Waking up flushed and sweaty several times 

a night left Cathy feeling tired all day. But 

when she began to feel hot on and off during 

the day as well, she went to see Dr. Kent. He 

told Cathy she was having hot flashes—a 

sign that she was starting the menopause 

transition. Dr. Kent talked about several 

ways to control her hot flashes. One was to 

use the hormone estrogen for a short time. 

He talked about the benefits and risks of this 

choice. Cathy said she remembered hearing 

something on a TV talk show about using 

hormones around menopause. Were they 

helpful? Were they safe? She didn’t know.

A hormone is a chemical substance made by an 

organ like the thyroid gland or ovary. Hormones 

control different body functions. Examples of 

hormones are estrogen, progesterone, testosterone, and thyroid hormone. In a woman’s 

body during the menopause transition, the 

months or years right before menopause 

(her final menstrual period), levels of several 

hormones, including estrogen and progesterone, 

go up and down irregularly. This happens as 

the ovaries begin working less and less well.

Menopause is a normal part of aging. It is 

not a disease or disorder. Women who have 

symptoms like hot flashes and night sweats 

may decide to use hormones like estrogen 

because of the benefits, but there are also 

side effects and risks to consider. 

Dr. Kent told Cathy to call back for a 

prescription if she decided to try using 

hormones to relieve her symptoms. She read 

pamphlets from the doctor’s office and talked 

to her friends. Lily, who had surgery to remove 

her uterus and ovaries, has been taking the 

hormone estrogen since the operation. Sandy 

said she’s had a few hot flashes, but isn’t really 

uncomfortable enough to take hormones. 

Melissa is bothered by hot flashes and can’t 

sleep, but her doctor thinks she should not use 

estrogen because her younger sister has breast 

cancer. Each friend had a different story. 

Cathy wanted more information. 

What about hormones?

Symptoms such as hot flashes might result 

from the changing hormone levels during 

the menopause transition. After a woman’s 

last menstrual period, when her ovaries make 

much less estrogen and progesterone, some 

symptoms of menopause might disappear, 

but others may continue or get worse.

Hormones and Menopause

Tips from the National Institute on Aging

National Institute on Aging 

National Institutes of health

NIH... Turning Discovery into Health®

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
HORMONES AND MENOPAUSE

2

To help relieve these symptoms, some women 

use hormones. This is called menopausal 

hormone therapy (MHT). This approach used to 

be called hormone replacement therapy or HRT. 

MHT is a more current, umbrella term that 

describes several different hormone combinations available in a variety of forms and doses.

How would I use menopausal 

hormone therapy?

Estrogen is a hormone used to relieve the 

symptoms of menopause. A woman whose 

uterus has been removed can use estrogen 

only (E). But a woman who still has a uterus 

must add progesterone or a progestin 

(synthetic progesterone) along with the 

estrogen (E+P). This combination lowers 

the chance of an unwanted thickening of 

the lining of the uterus and reduces the risk 

of cancer of the uterus, an uncommon, but 

possible result of using estrogen alone.

Cathy’s friend Stephanie takes a pill containing 

estrogen and progestin, but Cathy has trouble 

swallowing pills. If MHT is only available as 

a pill, that is something she’d consider when 

making her decision.

Estrogen comes in many forms. Cathy 

could use a skin patch, vaginal tablet, or 

cream; take a pill; or get an implant, shot, or 

vaginal ring insert. She could even apply a 

gel or spray. There are also different types of 

estrogen (such as estradiol and conjugated 

estrogens). Estradiol is the most important 

type of estrogen in a woman’s body before 

menopause. Other hormones, progesterone 

or progestin, can be taken as a pill, sometimes 

in the same pill as the estrogen, as well as a 

patch (combined with estrogen), shot, IUD 

(intrauterine device), gel, or vaginal 

suppository.

The form of MHT your doctor suggests may 

depend on your symptoms. For example, 

an estrogen patch (also called transdermal 

estrogen) or pill (oral estrogen) can relieve 

hot flashes, night sweats (hot flashes that 

bother you at night), and vaginal dryness. 

Other forms—vaginal creams, tablets, or 

rings—are used mostly for vaginal dryness 

alone. The vaginal ring insert might also 

help some urinary tract symptoms. 

