Hormone therapy: benefits, risks, decisions

Part 8 of 12 · All topics on the menopause

The question behind the debate

Hardly any topic around the menopause is discussed in such opposing ways as hormone therapy. Some accounts paint it as a dangerous treatment about which every woman must be warned. Others describe it as an almost universal remedy for ageing, weight gain, memory problems and chronic illnesses. Both distort the scientific picture.

The right starting question is: Which symptom is to be treated, what is the medical history, and which form of therapy has a favourable balance of benefit and risk for this person? For marked hot flushes, systemic hormone therapy can be very effective. For other aims – such as general dementia prevention or blanket protection against heart attacks – the same recommendation cannot be derived. [1] [2] [3]

Systemic or local: two different concepts

With a systemic therapy, hormones enter the bloodstream and act on various organs. They are given, for example, as a tablet, patch, gel or spray. Its most important use in the menopause years is the treatment of troublesome vasomotor symptoms; certain other symptoms can also improve. A local vaginal therapy acts mainly in the vagina and the surrounding tissue. It is used in much lower doses and serves mainly to treat genitourinary symptoms. The two approaches must not be treated as equal, either in their effectiveness or in how their safety is assessed.

If someone tells you “hormones are dangerous across the board” or “vaginal oestrogen replaces everything”, this very distinction is probably missing. Systemic therapy treats symptoms throughout the body. Local therapy is aimed at one particular site of complaint. Both can make sense, but not for the same reasons. [1] [4]

Why the womb matters in the choice

Oestrogen can stimulate the womb lining to grow. In a woman with an intact womb, longer-term systemic oestrogen treatment on its own would therefore raise the risk of excessive thickening of the lining and of endometrial cancer. As a rule, suitable endometrial protection is needed, through a progestogen or progesterone in an appropriate treatment regimen. After complete removal of the womb, oestrogen alone is often possible; special situations must be judged individually. [1]

The term “progestogen” describes a group of active substances. It includes various synthetic progestogens and natural micronised progesterone. These products are not identical in all their effects and risks. At the same time, it would be improper to claim freedom from risk across the board for a particular product as long as high-quality direct comparison data are lacking. The NICE guideline expressly points out that, for some assumed differences in breast cancer risk, the evidence is not suitable for a reliable ranking of all progestogens. [1]

In the perimenopause, cyclical or sequential regimens can make sense, in which predictable bleeding can occur. In a later phase, continuous combined regimens are often used. Which form fits depends on where you are in the transition, on bleeding patterns and on treatment preferences. A therapy does not have to look the same for all women.

Tablet, patch, gel: the route can matter

Hormones taken by mouth first reach the body by way of the digestive tract and the liver. Oestrogen given through the skin – for example by skin patch or gel – is taken up differently. For venous thromboembolism, that is, blood clots in deep veins or pulmonary embolism, observational studies point to a more favourable profile for transdermal than for oral oestrogen. This is relevant for the choice of treatment, especially in certain risk constellations.

The scientific limitation is important: the direct comparison of thrombosis risk between routes of administration is not as well established by large randomised comparison studies as the effectiveness of hormone therapy against hot flushes. The Menopause Society and NICE therefore take these differences into account in their differentiated advice, without concealing all the uncertainties. [3] [1]

The form of use can also matter in everyday life. Some women prefer a patch to a daily tablet, others dislike applying a gel. Medical suitability, tolerability and practicality belong equally in the decision.

What the WHI studies actually investigated

The Women’s Health Initiative (WHI) is among the most influential research programmes in menopause medicine. In the early 2000s, results from randomised studies caused great public uncertainty. The research showed relevant risks of certain therapies tested and rightly changed how indications and long-term use were handled. At the same time, the results were often greatly simplified in public debate.

