Hormone replacement therapy (HRT): a guide

What HRT actually is

Menopause symptoms are driven by the loss of ovarian estrogen. HRT supplements that estrogen, usually at the lowest effective dose. It comes in two broad forms:

• Systemic estrogen — pills, skin patches, gels, and sprays that circulate through the whole body. These treat hot flashes, night sweats, sleep disruption, mood changes, and help prevent bone loss.
• Local (vaginal) estrogen — low-dose creams, tablets, or rings that act mainly on vaginal and urinary tissues, with minimal absorption into the bloodstream.

If you still have a uterus, a progestogen (progesterone or a synthetic version) is added to protect the uterine lining. After a hysterectomy, estrogen alone is typically used. Some regimens take progesterone cyclically; others continuously. Many clinicians prefer transdermal (patch or gel) estrogen and micronized progesterone because evidence suggests a lower blood-clot risk than some oral forms — but the right formulation is an individual call.

Benefits the evidence supports

• The most effective treatment for hot flashes and night sweats.
• Prevention of bone loss and reduction of fracture risk.
• Relief of vaginal dryness and urinary symptoms (local estrogen).
• Improved sleep and quality of life when symptoms are disruptive — some women also report steadier mood.

Risks and who should be cautious

• A small increased risk of blood clots and stroke with some oral estrogens — transdermal routes appear to carry lower risk.
• Combined estrogen–progestogen therapy used for more than about 3–5 years is associated with a small increase in breast cancer risk; estrogen-alone therapy after hysterectomy is not, in the same trials.
• HRT is generally avoided with a personal history of breast cancer, active liver disease, unexplained vaginal bleeding, or prior blood clots or stroke — your clinician weighs the specifics.
• Timing matters: starting near menopause onset carries a different risk profile than starting after 60.

If hormones aren't for you

Non-hormonal options include fezolinetant (a prescription targeting hot-flash signaling), certain SSRIs/SNRIs, gabapentin, cognitive behavioral therapy, and lifestyle approaches. They help some symptoms for some women. A clinician can help you match options to what you're actually experiencing.

Prepare for the conversation

The most useful thing you can bring to a clinician visit is a clear record: your symptoms, their frequency, what you've tried, and your questions. Dot's Prepare Visit tool turns your tracked symptoms and history into a clinician-ready brief you can print or share.

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