The dose can also vary, as can the timing of 

those doses. Some doctors suggest that 

estrogen be used every day, but that the 

progesterone or progestin be used cyclically—

for 10 to 14 straight days every 4 weeks. A 

cyclic schedule is thought to mimic how the 

body makes estrogen and progesterone 

before menopause. This approach can cause 

some spotting or bleeding, like a light period, 

which might get lighter or go away in time. 

Alternatively, some women take estrogen 

and progesterone or progestin continuously—

every day of the month. 

Is there a downside to 

taking hormones?

A lot of the information Cathy read said that 

taking estrogen is the most effective way to 

relieve hot flashes, night sweats, and vaginal 

dryness. Estrogen also helps keep bones strong. 

Cathy thought that those seemed like good 

reasons to use MHT. But she wondered, is 

there a downside?

Research has found that, for some women, 

there are serious risks, including an increased 

chance of heart disease, stroke, blood clots, 

and breast cancer, when using MHT. The 

Women’s Health Initiative (see page 3) also 

found an increased risk of possible dementia 

in women who started MHT after age 65. 

These concerns are why every woman 
TIPs from the National Institute on Aging

3

needs to think a lot before deciding to use 

menopausal hormone therapy.

Also, some women develop noticeable side 

effects from using hormones:

•	 Breast tenderness 

•	 Spotting or a return of monthly periods 

•	 Cramping 

•	 Bloating

By changing the type or amount of the 

hormones, the way they are taken, or the 

timing of the doses, your doctor may be able 

to help control these side effects. Or, over 

time, they may go away on their own.

What more should I know about 

the benefits and risks of hormones? 

Cathy knows there have been news stories 

about menopausal hormone therapy research 

findings. But, several years ago, when she first 

heard about the risks of using estrogen, she 

didn’t really pay attention. Now she wants to 

know more about the risks.

Over the years, research findings have led to a 

variety of positive, negative, and sometimes 

conflicting reports about menopausal 

hormone therapy. Some of these findings 

came from randomized clinical trials, the 

most convincing type of research. Historically, clinical trials often used one type of 

estrogen called conjugated estrogens. Several 

other types of estrogen, as well as progesterone and progestins, have also been tested in 

small trials to see if they have an effect on 

heart disease, breast cancer, or dementia. 

Let’s look more closely at what we have 

learned from these small studies.

Hot flashes and night sweats. Estrogen will 

relieve most women’s hot flashes and night 

sweats. If you stop using estrogen, you may 

again start having hot flashes. Lifestyle 

changes and certain prescription medicines 

also might help some women with hot 

flashes. For most women, hot flashes and 

night sweats go away in time. 

Vaginal dryness. Estrogen improves vaginal 

dryness, probably for as long as you continue 

to use it. If vaginal dryness is your only 

symptom, your doctor might prescribe a 

vaginal estrogen. A water-based lubricant, 

but not petroleum jelly, may also relieve 

vaginal discomfort.

Cholesterol levels. Estrogen improves 

cholesterol levels, lowering LDLs (the “bad” 

kind of cholesterol) and raising HDLs (the 

“good” kind of cholesterol). The pill form of 

estrogen can cause the level of triglycerides 

(a type of fat in the blood) to go up. The 

estrogen patch does not seem to have this 

effect, but it also does not improve cholesterol to the same degree as the pill form. But, 

improving cholesterol levels is not a reason 

to take estrogen. Other medicines and 

lifestyle changes will improve cholesterol 

levels more effectively.

What is the Women’s Health 

Initiative? What have we learned 

from it?

Before menopause, women generally have 

a lower risk of heart disease than men. 

This led experts to wonder whether giving 

women estrogen after menopause might 

help prevent heart disease. In 1992, the 

National Institutes of Health (NIH), the 

nation’s premier medical research agency, 

began the Women’s Health Initiative 

(WHI) to explore ways postmenopausal 
HORMONES AND MENOPAUSE

4

women might prevent heart disease, as 

well as osteoporosis and cancer. One part 

of the WHI, the Hormone Trial, looked at 

oral conjugated estrogens used alone (E 

therapy or ET) or with a particular progestin 

(EPT) to see if, in postmenopausal women, 

estrogen could prevent heart disease without 

increasing the chance of breast cancer. 