In one important study arm, women with a womb received a particular combination of conjugated equine oestrogens and medroxyprogesterone acetate. In another study arm, women without a womb were studied on oestrogen alone. These results cannot simply be transferred to every product used today, every dose and every younger woman in the early perimenopause. The age structure and the question of how long ago the last menstruation was are also important for putting the results in context. [5] [2]

The WHI reassessment published in 2024 puts the long-term results in context and distinguishes the question of symptom treatment from the earlier-discussed primary prevention of chronic illnesses. This leads neither to an all-clear for every risk nor to a general condemnation of hormone therapy. What follows is a more precise indication. [2]

Breast cancer risk: the type of treatment matters

With combined systemic oestrogen-progestogen therapy, the risk of breast cancer can rise with longer use. How large the difference is depends on the starting risk, the product, the regimen, the duration of treatment and the studies used as a basis. For oestrogen alone after hysterectomy, the evidence has to be judged differently from combined therapy. Anyone who lumps these results together gets a misleading picture. [1] [6]

In a medical conversation, absolute risks help. A statement such as “the risk rises by 20 per cent” is hardly understandable without a starting value. If, for example, a hypothetical risk rises from 5 to 6 in 100 women, that is a relative increase of 20 per cent, but an absolute increase of one percentage point. This numerical example only illustrates the method of calculation and is expressly not an estimate of the breast cancer risk from hormone therapy.

For real risk figures related to age and therapy, NICE offers a graphical decision aid with figures per 1,000 women and a defined period of observation. That is why the direct link to this current presentation is given here, instead of taking over numbers without a treatment duration or starting risk: NICE: Discussion aid on hormone therapy. The examples in this decision aid relate to populations and are not an individual risk calculation. [1]

If you have had breast cancer yourself, systemic hormone therapy is as a rule not advisable; exceptions need specialist advice. Certain other illnesses can also speak against systemic therapy. This is one of the reasons why an internet checklist cannot replace a doctor’s medical history. [1]

Blood clots, stroke and cardiovascular health

Besides breast cancer, thromboses, strokes and other cardiovascular events are at the centre of the safety assessment. Age, smoking, blood pressure, personal or family history, body weight, clotting disorders and the route of administration of the hormones play a part here in particular. “A favourable balance of benefit and risk” therefore does not mean that risks are zero. It means that, in the specific situation, the expected benefit can outweigh the expected disadvantages.

A woman in her early fifties with severe hot flushes and no relevant contraindications poses a different clinical question from a woman in her mid-seventies who wants to take systemic hormones for the first time to protect her heart, as she sees it. The risk assessment can differ markedly in these situations. Professional societies accordingly stress that new systemic therapy closer to the menopause can often be judged more favourably than a first start at a much higher age. This is not a rigid age limit and not an automatic consent. [3] [2]

Bones, mood, sleep and the limits of the indication

Systemic hormone therapy can reduce bone loss and prevent fractures, but treatment solely for preventing osteoporosis has to be weighed against other available options and personal risks. With an early menopause or premature ovarian insufficiency, this weighing shifts, because a long phase of low hormone levels may lie ahead. Specialist advice is particularly important here. [7] [3]

Some women sleep better when their hot flushes are treated successfully. That does not make hormone therapy a universal therapy for every insomnia, though. Likewise, subjective mood and energy can improve when night-time symptoms lessen. With a depression of its own or chronic sleep disorder, additional or different treatment may be needed. And for memory problems, there is no reliable general evidence that hormone therapy is an effective prevention of dementia or a general boost to cognitive performance. [8]

What should be discussed before starting

Before systemic hormone therapy, a careful medical history is part of the process: Which symptoms are really distressing? How old are you? When was your last bleed? Do you still have your womb? Have there been thromboses, breast or womb cancer, unexplained bleeding, liver disease or cardiovascular events? Which medicines do you take? Which aims matter to you? Which risks do you want to avoid? [1]

A sensible decision has an aim that can be checked. “I want to sleep six hours again without waking from sweating” is more concrete than “My hormones should be back in balance”. The first statement later allows you to judge whether a treatment is helping. The second sounds plausible, but does not yet give a measurable health question.

