What are the risks and benefits of hormone replacement therapy (HRT) for a peri-menopausal or post-menopausal woman with moderate to severe menopausal symptoms?

Evidence-Based Script for Discussing Hormone Replacement Therapy with Menopausal Patients

For women under 60 or within 10 years of menopause with moderate to severe hot flashes or night sweats, hormone replacement therapy is the most effective treatment available and has a favorable benefit-risk profile when used at the lowest effective dose. 1

Opening Statement: What HRT Can Do For You

"Hormone therapy is the gold standard treatment for hot flashes and night sweats, reducing these symptoms by approximately 75%." 1

• HRT also effectively treats vaginal dryness and painful intercourse, with low-dose vaginal preparations improving these symptoms by 60-80%. 1
• For bone health, HRT reduces fracture risk by 30-50%, though this is not a reason to start therapy on its own. 1

The Timing Window: Why Age and Years Since Menopause Matter

The benefit-risk balance is most favorable if you're under 60 years old OR within 10 years of your last period. 1, 2

• If you're over 60 or more than 10 years past menopause, the risks—particularly stroke and blood clots—outweigh the benefits for most women. 2
• Starting HRT more than 5 years after your last period is not recommended due to increased cardiovascular risks. 2

The Risks: What You Need to Know

For Combined Estrogen-Progestin Therapy (if you have a uterus):

For every 10,000 women taking combined therapy for one year, we expect: 1, 3

• 8 additional cases of invasive breast cancer (risk doesn't appear until after 4-5 years of use) 1, 3
• 8 additional strokes 1, 4
• 8 additional blood clots in the lungs 1, 4
• 7 additional heart attacks 1

Balanced against these benefits: 1

• 6 fewer cases of colon cancer 1
• 5 fewer hip fractures 1
• 75% reduction in hot flashes 1

For Estrogen-Alone Therapy (if you've had a hysterectomy):

• No increased breast cancer risk—may actually be protective 1, 3
• 8 additional strokes per 10,000 women per year 1
• 8 additional blood clots per 10,000 women per year 1
• Same fracture benefits as combined therapy 1

Other Important Risks:

• 2- to 4-fold increased risk of gallbladder disease requiring surgery 3
• Possible increased risk of ovarian cancer with long-term use (relative risk 1.41), though data are inconsistent 3
• For women 65 and older, increased risk of dementia (45 vs 22 cases per 10,000 women-years for combined therapy) 3

Who Should NOT Take HRT: Absolute Contraindications

You cannot take HRT if you have: 1, 5

• History of breast cancer or other hormone-sensitive cancers 1
• History of blood clots (DVT or pulmonary embolism) 1, 5
• History of stroke 1, 5
• History of heart attack or coronary heart disease 1, 5
• Active liver disease 1, 5
• Antiphospholipid syndrome or positive antiphospholipid antibodies 1
• Unexplained vaginal bleeding 1

Relative contraindications requiring caution: 1

• History of gallbladder disease (especially with oral HRT) 1
• Smoking over age 35 (significantly increases cardiovascular and clot risks) 1

The Recommended Regimen: What I Would Prescribe

If You Have a Uterus:

"I recommend starting with a transdermal estradiol patch releasing 50 micrograms daily, changed twice weekly, combined with micronized progesterone 200 mg taken orally at bedtime." 1

• The patch is preferred over pills because it bypasses the liver, reducing risks of blood clots and stroke compared to oral estrogen. 1
• Micronized progesterone is safer for breast tissue than synthetic progestins like medroxyprogesterone acetate. 1
• The progesterone is absolutely required to protect your uterus from cancer—estrogen alone increases endometrial cancer risk 10- to 30-fold. 1

If You've Had a Hysterectomy:

"I recommend transdermal estradiol 50 micrograms daily, changed twice weekly, without any progesterone." 1

• You don't need progesterone because you don't have a uterus to protect. 1
• This regimen has no increased breast cancer risk and may even be protective. 1

For Vaginal Symptoms Only:

"Low-dose vaginal estrogen cream, ring, or suppository can be used without systemic hormones or progesterone." 1

• These deliver high local concentrations with minimal absorption into your bloodstream. 1
• They improve vaginal dryness by 60-80% with very low systemic risks. 1

Duration and Monitoring: The Plan Going Forward

"We'll use the lowest effective dose for the shortest time necessary to control your symptoms." 1, 5

• At your annual visit, we'll reassess whether you still need HRT and attempt to reduce the dose or stop if possible. 1
• Breast cancer risk increases with duration beyond 5 years, so we'll be particularly cautious about long-term use. 1, 3
• You'll need annual mammograms and clinical breast exams. 3
• No routine blood tests are needed unless you develop specific symptoms. 1

What We're NOT Using HRT For

"I want to be clear: we're prescribing this to treat your symptoms, not to prevent heart disease, dementia, or osteoporosis." 1, 2

• The U.S. Preventive Services Task Force gives a Grade D recommendation (recommends against) using HRT solely for chronic disease prevention. 2
• For osteoporosis prevention alone, bisphosphonates or other medications are preferred. 2
• HRT does not reduce heart disease risk and may increase it, especially in older women. 6, 2

Non-Hormonal Alternatives If You Prefer

If you decide HRT isn't right for you, effective alternatives include: 1

• SSRIs or SNRIs (antidepressants) can reduce hot flashes without cardiovascular risk 1
• Gabapentin for vasomotor symptoms 1
• Cognitive behavioral therapy or clinical hypnosis can reduce hot flashes 1
• Vaginal moisturizers and lubricants reduce vaginal symptoms by up to 50% 1

Special Situations

If You Had Early Menopause (Before Age 45):

"Women with surgical menopause before age 45 should strongly consider HRT until at least age 51, then reassess." 1

• Early menopause increases stroke risk by 32% and accelerates bone loss. 1
• The benefit-risk profile is highly favorable for younger women replacing hormones lost prematurely. 1

If You're Over 60 or More Than 10 Years Past Menopause:

"At this point, I would only recommend HRT if your symptoms are severe and significantly impacting your quality of life, and only after trying non-hormonal options first." 2

• The cardiovascular and stroke risks exceed benefits for most women in this age group. 2
• If we do proceed, we'll use the absolute lowest dose possible and reassess every 6 months. 1

The Bottom Line

"HRT is highly effective for menopausal symptoms when started at the right time in the right women. The absolute risks are modest—we're talking about 8 additional cases per 10,000 women per year for most serious complications. For women under 60 with bothersome symptoms and no contraindications, the benefits of symptom relief generally outweigh these risks. However, this is your decision, and I want you to have all the information to make the choice that's right for you." 1, 5, 7