Can HRT Cause Dizziness?
Yes, dizziness can occur in the context of HRT, but the relationship is complex: dizziness is more commonly associated with menopausal vasomotor symptoms themselves rather than being a direct side effect of HRT, and evidence suggests HRT may actually improve dizziness in women with hot flashes.
Understanding the Relationship Between Menopause, Dizziness, and HRT
The evidence reveals a paradoxical relationship where dizziness appears linked to the menopausal state rather than hormone therapy itself:
Dizziness as a Menopausal Symptom
Women with frequent vasomotor symptoms (hot flashes) have significantly higher rates of dizziness and unsteadiness. In postmenopausal women with daily vasomotor symptoms, 14% reported weekly or daily unsteadiness compared to only 3% of women without vasomotor symptoms (odds ratio 7.58) 1.
Rotatory vertigo is also more common in women with vasomotor symptoms, with 10% of women experiencing daily hot flashes reporting weekly or daily vertigo versus 2% of women without symptoms (odds ratio 5.21) 1.
Recovery from menopause-related dizziness takes longer in women with vasomotor symptoms. Over a 2-month period, women without vasomotor symptoms recovered from vertigo significantly faster than those with hot flashes 2.
HRT's Effect on Dizziness
HRT users had the same prevalence of balance disturbances as non-users in cross-sectional analysis, suggesting HRT does not cause dizziness 1.
Women with vasomotor symptoms who received HRT showed a trend toward faster recovery from dizziness compared to those not treated with HRT, though this did not reach statistical significance in one small study (n=7 vs n=22) 2.
Tibolone (a synthetic steroid with estrogenic, progestogenic, and androgenic properties) demonstrated superior improvement in "feeling dizzy or faint" compared to standard HRT (estradiol valerate plus medroxyprogesterone acetate), with a mean improvement difference of -0.7 ± 0.8 versus -0.0 ± 0.9 (p = 0.004) 3.
Common Side Effects of HRT (Not Including Dizziness)
The well-documented side effects of HRT from clinical guidelines include 4:
- Vaginal bleeding (particularly irregular bleeding requiring endometrial biopsy to rule out hyperplasia)
- Nausea (may improve with transdermal rather than oral administration)
- Breast tenderness
- Migraine headaches
- Mood alterations
- Abdominal bloating
Notably, dizziness is not listed among the common side effects requiring management in guideline-based HRT management protocols 4.
Serious Risks of HRT (Affecting Morbidity and Mortality)
The major risks that should concern clinicians include 5, 6, 7:
- Increased stroke risk (RR 1.12-1.41), which could theoretically cause dizziness as a neurological symptom
- Venous thromboembolism (RR 2.14), highest in the first year of use (RR 3.49)
- Breast cancer incidence increase with combined estrogen-progestin (RH 1.26)
- Coronary heart disease events (RH 1.29) in the WHI study
Clinical Approach to Dizziness in Women on or Considering HRT
If a Patient Reports Dizziness While on HRT:
Evaluate for serious cardiovascular or cerebrovascular events first - stroke, transient ischemic attack, or cardiac arrhythmias, given HRT's known risks for these conditions 5, 7.
Assess whether dizziness preceded HRT initiation or developed afterward - if it preceded HRT and correlates with vasomotor symptoms, HRT may actually help rather than harm 2, 1.
Consider switching from oral to transdermal estradiol if the patient is on oral formulations, as transdermal routes have lower cardiovascular and thrombotic risks 6, 7.
Evaluate for other causes of dizziness through neuro-otological examination, as menopause-related dizziness has multiple potential mechanisms beyond hormone effects 2.
If Dizziness Persists or Worsens:
Consider tibolone as an alternative if available and appropriate, given its superior efficacy for dizziness symptoms compared to standard HRT 3.
Reassess the risk-benefit ratio of continuing HRT, particularly if the patient is over 60 or more than 10 years past menopause, when risks exceed benefits 6, 8.
Critical Caveats
Do not assume dizziness is a benign HRT side effect - it may represent a serious cardiovascular or cerebrovascular complication requiring immediate evaluation 5, 7.
Do not discontinue HRT solely for dizziness without proper evaluation, especially if the patient has severe vasomotor symptoms, as the dizziness may be related to the underlying menopausal state rather than the treatment 2, 1.
Recognize that the evidence linking HRT to dizziness improvement is limited and not definitive - only small studies with trends toward benefit exist 2.