Contraception must also be considered separately: usual menopausal hormone therapy does not prevent pregnancy. If you can still become pregnant in the perimenopause and do not want that, you need a contraception plan of your own. This was explained on the page Bleeding and diagnosis, but it remains practically relevant for the decision about therapy. [1]

Follow-up, side effects and the end of a treatment

The process is not finished once a decision on therapy has been made. After starting, breast tenderness, nausea, changes in bleeding or other side effects can occur, for example. Some symptoms improve after the product or dose is adjusted, others need further investigation. Unexpected or persistent bleeding is particularly important. In 2026, NICE updated its recommendation on investigating bleeding during systemic therapy. If you develop such symptoms, you should discuss your individual situation promptly rather than guessing what is still normal. [1]

A regularly renewed assessment of benefit and risk makes sense. The question is: Is the treatment still helping? Have new risks or illnesses arisen? Do you want to continue, change or end it? Symptoms can return after stopping. There is no single duration that is right for all women; at the same time, a therapy should not run on indefinitely out of habit without the indication being checked again.

Decision overview

A treatment aim is not a worldview

On hardly any other topic on these pages are scientific research and public debate as far apart as on hormone therapy. For some it is a treatment that was unjustly feared for years; for others a fundamentally dangerous intervention. Both attitudes can tempt people to pick the information that confirms their own picture. A medically helpful starting point is more sober: Which symptom is to be treated, which products are available for it, and which risks and benefits are relevant in my situation?

For marked hot flushes, systemic menopausal hormone therapy is among the most effective treatments. That is not a promise that every woman will benefit, and not an instruction to take it as early as possible. The current NICE guideline recommends discussing the possible options individually and offering hormone therapy for vasomotor symptoms where it is suitable. [1]

A decision begins with the aim: Do you want less night sweats, to sleep through again, to ease vaginal pain or to feel healthier overall? The answer changes the suitable treatment. A woman with only vaginal symptoms may not need systemic therapy. Another with marked hot flushes wants to learn about her options along with the risks. A third case concerns a woman with an early menopause, for whom long-term health may need to be judged differently from a natural menopause at around 51.

Why products cannot be compared at will

Systemic oestrogens can be used as tablets, through the skin or in other approved forms. When the womb is present, suitable progestogen protection is as a rule necessary for the safety of the endometrium. Without a womb, oestrogen alone may be considered, though exceptions depend on individual medical circumstances. The choice between a sequential and a continuous regimen also affects bleeding patterns and use. [1]

The route of use can also matter. Oral oestrogens first pass through the liver and can affect clotting and metabolic parameters differently from transdermal products. Guidelines therefore expressly distinguish between oral and transdermal. The evidence base, however, varies by outcome: not every assumption rests on large direct comparison studies with hard clinical outcomes. Anyone who says “patches are always safe” is claiming more than can be shown in general. [3]

The word “progesterone” also has to be used precisely. Natural or micronised progesterone products and synthetic progestogens are not pharmacologically identical. Observational data on different breast cancer or thrombosis risks are interesting, but not automatically sufficient to quantify exactly all long-term risks for all combinations. The clinical benefit of a particular formulation follows from the indication, the licence, the dosing plan and the individual history.

Reading the WHI study without the historical baggage

In large randomised studies, the Women’s Health Initiative investigated specific hormone regimens in women between 50 and 79 years of age. One well-known study group received conjugated equine oestrogens together with medroxyprogesterone acetate. Another trial tested oestrogen alone in women without a womb. These differences are decisive. The results of the two arms must neither be thrown together nor passed off as statements about all modern products.

The overall assessment of the WHI research published in 2024 makes clear that hormone therapy for treating distressing vasomotor symptoms has to be judged differently from its use for general prevention of chronic illnesses. It confirms important health risks from randomised data, but also that the situation of a younger woman with symptoms can differ from that of an older study participant without symptoms. [2] [5]

The separation of relative and absolute risks is particularly helpful. If a risk rises in relative terms by a certain percentage, that alone does not yet say how many women will actually be affected. What matters are the starting risk, the duration and the treatment studied. A reliable guide must therefore explain, for every figure, over what period and for which group it applies. [1]

A personal balance of risk instead of a general verdict

For the individual weighing up, earlier breast cancer, unexplained vaginal bleeding, thromboses or certain clotting disorders, severe liver disease and personal cardiovascular risk are among the things that matter. That does not mean that every such situation has automatically the same consequence. Some are clear contraindications for certain systemic therapies, others call for a specialist assessment. The current product information and the medical history are essential for this.

