The transition to menopause is a natural and normal part of life, but that doesn’t mean it’s easy. In the years before and after your menstrual period stops, you can experience hot flashes, night sweats, mood changes, insomnia, and vaginal and urinary symptoms.
For some, these symptoms are subtle and short-lived; for others, they are debilitating and can last for years.
“There’s an idea that women have to power through these symptoms, and there’s a culture of dismissing some of these concerns,” says UNC Health OB-GYN Katelin Zahn, MD. “It’s important that women mention these symptoms to their provider.”
UNC Health OB-GYN Rachel Urrutia, MD, adds, “These symptoms might not be life-threatening, but they can significantly impact relationships and the ability to enjoy daily activities. If you’re not sleeping, you’re feeling depressed and you can’t concentrate, it will affect your quality of life.”
One option for relieving menopausal symptoms is hormone therapy. Drs. Zahn and Urrutia explain the hormonal changes happening during menopause and how hormone therapy can help.
Hormonal Changes Around Menopause
Menopause is the point at which you have not had a menstrual period for one year. The average age for menopause is 51, and at that point, estrogen and progesterone, the hormones that regulate the menstrual cycle and support pregnancy, will have diminished.
You can expect a variety of hormonal changes during perimenopause, the term for the four to eight years leading up to and including the year after your last period.
“The perimenopausal transition is characterized by significant hormonal fluctuations,” Dr. Zahn says. “It’s not as simple as a steady decline in estrogen.”
Dr. Urrutia says, “In the years leading up to menopause, your ovaries are less responsive to brain hormones that tell them to ovulate. Your brain may send out extra hormones to try to stimulate ovulation, and if the ovaries respond, there can be higher levels of estrogen some months.”
One of the first symptoms you might notice is a shorter cycle, which is due to the brain working to spur ovulation. Eventually, the ovaries will stop producing estrogen, though the levels of brain hormones will remain high. These shifts in estrogen will cause the classic menopause symptoms.
“The body has a thermostat in the hypothalamus, and input to this thermostat is sensitive to estrogen,” Dr. Zahn says. “Vasomotor symptoms like hot flashes and night sweats are the result of that thermostat responding to changing estrogen.”
People tend to have symptoms most intensely in the two years before the last cycle and right after, though some have them for longer.
Hormone Therapy During Menopause
Menopause hormone therapy is the use of estrogen and sometimes a form of progesterone (such as progestin) to relieve menopausal symptoms. The therapy is most associated with relief of hot flashes and night sweats, though some people also report improvements in mood, sleep, joint pain, and vaginal and urinary symptoms. Hormone therapy does not cause weight gain during menopause.
“Estrogen has the most impact on hot flashes and night sweats, but progestin may help with mood stabilization and sleep,” Dr. Urrutia says. “The dosing typically involves estrogen every day, and then either a small amount of progestin daily or a larger amount of progestin for 10 to 12 days each month.”
Estrogen also improves bone health and decreases the risk of osteoporosis.
If you still have a uterus, a form of progesterone is an important part of hormone therapy, as it protects the lining of the uterus from cancers that could form from excess estrogen.
Your provider will determine the amount of hormones necessary and the way they’re administered, depending on your needs and symptoms. You may apply a skin patch, take a pill, or use a gel, spray or vaginal ring.
“When we prescribe menopause hormone therapy, we’ll see the person around six weeks later to see if symptoms have been relieved and they’re on the right dose,” Dr. Zahn says. “Then, we would see the person each year to analyze any new medical concerns and determine whether it’s safe to continue the hormone therapy.”
Dr. Urrutia says, “We’re looking to help symptoms with the smallest dose. There may be a time of trial as we see how they feel.”
If you have vaginal and urinary symptoms related to menopause, including vaginal dryness, pain with intercourse or urinary irritation, local hormone therapy is an option. Rather than taking a dose that affects the entire body, you can use a low-dose estrogen cream, tablet or ring in the vagina to relieve symptoms. This method of hormone therapy is associated with lower health risks than systemic hormone therapy.
Hormone Therapy Risks
Hormone therapy can increase your risk of certain conditions, so your doctor will help you assess the benefits of symptom relief against your health history.
“The risk for a blood clot doubles on estrogen,” Dr. Urrutia says. “People in their 40s and 50s generally have a very low risk for blood clots, but it is an increase.”
Hormone therapy is also associated with an increased risk of breast cancer.
“The risk seems to be specific to people using hormones for more than five years, so we might have people use the therapy for four years and then consider tapering off, particularly people with a family history of breast cancer,” Dr. Urrutia says.
If you need symptom relief for longer than five years, talk to your doctor about a plan.
“We know that a third of women will have bothersome symptoms for longer than 10 years,” Dr. Zahn says. “While there used to be a hard stop at five years, we can consider extending the therapy if the benefits outweigh the risk.”
If you are at a higher risk of heart attack or stroke, you may not be a good candidate for hormone therapy, though age is an important consideration.
“If a woman goes through early menopause, estrogen may provide some benefit to the heart in the long term, so hormone therapy might be highly recommended,” Dr. Urrutia says. “If the patient is over the age of 60 and more than 10 years from the onset of menopause, the risk of heart attack and stroke is much higher, and we typically don’t recommend hormone therapy.”
Alternatives to Hormone Therapy
A few nonhormonal medications have been shown to be effective at relieving hot flashes and night sweats. These include two classes of antidepressants called selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs); gabapentin, typically used to treat seizures; oxybutynin, typically used to treat overactive bladder; and clonidine, typically used for high blood pressure. In 2023, the Food and Drug Administration approved the use of Veozah (fezolinetant) for hot flashes. All of these medications have side effects that you should discuss with your doctor.
Besides medications, cognitive behavioral therapy and clinical hypnosis can be effective in managing hot flashes.
Other options are available but don’t have as much evidence supporting their efficacy.
“There’s a booming industry of supplements related to menopausal symptoms right now, but there’s not much data on how well they work,” Dr. Zahn says. “Some of these supplement subscriptions are very expensive, and your money can be more valuably spent on something with more evidence.”
If you have questions about menopause, talk to your doctor. Need a doctor? Find one near you.