What Is HRT? A Guide to Hormone Therapy for Women

Hormone replacement therapy (HRT), also called menopause hormone therapy, is a treatment for the symptoms of perimenopause and menopause. It works by supplementing the reproductive hormones your body naturally produces less of as you approach menopause.

If you're dealing with hot flashes, trouble sleeping, mood changes, or vaginal dryness, HRT is one of the most effective treatment options available. But there's a lot of conflicting information out there, and it can be hard to sort through what's current and what's outdated.

This guide covers how HRT works, the types available, the benefits, and the risks, so you can have a more informed conversation with your provider.

How Does HRT Work?

As you approach menopause, your ovaries gradually stop producing estrogen and progesterone. This decline is what causes most menopause symptoms.

Estrogen levels start dropping during perimenopause, the transitional phase leading up to menopause. Perimenopause typically begins in your mid-40s (sometimes earlier) and lasts 4 to 8 years on average. You've officially reached menopause when you've gone 12 consecutive months without a period.

HRT works by raising your estrogen levels enough to relieve symptoms. It can be delivered systemically (throughout your body) or locally (targeted to a specific area, like vaginal tissue).

Types of Hormone Replacement Therapy

HRT falls into two main categories: systemic and local. If HRT is right for you, your provider will consider your symptoms, health history, and preferences when recommending a specific type and form.

Systemic Hormone Therapy

Systemic HRT enters your bloodstream and circulates throughout your body. It contains higher doses of estrogen than localized treatments and is used to treat a wider range of symptoms, including hot flashes, night sweats, mood changes, sleep disruption, and vaginal symptoms.

Forms of systemic HRT include:

• Estrogen-only pills
• Combined estrogen and progesterone pills
• Skin patches (estrogen-only or combined)
• Gels and sprays applied to the skin

Estrogen-Only vs. Combined Therapy

If you've had a hysterectomy, your provider will typically prescribe estrogen-only therapy. If you still have your uterus, you'll need a combination of estrogen and progesterone.

The reason: estrogen on its own can cause the uterine lining to grow abnormally, which increases the risk of endometrial cancer. Progesterone balances this out and protects the uterine lining.

HRT can be taken continuously or, for those who still get a period, in cycles. Cyclic HRT mimics your menstrual cycle, with daily estrogen and progesterone added for about two weeks each month. Continuous HRT is usually for women who are postmenopausal and prefer to avoid monthly bleeding.

Local (Low-Dose Vaginal) Estrogen

Local estrogen therapy is designed specifically for vaginal and urinary symptoms: dryness, itching, pain during sex, and recurrent urinary tract infections.

It delivers a low dose of estrogen directly to vaginal tissue, with minimal absorption into the bloodstream. It comes as vaginal cream, suppositories, or a timed-release ring.

Because the dose is low and localized, it carries fewer risks than systemic HRT and is considered safe for long-term use. But it won't help with symptoms like hot flashes, mood changes, or sleep problems. It's a common choice for women who have already reached menopause, since vaginal symptoms tend to persist or get worse without treatment even as other symptoms improve.

The Benefits of HRT

HRT is the most effective available treatment for menopause symptoms. Studies show it helps with:

• Hot flashes and night sweats
• Vaginal dryness and irritation
• Pain during sexual activity
• Mood changes and irritability
• Sleep disruption and insomnia
• Urinary symptoms (leaking, urgency, recurrent UTIs)
• Joint pain and stiffness

The Risks of HRT

The risks of HRT are relatively low for most healthy women, but they exist and are worth understanding. Risk levels vary based on your age, health history, and the type of HRT you use.

Research has linked HRT to a slightly increased risk of:

Breast cancer. For most women, the relative risk is small and comparable to risk factors like obesity and low physical activity. Risk varies based on the type of HRT and how long you use it. The estrogen-only arm of the WHI study actually showed a decrease in breast cancer risk. Combined therapy carries a small increase.

Blood clots and stroke. HRT pills have been associated with a slightly increased risk, but the risk is very low for women under 60. Patches, gels, and sprays don't carry this same risk because they bypass the liver.

Endometrial cancer. Only a concern for women with a uterus who take estrogen without progesterone. Combined therapy eliminates this risk.

Gallbladder issues. HRT can increase the risk of gallstones and gallbladder disease.

Who Should Not Take HRT

HRT may not be suitable for you if you are pregnant or have a history of breast, ovarian, or uterine cancer, blood clots or stroke, liver disease, unmanaged high blood pressure, or heart disease.

If any of these apply, talk to your provider about alternatives. There are effective non-hormonal options available.

HRT Side Effects

Like any medication, HRT can cause side effects, especially in the first few weeks as your body adjusts. Common side effects include headaches, breast tenderness, spotting between periods, nausea, mood changes, fatigue, and skin changes.

These typically improve within a few weeks. If side effects persist or bother you, your provider can adjust your dose or switch you to a different formulation.

Alternatives to HRT

If HRT isn't an option or the right fit, there are non-hormonal treatments that can help manage menopause symptoms:

• SSRIs and SNRIs (antidepressants) can reduce hot flashes and help stabilize mood.
• Gabapentin may reduce hot flashes and improve sleep.
• Fezolinetant (Veozah) is FDA-approved specifically for menopause-related hot flashes and night sweats. It's non-hormonal.
• Ospemifene is a non-hormonal pill that improves vaginal dryness and reduces pain during sex.
• Vaginal moisturizers and lubricants for dryness relief. Look for fragrance-free, pH-balanced options.

Lifestyle changes also matter: regular exercise (especially strength training), balanced nutrition, stress management, and good sleep hygiene can all help reduce the severity of symptoms.

The Bottom Line

HRT is a safe and effective treatment for most women going through perimenopause and menopause. It comes in many forms, and the right choice depends on your symptoms, health history, and personal preferences. The most important thing is working with a provider who understands menopause and can help you weigh the options.

If you're experiencing menopause symptoms and want to understand your options, Embirwell's free assessment takes a few minutes and connects you with a clinician who specializes in menopause care.