The two most common false conclusions are: “It works wonderfully for my friend, so it is ideal for me too” and “My aunt had a thrombosis, so hormones are ruled out altogether”. Both can contain important clues, but neither replaces a structured weighing up. Good counselling asks about existing illnesses, age, product, route of administration, severity of symptoms, any wish to have children and personal preference. [1] [3]

The treatment is reviewed over time. If symptoms change, side effects appear or new risks arise, the choice can be adjusted. The decision is therefore not a lifelong contract and should not be understood as a final answer to growing older. Regular discussions help to weigh benefits and disadvantages again.

Understanding bleeding on hormone therapy

Bleeding on systemic hormone therapy can occur especially at the start or after changes of dose. It does not follow that every bleed is harmless. In April 2026 the NICE guideline updated its advice on investigating unscheduled bleeding. It recommends paying attention to the timing in relation to the start or a change of treatment, and having bleeding outside the described initial or changeover periods checked medically without delay. Other warning signs also remain relevant. [1]

It is important not to keep bleeding problems to yourself out of fear of a change of therapy. Many questions can be settled by adjusting the regimen or by an examination. A guide can help you gather the right information: timing, heaviness, duration, products used and recent changes. It cannot decide whether an individual bleed is harmless.

Three decisions, three different outcomes

Example one: A 48-year-old woman has frequent night-time hot flushes and hardly any sleep. After a medical work-up there are no recognisable contraindications, and she would like an effective drug treatment. Systemic hormone therapy can be an understandable option. The aim would be a lower symptom burden, not a general “rejuvenation”.

Example two: A 57-year-old woman has had no period for years and suffers mainly from dryness during sex. She has no marked hot flushes. For her, local treatments come first, as long as the examination shows no other cause. The weighing of benefit and risk differs substantially from that for systemic therapy. [4]

Example three: A 45-year-old woman with a hormone-dependent cancer in her history wants treatment because of severe night sweats. The choice has to be made with the specialist doctors responsible. Non-hormonal options and her individual cancer history carry particular weight. The three cases are invented and serve solely to illustrate the path to a decision.

The ten minutes before the appointment

Write down which symptom bothers you most and what you want to achieve with a treatment. Add known illnesses, medicines you take regularly, earlier thromboses or cancers, any abnormal bleeding, and a possible question about pregnancy or contraception. Then ask: Which two or three options suit my situation? Which risks are likely to be relevant for me? What is unclear? When will we check whether the chosen measure is helping?

You do not have to decide before the appointment whether you are “for” or “against” hormones. You may ask questions, weigh up risks and decide differently later. Scientifically grounded treatment is not about camps, but about a reasoned decision that can be revised.

Hormone therapy can look different

In everyday talk, people often speak as if there were “the” hormone therapy. In fact, the options differ in the type of oestrogen, the progestogen component, the dose, the form of use and the treatment regimen. When the womb is present, the womb lining generally has to be protected; after complete removal of the womb, different principles apply. The question of whether you still have bleeds of your own also influences the choice of a suitable regimen. [1]

The route through the skin and the oral route can have different effects on clotting and metabolism. That does not mean that a transdermal product rules out every risk or is better for every person. Anyone who talks about a treatment should therefore know the name, the active substances and the route of use of the specific product. Only then can studies be matched to it properly.

What “lowest effective dose” means

For symptomatic treatment, guidelines recommend aiming for sufficient effect with the most suitable, often low, dose and checking the need regularly. This is not a competition to take as little as possible. If a dose does not ease symptoms enough, the treatment may not be set up sensibly. Conversely, a higher dose can cause more side effects without bringing extra benefit. The adjustment belongs in a shared medical decision.

A person may also want to end her treatment when symptoms have eased or priorities have changed. Symptoms can return. This is not a sign of dependence, but can simply mean that the underlying transition is still causing symptoms. At the review, you can consider whether renewed treatment, a different strategy or another attempt without medicines makes sense. [1]

Breast cancer risk: understandable, but without false certainty

In discussions about breast cancer risk, the type of treatment matters. Large observational analyses show different associations for different forms of systemic hormone therapy. The WHI studies provide important randomised data on particular regimens. Both types of evidence have strengths and limits, and they cannot be summed up by the simple claim that modern products are safe across the board or that all systemic hormones carry the same risk. [6] [2]

In individual counselling, absolute risks, age, family and personal history and duration of use should be discussed. A good graphic would show, for example, how many of 1,000 women in a clearly defined group would be affected over a given period. What matters is that the starting risk, age group and product studied are stated in the caption. Without this information, a seemingly precise number would be misleading.

