What are the hormonal treatment options for menopause (perimenopause or postmenopause)?

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Dainyal Siddiqui, MD

Internal Medicine

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Manuel Jimenez, MD

Cardiology

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Franz Pierre-Louis, MD

Infectious Disease

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Last updated: April 7, 2025 • View editorial policy

From the Guidelines

Hormone replacement therapy (HRT) is the most effective treatment for managing menopausal symptoms, and the standard approach includes estrogen therapy for women who have had a hysterectomy, or estrogen plus progestogen for women with an intact uterus to protect against endometrial cancer. The decision to use HRT should be individualized based on symptom severity and risk factors, with treatment duration and dosage tailored to each patient's needs 1.

Key Considerations

  • Estrogen therapy is recommended for women who have had a hysterectomy, while estrogen plus progestogen is recommended for women with an intact uterus to protect against endometrial cancer.
  • Common estrogen preparations include oral estradiol (0.5-2mg daily), transdermal estradiol patches (25-100mcg/day), or estradiol gel (0.5-1.5g daily).
  • For women with a uterus, progestogens like micronized progesterone (200mg daily) or medroxyprogesterone acetate (5-10mg daily for 12-14 days per month in cyclic regimens or 2.5-5mg daily in continuous regimens) are added.
  • Treatment typically begins with low doses and increases as needed to control symptoms.
  • HRT is most beneficial when started within 10 years of menopause or before age 60, with treatment duration individualized based on symptom severity and risk factors.

Alternatives and Contraindications

  • Alternatives to HRT, such as low-dose vaginal estrogen preparations, can safely treat vaginal symptoms without significant systemic absorption in women with contraindications to systemic HRT (such as history of breast cancer, stroke, or venous thromboembolism) 1.
  • HRT is contraindicated in survivors with a history of hormonally mediated cancers, and should be used with caution in survivors with coronary heart disease or hypertension, in current smokers, and in those with an increased genetic cancer risk.
  • Custom compounded bioidentical hormones are not recommended due to lack of data supporting their safety and efficacy compared to standard hormones 1.

Additional Options

  • Young cancer survivors experiencing menopause at an early age can consider oral contraceptives or MHT for symptom relief and potential cardiac and bone benefits, as long as not contraindicated 1.
  • Vaginal dryness can be treated with over-the-counter vaginal moisturizers, gels, oils, and topicals, as well as local hormonal treatments, although some controversy exists regarding their safety in survivors of hormone-dependent cancers 1.

From the FDA Drug Label

The primary source of estrogen in normally cycling adult women is the ovarian follicle, which secretes 70 to 500 mcg of estradiol daily, depending on the phase of the menstrual cycle. After menopause, most endogenous estrogen is produced by conversion of androstenedione, secreted by the adrenal cortex, to estrone by peripheral tissues Thus, estrone and the sulfate conjugated form, estrone sulfate, are the most abundant circulating estrogens in postmenopausal women.

Estrogens act through binding to nuclear receptors in estrogen-responsive tissues. To date, two estrogen receptors have been identified. These vary in proportion from tissue to tissue Circulating estrogens modulate the pituitary secretion of the gonadotropins, luteinizing hormone (LH) and follicle stimulating hormone (FSH), through a negative feedback mechanism. Estrogens act to reduce the elevated levels of these hormones seen in postmenopausal women.

Hormonal Treatment for Menopause:

  • Estradiol is used as a hormonal treatment for menopause.
  • The goal of hormonal treatment is to reduce the symptoms of menopause, such as hot flashes and osteoporosis.
  • Estradiol works by binding to estrogen receptors in the body and reducing the levels of gonadotropins, such as luteinizing hormone (LH) and follicle stimulating hormone (FSH).
  • The treatment should be individualized for each patient, and the lowest effective dose should be used for the shortest duration consistent with treatment goals and risks for the individual woman 2.
  • The Women's Health Initiative (WHI) studies have shown that estrogen therapy can increase the risk of certain health problems, such as blood clots, stroke, and breast cancer, but can also reduce the risk of osteoporosis and fractures 3.

From the Research

Hormonal Treatment for Menopause

  • Hormone therapy is considered the most effective treatment for hot flashes and other menopausal symptoms, with estrogen therapy being the primary option 4, 5, 6.
  • The decision to use hormone therapy involves balancing the potential benefits against the potential risks, such as excess coronary risk and breast cancer 4, 5, 6.
  • Short-term estrogen therapy, using the lowest effective estrogen dose, is a reasonable option for recently menopausal women with moderate to severe symptoms who are in good cardiovascular health 4, 6.
  • Low-dose vaginal estrogens are highly effective for genitourinary atrophy symptoms, with minimal systemic absorption and endometrial effects 4, 5, 7.
  • Nonhormonal options, such as gabapentin, selective serotonin reuptake inhibitors, and serotonin norepinephrine reuptake inhibitors, are also available for women who are not candidates for hormonal treatments or prefer alternative options 5, 7.

Benefits and Risks of Hormone Therapy

  • Hormone therapy can prevent and treat osteoporosis, but is rarely used solely for this indication 6.
  • The risks of hormone therapy increase with increasing age, time since menopause, and duration of use 4, 6.
  • Contraindications to hormone therapy use include breast or endometrial cancer, cardiovascular disease, thromboembolic disorders, and active liver disease 6.
  • Women must be informed of the potential benefits and risks of all therapeutic options, and care should be individualized based on a woman's medical history, needs, and preferences 6, 7.

Current Recommendations for Hormone Replacement Therapy

  • The benefits of hormone replacement therapy (HRT) in improving menopausal symptoms are well-established, but the potential risks associated with HRT must also be considered 5, 8.
  • HRT is currently estimated to be used by approximately a million women in the UK for control of their menopausal symptoms 8.
  • The current recommendations for HRT use in menopausal women emphasize the importance of individualized care and shared decision-making 7, 8.

References

1
Guideline

survivorship, version 2.2017, nccn clinical practice guidelines in oncology.

Journal of the National Comprehensive Cancer Network : JNCCN, 2017

4
Research

Approach to the patient with menopausal symptoms.

The Journal of clinical endocrinology and metabolism, 2008

6
Research

Role of hormone therapy in the management of menopause.

Obstetrics and gynecology, 2010

8
Research

Hormone replacement therapy - Current recommendations.

Best practice & research. Clinical obstetrics & gynaecology, 2022

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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