What is menopausal hormone therapy (HRT)?

Menopausal hormone therapy means taking estrogen, with a progestogen added if you still have a uterus, to relieve symptoms caused by falling ovarian hormones. It is the most effective treatment available for hot flashes and night sweats and the only one that also prevents the bone loss of early menopause. It comes as pills, patches, gels, sprays, and vaginal products, and the right form depends on your symptoms and your health history.

The names, and what they mean

You will see three terms used interchangeably: hormone replacement therapy (HRT), hormone therapy (HT), and menopausal hormone therapy (MHT). The Menopause Society and ACOG use “hormone therapy.” The word “replacement” has fallen out of favor because the aim is symptom relief at the lowest useful dose, not restoring premenopausal hormone levels.

Two distinctions matter more than the name.

Systemic versus local. Systemic therapy raises estrogen levels throughout the body. It treats hot flashes, night sweats, the sleep disruption they cause, and vaginal symptoms, and it protects bone. Local therapy is low-dose vaginal estrogen as a cream, tablet, insert, or ring. It treats vaginal dryness and painful sex with very little absorption into the bloodstream, does not treat hot flashes, and does not require a progestogen.

Estrogen alone versus estrogen plus a progestogen. This depends on whether you have a uterus.

	Estrogen alone (ET)	Estrogen plus progestogen (EPT)
Who	Women who have had a hysterectomy	Women with a uterus
Why	No uterine lining to protect	Progestogen prevents the lining from overgrowing
Progestogen options	None needed	Micronized progesterone, a synthetic progestin, or a levonorgestrel IUD (off-label)

“Progestogen” is the umbrella term. It includes micronized progesterone, which is chemically identical to the hormone the ovaries make, and synthetic progestins such as medroxyprogesterone acetate and norethindrone.

How it works

During perimenopause, estrogen production becomes erratic and then falls. Those changes are believed to trigger hot flashes and night sweats. Estrogen also maintains vaginal tissue, bone density, and other systems, so its loss shows up in several places at once.

Hormone therapy steadies estrogen levels. In the Cochrane review of oral estrogen trials, hot flash frequency fell by about 75 percent compared with placebo across 24 trials and 3,329 women, and severity fell as well. A 2023 review in JAMA put the reduction at roughly 75 percent for systemic estrogen with or without a progestogen, with oral and transdermal forms working equally well. Nonhormonal prescription options reduce frequency by about 40 to 65 percent.

The forms

Form	How taken	Notes
Estradiol or conjugated estrogen pill	Daily by mouth	Longest track record; passes through the liver first
Estradiol patch	Changed once or twice a week	Bypasses the liver; preferred when clot risk is higher
Estradiol gel or spray	Daily on the skin	Same advantage as the patch; dose can be fine-tuned
Combination patch or pill	Estrogen and a progestin together	Convenient if you have a uterus
Low-dose vaginal estrogen	Cream, tablet, insert, or ring	For vaginal and urinary symptoms only; no progestogen needed

Progestogen comes as a capsule taken at bedtime (micronized progesterone), a pill, a combined product, or a hormonal IUD.

If you have a uterus, there are two ways to schedule the progestogen. In continuous-combined therapy you take both hormones every day and usually have no bleeding after the first months. In cyclic therapy you take estrogen daily and the progestogen for 10 to 14 days each month, which produces a predictable monthly bleed. Cyclic regimens are often used in perimenopause, when your own cycles continue.

What it treats, with evidence

• Hot flashes and night sweats. Hormone therapy is FDA-approved as first-line treatment, with the roughly 75 percent reduction described above. The Menopause Society notes that frequent symptoms last 7.4 years on average, so the relief is not a small thing.
• Sleep. When night sweats are what wake you, treating them improves sleep. If you wake at 3 a.m. without sweats, read our guide on why perimenopause wakes you at 3 a.m., because other causes are common.
• Vaginal dryness and painful sex. Both systemic and local estrogen work. Local estrogen is enough if these are your only symptoms.
• Bone. Systemic estrogen prevents the bone loss of early menopause and reduced fractures in the Women’s Health Initiative. It is FDA-approved to prevent, not treat, osteoporosis.

Hormone therapy is not approved to prevent heart disease, dementia, or other chronic conditions, and the evidence does not support using it for those purposes.

The risks, briefly

The serious risks of systemic hormone therapy are rare, which The Menopause Society defines as fewer than 10 extra events per 10,000 women per year. They include blood clots and gallbladder disease with any systemic estrogen, and a small increase in stroke and breast cancer with estrogen plus progestogen after several years of use. Oral estrogen carries more clot risk than the patch. All of these risks rise with age and with starting more than 10 years after menopause.

Common, non-dangerous side effects include breast tenderness, bloating, nausea, headaches, and spotting, which usually settles within 6 months. Adjusting the dose or the form often fixes them.

We cover the numbers in Is hormone therapy safe? and Hormone therapy and breast cancer risk.

Who it is for, and who should avoid it

The Menopause Society’s 2022 position statement, which ACOG broadly shares, concludes that for women younger than 60 or within 10 years of menopause who have bothersome symptoms and no contraindications, the benefit-risk balance is favorable. Starting later is less favorable because the baseline risks of heart disease, stroke, and clots are higher at older ages.

Systemic hormone therapy is usually not recommended if you have had:

• breast cancer or another estrogen-sensitive cancer
• a blood clot in a leg or lung, or an inherited clotting disorder
• a stroke or heart attack
• unexplained vaginal bleeding
• active liver disease

It is not used in pregnancy, and it is not a contraceptive.

What hormone therapy is not

It is not the same as compounded “bioidentical” hormones. FDA-approved estradiol and micronized progesterone are already identical to the body’s own hormones. Custom-compounded creams and pellets are not FDA-tested for dose accuracy or safety, and ACOG recommends FDA-approved products over them.

It is not a one-time decision. ACOG advises revisiting the choice every year based on your symptoms, risks, and preferences. There is no fixed stopping age.

Questions to ask your clinician

• Given my history, is systemic hormone therapy an option for me?
• Patch, gel, or pill: which do you suggest, and why?
• If I have a uterus, which progestogen and on what schedule?
• What should I expect in the first 3 months, and when will we review?
• If hormone therapy is not right for me, what else works?

If your current clinician does not have these conversations, our guide on how to find a menopause specialist explains the credentials to look for, and you can search our OB-GYN directory. To bring a clear picture of your symptoms, start with our symptom check.