If you do not want to decide straight away

There may be time between an information appointment and a prescription. You can take information material with you, work through the risks and come back later. A delay can make sense, as long as no symptoms or medical circumstances call for faster action. If you decide on a treatment, you should at the same time arrange a follow-up appointment, so that effect and tolerability are not discussed only in passing.

It is no weakness to get a second opinion when the decision is complicated, for example with a special cancer or thrombosis history. That two professionals weigh different aspects can point to real uncertainties. What matters then is a transparent explanation of each proposal, not a power struggle over who is right.

A treatment for symptoms – not a definition of womanhood

The question of whether you want hormone therapy can become surprisingly personal. Some women link it with the hope of getting their familiar body back. Others want as little medical intervention as possible. Still others feel unsettled by contradictory media reports. Good counselling takes such attitudes seriously, but does not replace medical information with a fixed position for or against hormones.

In the menopause years, the hormone production of the ovaries falls over time, but a woman’s life experience cannot be reduced to a blood value. Hormone therapy changes certain biological processes and can ease certain symptoms. It makes a person neither “younger” nor “more complete”. Anyone who does not need it or does not want it is acting no less responsibly. Anyone who has considerable symptoms and is treated after careful weighing up does not have to justify it.

The aim should therefore come before the choice of medicine in the conversation. If you wake three times a night with heavy night sweats, the question of effective symptom relief is central. If you have merely reached midlife but have no symptoms, that alone is no reason for a general anti-ageing treatment. If you have particular risks after an early menopause, other considerations apply again. [3] [9]

How a study becomes individual advice

Scientific studies deliver average values under defined conditions. A randomised study can test, for example, how much hot flushes fall under a particular combination of oestrogen and progestogen compared with placebo. That does not yet answer whether the same treatment is suitable for a person with an earlier thrombosis, migraine or a particular cancer. Applying the findings requires a clinical assessment.

Observational studies can also answer important questions, especially when they follow large groups for years. But they can be prone to differences between treated and untreated women. Perhaps healthier women more often receive a particular therapy; perhaps women with a great deal of distress differ from those with no symptoms. Such factors have to be taken into account analytically and can still leave uncertainty. That is why randomised studies and careful observational data are not interchangeable sources.

If you read in an article that a product is “30 per cent safer”, ask which outcome was compared. Was it thromboses, breast cancer, strokes or something else entirely? How large was the starting risk? How long did the observation last? Were comparable women studied? Without this information, the number is not very helpful. These pages are meant to guide such questions, rather than supply apparently exact universal figures.

What the WHI actually changed

When results of the Women’s Health Initiative were published in the early 2000s, the handling of systemic hormone therapy changed worldwide. The study was large, randomised and scientifically important. It tested, however, specific oral hormone regimens in particular postmenopausal age groups. In one group a combination of conjugated equine oestrogens and medroxyprogesterone acetate was studied. In another group, oestrogen alone was used in women without a womb.

The results of these different arms should not be pulled together into a statement about all the oestrogens, progestogens, doses and routes of administration available today. At the same time, it would be wrong to dismiss the WHI across the board as “outdated”. It provided important information about risks and about the limits of hormone therapy for general disease prevention. The overall scientific assessment published in 2024 shows why a differentiated view is necessary. [2] [5]

A media lesson can also be learned from this history. Medical knowledge does not develop only through individual spectacular studies. What matters is how new data are placed within the existing state of knowledge. Some conclusions are confirmed, others are differentiated by population or treatment regimen. A good account does not have to choose between a heroic and a catastrophic story.

Why “starting early” does not mean the same for everyone

You often read that hormone therapy is especially favourable if it is started before a certain age or within a certain period after the menopause. Such considerations have a scientific basis, but are easily misunderstood as a blanket deadline. The timing of the start has to be judged together with age, symptoms, existing illnesses and the particular treatment. A woman of 48 with severe hot flushes has a different starting position from a woman of 72 who has had no period for decades and wants to begin hormone therapy for prevention without symptoms.