In July 2002, the EPT part of the WHI 

Hormone Trial was stopped early because it 

became clear to the researchers that the overall 

risk of taking E+P outweighed the benefits: 

Benefits

•	 Fewer fractures 

•	 Less chance of cancer in the colon and/

or rectum 

Risks

•	 More strokes 

•	 More serious blood clots 

•	 More heart attacks 

•	 More breast cancers 

In April 2004, the rest of the Hormone Trial, 

the E alone or ET trial, was also halted 

because using estrogen alone increased the 

risk of stroke, and it was not likely that there 

would be a positive effect on heart attacks. 

Unlike using estrogen plus progestin, using 

estrogen alone did not increase the risk of 

heart attacks or breast cancer, but like the 

EPT trial, there were fewer fractures. 

During the first 3 years after stopping the 

WHI EPT trial, women were no longer at 

greater risk of heart disease, stroke, or serious 

blood clots than women who had not used 

MHT. On the other hand, they also no longer 

had greater protection from fractures. The 

women still had an increased risk of breast 

cancer, but their risk was smaller than it was 

while they were using hormones. During the 

first 4 years after stopping the WHI ET trial, 

the increased risk of stroke disappeared, there 

was no effect on risk of heart attack, but the 

slightly lower risk of breast cancer continued.

It appears from the WHI that women should 

not begin using MHT to protect their health—

it does not appear to prevent heart disease 

or dementia when started several years after 

menopause. In fact, older women in the 

study using MHT were at increased risk of 

certain diseases. Women who were less than 

age 60 did not appear to be at increased risk 

of heart disease but were at increased risk of 

stroke. For these women, the overall risks and 

benefits appeared to be balanced, but there is 

no strong evidence to support women under 

age 60 using MHT to prevent chronic diseases 

of aging, such as heart disease and dementia. 

It is important to remember that the WHI 

findings are based on the specific oral form 

(rather than patch, gel, etc.), dose, and type of 

estrogen and progestin studied in the WHI. 

Which hormones and dose you use and the 

way you take them might change these benefits 

and risks. We don’t know how the WHI 

findings apply to these other types, forms, and 

doses of estrogen and progesterone or progestin. 

What are some other options?

Cathy is like a lot of women bothered by 

symptoms of menopause. After learning 

about some research results, she is concerned 

The U.S. Food and Drug Administration 

(FDA) now recommends that women 

with moderate to severe menopausal 

symptoms who want to try menopausal 

hormone therapy for relief use it for the 

shortest time needed and at the lowest 

effective dose.
TIPs from the National Institute on Aging

5

about using menopausal hormone therapy 

for relief of her symptoms. But it’s been 

several years since some study findings raised 

concerns, and now Cathy is wondering 

whether there is anything new. 

Women now have more options than when 

the WHI study was first planned. More 

types of estrogens are available, and some 

of them come in a variety of forms. For 

example, synthetic estradiol, now available 

in several forms (pill, patch, cream, gel, 

etc.), is chemically identical to the estrogen 

most active in women’s bodies before 

menopause. If it is not taken by mouth, but 

rather applied to the skin or taken as a shot, 

estradiol appears to work the same way as 

estradiol made in the body. Lower doses of 

estrogen are available. Investigators are now 

studying a low-dose estradiol patch (transdermal estradiol) compared to a low-dose 

conjugated-estrogens pill to see whether 

one or both slow hardening of the arteries in 

women around the age of menopause and 

whether the estradiol patch is as effective 

and, perhaps, safer than the conjugatedestrogens pill. These alternatives are creating 

more choices for women seeking relief from 

their menopausal symptoms, as well as a 

variety of new opportunities for research.

Besides a pill, some estrogens come in 

different and sometimes new forms—skin 

patch, gel, emulsion, spray, and vaginal ring, 

cream, and tablet. These forms work in the 

body somewhat differently than a pill by 

entering your body directly through the skin 

or walls of the vagina. Oral estrogen (a pill) 

is chemically changed in the liver before 

reaching your tissues. Some studies suggest 

that if estrogen enters through the skin and 

bypasses the liver, the risk of serious blood 

clots might be lower. Others suggest a lower 

risk of gallbladder disease. This may also 

allow a change in dosage—further testing may 

show that the same benefits might come from 

lower doses than are needed with a pill.

What questions remain 

unanswered?

