therapy seems to increase these risks, Santoro said.

The biggest challenge is that women are inundated with what she calls a “tsunami of social media enthusiasm” that hormones prevent heart disease, dementia, and many other conditions.

“This is what patients are hearing, so it’s a really tough disinformation battle,” she said.

Experts with the American College of Obstetricians and Gynecologists are publishing a new book for patients that Santoro co-edited with evidence-based information about menopause and hormone therapy.

“That’s going to be really helpful for patients and debunk a lot of mythology,” she said.

Do I need to suffer through menopause?

The bottom line is that menopause is a universal and normal transition for women, but they don’t need to suffer with the symptoms.

Most women under age 60 can safely use hormone therapy for menopausal symptoms in the years before their periods end. Women who have a risk or history of breast cancer, heart disease or blood clots should talk to their doctor to get help with their menopausal symptoms, whether with hormones or other drugs or lifestyle changes.