It is therefore not sensible to put every woman from 40 under time pressure because she might supposedly miss a narrow “hormone window”. If there is a need for treatment, it should be discussed promptly and competently. An individual decision, however, needs no artificial urgency from advertising copy. [3]

The womb and protecting the lining

With systemic oestrogen therapy, suitable progestogen protection must as a rule be provided when the womb is present, because oestrogens can stimulate the womb lining. This is a safety question and not merely a cosmetic decision about bleeding patterns. Whether a sequential or a continuous combined regimen is chosen depends on the medical context and the treatment situation. [1]

Women who have had their womb removed usually do not need corresponding protection of the womb lining; with certain medical histories, however, the situation can be more complex. Anyone starting hormone therapy should therefore know which organs were removed in an operation. A hysterectomy does not automatically mean that the ovaries were removed as well. This distinction influences both the hormonal starting situation and the choice of treatment.

By mouth or through the skin?

Tablets and transdermal products differ, among other things, in how the active substance is absorbed and metabolised. Oral oestrogens first pass through the liver; with absorption through the skin, this first pass is different. Certain effects on clotting and metabolism can therefore differ. Guidelines take the route of administration into account in the individual weighing of risk. [1]

It would still be too simple to make a universal ranking out of this information. The observed safety depends on the particular outcome, the products used and the characteristics of the people treated. For some questions there are good comparison data, for others mainly observational studies. A medically sensible choice looks at this evidence together with practicality and preference: Do you tolerate patches well? Do you want to apply a gel every day? Are there skin conditions or other reasons that make one route easier or harder? The specific choice belongs in professional counselling.

What a bleeding episode on therapy can mean

Unscheduled bleeding can occur especially at the start of systemic hormone therapy or after changes to the regimen. Its meaning, though, depends on timing, heaviness, duration and risk factors. The NICE guideline and the British professional society guideline on investigating such bleeding describe differentiated approaches. Heavy, long-lasting or late-onset new bleeding should not be dismissed with general reassurance. [1] [10]

The woman concerned does not have to be a medical specialist for this. What matters is to record changes and to contact the healthcare professional treating you if warning signs or unusual patterns appear. For bleeding after twelve months of natural absence of bleeding without hormone therapy, there are likewise clear grounds for investigation. These questions belong to diagnosis on the page Bleeding and diagnosis and are related here only to therapy.

Which risks should be discussed in particular

When systemic hormone therapy is compared, breast cancer, thromboses, stroke and certain cardiovascular diseases are often the focus. The exact risk estimate depends, among other things, on the treatment, age and history. The large studies and meta-analyses show that not every combination can be judged the same way. At the same time, a claim such as “There is no relevant risk if the hormones are bioidentical” is not scientifically justified. [6] [2]

An understandable consultation should explain the order of magnitude in absolute numbers. How many women in a particular age group would be affected under the conditions compared? How many without treatment? Over what period? Without this information, relative percentages are only of limited help. It is just as important to recognise the difference between an uncertainty in studies and a known, proven risk.

A conversation in three steps

Step one: formulate aims. Which specific symptom should change? How severe is it? What would be a noticeable improvement for you? Step two: understand the options. Which systemic, local or non-hormonal treatments fit? What are typical side effects, contraindications and checks? Step three: check the effect. When should the treatment be discussed again, what would be a reason to get in touch sooner, and what do we do if the chosen option does not help enough?

These steps are deliberately simple. Medical professionals will take more factors into account. For the reader, though, they offer a way through a complex debate. If you know which question you want to answer, you can sort the many pieces of media information better.

If you would rather manage without hormones

The wish not to take systemic hormones is a legitimate preference. It should not be confused with medical ignorance. Non-hormonal options now include, besides certain medicines, targeted psychological approaches. The choice depends on effectiveness, side effects and your personal treatment aim. The page Treatment without hormones explains these possibilities in detail.

It is just as legitimate to choose hormone therapy if it seems suitable for your individual situation. Neither the decision for it nor the decision against it is a sign of special strength. The better question is: Were the possibilities explained properly, have the relevant risks been taken into account, and does the decision fit your own needs?