Cathy was beginning to understand more about 

the benefits and risks of using hormones, but 

she wondered whether there are still questions 

about the WHI results and menopausal 

hormone therapy in general. What else needs 

to be looked at?

Experts now know more about menopause 

and have a better understanding of what the 

WHI results mean. But, they have new 

questions also. 

•	 The average age of women participating 

in the trial was 63, more than 10 years 

older than the average age of menopause, 

and the WHI was looking at reducing 

the risk of chronic diseases of growing 

older like heart disease and osteoporosis. 

Do the WHI results apply to younger 

women choosing MHT to relieve symptoms around the time of menopause 

or to women who have early surgical 

menopause (surgery to remove both 

ovaries or the uterus)? 

•	 Other studies show that lower doses of 

estrogen than were studied in the WHI 

provide relief from symptoms of menopause for some women and still help 

women maintain bone density. What are 

the long-term benefits and risks of lower 

doses of estrogen? 

•	 In the WHI, women using E alone 

did not seem to have a greater risk of 

heart disease than women not using 

hormones. Does this mean that healthy 

women in their 50s who start using 

estrogen alone are not at higher eventual 
HORMONES AND MENOPAUSE

6

risk for heart disease than women who 

don’t use estrogen? 

•	 Would using progesterone or a different 

progestin than the one used in the WHI 

be less risky to a woman’s heart, blood 

vessels, and breasts? 

•	 The combination menopausal hormone 

therapy used in the WHI makes it 

somewhat more likely that a woman 

could develop breast cancer, especially 

with long-term use. Is using a different 

type of estrogen, a smaller dose of 

estrogen or progesterone, or a different 

progestin (instead of medroxyprogesterone acetate) safer? 

•	 Does using estrogen around the time of 

menopause increase the risk of possible 

dementia in later life, as starting it after 

age 65 did in the WHI Memory Study 

(WHIMS)? Or does it decrease the risk 

of dementia later in life?

The National Institute on Aging and other 

parts of the National Institutes of Health, 

along with other medical research centers, 

continue to explore questions such as these. 

They hope that in the future these studies 

will give women additional facts needed to 

make informed decisions about relieving 

menopausal symptoms.

What are “natural hormones”?

Cathy’s friend Susan thinks she is not at risk 

for serious side effects from menopausal 

hormone therapy because she uses “natural 

hormones” to treat her hot flashes and night 

sweats. Cathy asked Dr. Kent about them. 

He told her that there is very little reliable 

scientific information from high-quality 

clinical trials about the safety of “natural” or 

compounded hormones, how well they control 

the symptoms of menopause, and whether 

they are as good or better to use than 

FDA-approved estrogens, progesterone, 

and progestins.

The “natural hormones” Susan uses are 

estrogen and progesterone made from 

plants such as soy or yams. Some people also 

call them bioidentical hormones because 

they are supposed to be chemically the 

same as the hormones naturally made by 

a woman’s body. These so-called natural 

hormones are put together (compounded) 

by a compounding pharmacist. This 

pharmacist follows a formula decided on 

by a doctor familiar with this approach. 

Compounded hormones are not regulated 

or approved by the FDA. So, we don’t know 

much about how safe or effective they are 

or how the quality and quantity vary from 

batch to batch. 

Some drug companies also make estrogens 

and progesterone from plants like soy and 

yams. Some of these are also chemically 

identical to the hormones made by your 

body. These other forms of MHT are 

available by prescription. Importantly, 

these estrogens and progesterone made by 

drug companies are regulated and approved 

by the FDA.

There are also “natural” treatments for the 

symptoms of menopause that are available 

over-the-counter, without a prescription. 

Black cohosh is one that women use, but a 

couple of clinical trials have shown that it 

did not relieve hot flashes in postmenopausal 

women or those approaching menopause. 

Because of rare reports of serious liver 

disease, scientists are concerned about the 

possible effects of black cohosh on the liver. 

Other “natural” treatments are made from 

soy or yams. None of these are regulated or 

approved by the FDA.
TIPs from the National Institute on Aging

7

In all cases, talk to your doctor about how best 

to treat or prevent your menopause symptoms 

or diseases for which you are at risk. 

If you are already using menopausal hormone 

therapy and think you would like to stop, first 

ask your doctor how to do that. Some doctors 

suggest tapering off slowly.