Follow-up is part of the treatment

A good plan does not end with the prescription. After starting a therapy, you should discuss whether symptoms have eased enough, whether side effects are present and whether the regimen works in practice. The NICE guideline recommends a review after about three months and regular checks afterwards, at which benefits and risks are discussed again. Unusual bleeding or new symptoms can make an earlier assessment necessary. [1]

That a treatment works well at first does not mean it must go on forever without being checked again. Conversely, a long period of use does not automatically mean it has to be stopped at once. What matters is a recurring weighing up, with reasons given for the individual. Some women reduce or stop treatment later, others have symptoms again and discuss a different route. Medical decisions are allowed to develop.

What these pages expressly do not claim

There is no single hormone therapy that all women from 40 need. There is no reliable hormone value that dictates the optimal treatment plan for every woman. There is no scientific reason to use systemic hormones across the board as an anti-ageing agent. And it would be just as wrong to play down severe symptoms without an individual check. Effective treatment and differentiated weighing of risk are not a contradiction.

With this attitude you can use the pages on therapy: not as an instruction to demand a particular product, but as a basis for understanding the important differences in conversation. The next question is then which possibilities are available if you do not want systemic hormone therapy or if it is medically not suitable.

How to judge risks in studies better

When making a decision about therapy, numbers can help if they are explained correctly. An absolute risk figure describes, for example, how many of 1,000 comparable women experience an event over a given period. A relative risk figure, by contrast, describes the ratio between groups. Without the underlying starting risk, a relative increase can look dramatic although the absolute change is small – or the other way round.

A simple calculation can show the principle: if in a hypothetical group two of 1,000 women are affected and in a second group four of 1,000, the relative probability is doubled, but the absolute difference is two additional cases per 1,000. These numbers are expressly a teaching example and not a statement about hormone therapy. In a real medical comparison, the values must come from the appropriate study and take account of age, product, length of observation and starting risks.

With hormone therapy this care is especially important, because studies investigate different treatment regimens. A number from an observational study on one particular combination cannot be transferred directly to another combination. The balance of benefit and risk also changes if a woman already has a relevant illness. A personal risk estimate therefore belongs in professional counselling. [2] [6]

Three questions that make a treatment recommendation more transparent

What is the indication? That is: which specific symptom or medical situation is to be treated? What is the most important alternative? Sometimes it is another form of hormone, sometimes a non-hormonal treatment, sometimes a local therapy. How do we check the benefit? A treatment should be assessed again over time, because symptoms and personal risks can change.

If a particular form of administration is recommended in the conversation, you can ask for the reason. Is the route of use important because of an individual risk factor? Are there differences in tolerability, bleeding pattern or practical effort? What does it mean if a dose is missed? Concrete questions like these make an informed decision easier than the general search for “the best hormone therapy”.

What stays important with long-term use

Long-term decisions are seldom fixed for ever. Even if hormone therapy helps very well at first, symptoms, side effects, existing illnesses and wishes should be looked at anew regularly. That does not mean that every woman has to stop after a rigid number of months. Equally, it does not mean that a therapy once started should run on without limit and without being checked again. [1]

A sensible follow-up appointment can start with a few questions: Has the original symptom got better? Has a new health problem arisen? Does the treatment work in daily life? Do I want to continue it? The more clearly these questions are answered, the less the decision depends on general debates or personal accounts.

No treatment is also a decision

If symptoms are mild and hardly bother you, it can be reasonable to observe at first and keep an eye on long-term health. Some women never need therapy for menopause symptoms. Others alternate between phases without and with treatment. An informed decision includes the option of going without a medicine, as long as there are no particular medical reasons against it.

It is important to distinguish this from the situation of a woman with an early or premature menopause. There, long-term health considerations may be additionally relevant, and medical advice partly follows other recommendations. A blanket statement such as “Hormones are always a voluntary comfort therapy” would therefore also be too imprecise. [7]

Preparing the decision about therapy

First write down which aim you want to achieve. A realistic sentence could be: “I want to wake less often at night because of hot flushes” or “I want to have no more pain during sex.” Then state which features of a treatment matter to you: strong relief of symptoms, as few interactions as possible, no daily use, a local treatment or an option without systemic hormones.