Whatever decision you make now about 

using MHT is not final. You can start or end 

the treatment at any time, although, as we 

learned from the WHI, it appears that it is 

best not to start MHT many years after 

menopause. If you stop, some of your risks 

will lessen over time, but so will the benefits. 

Discuss your decision about menopausal 

hormone therapy with your doctor at your 

annual checkup.

MHT is not one size fits all

Cathy realized that talking to her friends about 

what each is doing to relieve menopause 

symptoms was helpful, but that her decision 

needed to be just for her. And she was sure that 

basing her decision just on what she heard on 

a TV show might not be the best way to choose. 

She tried to find sources of information that 

seemed to be unbiased and didn’t have a 

product to promote. She felt most comfortable 

with science-based websites like the National 

Institutes of Health, the U.S. Food and Drug 

Administration, or doctors’ professional groups.

Each woman is different, and the decision for 

each one about menopausal hormone therapy 

will probably also be different. But, almost 

every research study helps give women and 

their doctors more information to answer the 

question: Is menopausal hormone therapy 

right for me?

What’s right for me? 

There is no single answer for all women who 

are trying to decide whether to use MHT. You 

have to look at your own needs and weigh 

your own risks. Here are some questions you 

can ask yourself and talk to your doctor about:

•	 Do menopausal symptoms such as hot 

flashes or vaginal dryness bother me a 

lot? Like many women, your hot flashes 

or night sweats will likely go away over 

time, but vaginal dryness may not. MHT 

can help with troubling symptoms. 

•	 Am I at risk for developing osteoporosis?

Estrogen might protect bone mass while 

you use it. However, there are other 

drugs that can protect your bones without MHT’s risks. Talk to your doctor 

about the risks and benefits of those 

medicines for you. 

•	 Do I have a history of heart disease or 

risk factors such as high blood cholesterol?

If so, using estrogen and progestin can 

increase that risk even more. 

•	 Do I have a family history of breast 

cancer? If you have a family history of 

breast cancer, check with your doctor 

about your risk. 

•	 I have high levels of triglycerides and 

a family history of gallbladder disease. 

Can I use MHT? The safety of any kind 

of MHT in women with high levels of 

triglycerides or a family history of gallbladder disease is not known. But some 

experts think that using a patch will not 

raise your triglyceride level or increase 

your chance of gallbladder problems. 

Using an oral estrogen pill might. 

•	 Do I have liver disease or a history of 

stroke or blood clots in my veins? MHT, 

especially taken by mouth, might not be 

safe for you to use.
HORMONES AND MENOPAUSE

For More Information

Other resources on menopausal hormone 

therapy include:

National Institutes of Health

Menopausal Hormone Therapy Information

www.nih.gov/PHTindex.htm

The National Library of Medicine 

MedlinePlus 

www.medlineplus.gov 

The National Library of Medicine website 

has information on many health subjects, 

including menopause. Click on Health 

Topics. Choose any topic you are interested 

in, such as menopause, menopausal 

hormone therapy, or osteoporosis, by 

clicking on the first letter of the topics and 

scrolling down the list to find it.

American College of Obstetricians 

and Gynecologists

409 12th Street, SW

P.O. Box 70620

Washington, DC 20024-9998

1-202-638-5577

1-800-673-8444 (toll-free)

www.acog.org

Food and Drug Administration

10903 New Hampshire Avenue

Silver Spring, MD 20993-0002

1-888-463-6332 (toll-free)

www.fda.gov

North American Menopause Society

5900 Landerbrook Drive

Suite 390

Mayfield Heights, OH 44124

1-440-442-7550

www.menopause.org

To order free publications (in English or Spanish) or sign up for email alerts, go to www.nia.nih.gov/health

Visit www.nihseniorhealth.gov, a senior-friendly website from the National Institute on Aging and the National Library of 

Medicine. This website has health and wellness information for older adults. Special features make it simple to use. 

For example, you can click on a button to make the type larger.

august 2012

NIH Publication NO. 09-7482

For more information about health and aging, contact:

National Institute on Aging Information Center

P.O. Box 8057

Gaithersburg, MD 20898-8057

1-800-222-2225 (toll-free)

1-800-222-4225 (TTY/toll-free)

www.nia.nih.gov

www.nia.nih.gov/espanol