If you already have illnesses or take medicines regularly, this information belongs in the conversation. Particular histories such as breast cancer, thromboses, stroke, severe liver disease or unusual bleeding can influence the choice of treatment. That does not mean you have to diagnose a list of contraindications yourself. It means that the healthcare professional should base the decision on complete information.

It is important not to make decisions only according to the greatest possible effectiveness. A therapy that works well but is impractical in your own daily life or medically unsuitable cannot be the best choice. Conversely, you should not put up with severe symptoms for no reason just because a treatment involves follow-up checks. The personal weighing of benefit and risk is the core of shared decision-making. [1]

Three examples of different treatment aims

Hot flushes: If frequent sweating episodes dominate the day or the night, their frequency, severity and burden are at the centre. Studies on systemic hormone therapy and on certain non-hormonal medicines provide important efficacy data for this. The personal risks and the possible need for follow-up checks change the decision. A psychological intervention can additionally reduce the burden and sleep problems. [1] [11]

Sleep: If long periods lying awake, marked daytime sleepiness or repeated waking are the main issue, it must first be clarified what kind of sleep problem is present. An insomnia of its own often needs different measures from sleep that is interrupted only by night sweats. Behavioural therapy for insomnia has been scientifically studied; with signs of sleep apnoea or other illnesses, special tests may be needed. [12]

Genitourinary symptoms: If dryness, burning or pain during sex are the main problems, examination and local options, or options aimed specifically at these symptoms, come first. Systemic medicines for hot flushes are not automatically sensible for this. With a cancer diagnosis in the history, decisions about hormonal local products should be agreed especially carefully. [4]

These three examples show why there is no single “menopause therapy”. The diagnosis and the specific treatment aim have to fit together. The tables on these pages serve to prepare for counselling, not as a substitute for a prescription.

Common questions

What is the difference between systemic and local hormone therapy?

Systemic hormones enter the bloodstream and act on many organs. Their main use is troublesome hot flushes and night sweats. Local vaginal therapy acts mainly on the vagina and the surrounding tissue, is used in a much lower dose and is mainly for symptoms in the intimate area and the urinary tract. The two must not be treated as equal in effect or in safety.

Is a hormone patch safer than tablets?

For blood clots in the deep veins, observational studies point to a more favourable profile for patch or gel. But this is not as well established by large randomised comparison trials as the effect on hot flushes. Anyone who says patches are always safe is claiming more than the evidence shows. Which route suits you also depends on your risks and preferences.

Does hormone therapy raise the risk of breast cancer?

With combined systemic therapy containing oestrogen and progestogen, the risk of breast cancer can rise with the length of use. How big the difference is depends on the starting risk, the product, the dosing schedule and the length of treatment. For oestrogen alone after removal of the womb, the evidence has to be judged differently. In the consultation, ask for absolute numbers, for example per 1,000 women over a given period.

How long may I take hormone therapy?

There is no length of time that is right for all women. A guideline recommends a first review after about three months and regular check-ups after that. You discuss whether the treatment still helps, whether new risks have come up and whether you want to continue, change or stop it. Symptoms can return after stopping.

Sources

1. NICE: Menopause: identification and management (NG23). NICE
2. Manson et al.: The Women's Health Initiative Randomized Trials and Clinical Practice: A Review (2024). PubMed
3. The Menopause Society: 2022 hormone therapy position statement. PubMed
4. Danan et al.: Hormonal treatments and vaginal moisturizers for genitourinary syndrome of menopause (2024). PubMed
5. WHI: Risks and benefits of estrogen plus progestin in healthy postmenopausal women (2002). PubMed
6. Collaborative Group: Type and timing of menopausal hormone therapy and breast cancer risk (2019). PubMed
7. Panay et al.: Evidence-based guideline: premature ovarian insufficiency (2024). PubMed
8. Andy et al.: Effects of menopause hormone therapy on cognition (2024). PubMed
9. European Society of Endocrinology: Clinical practice guideline for evaluation and management of menopause and the perimenopause (2025). DOI
10. British Menopause Society: Management of unscheduled bleeding on HRT (reviewed May 2026). BMS
11. The Menopause Society: 2023 nonhormone therapy position statement. PubMed
12. McCurry et al.: Telephone-based CBT for insomnia in perimenopausal and postmenopausal women (2016). PubMed