If you’ve ever kicked off the covers at 3 a.m. or been caught in the middle of a hot flash at work, you know how much menopause symptoms can derail your day. Hormone replacement therapy (HRT), also called menopause hormone therapy (MHT), can offer relief and help you feel more like yourself.
From pills and patches to gels and vaginal rings, treatment choices and access are expanding.
In this blog, we’ll look at how a generation of women missed out on HRT and why it’s now considered a safe, effective option for many. We’ll also cover the symptoms it can help with, how it works, and its impact on your gut and vaginal health.
How we got here: The WHI story
In 2002, the Women’s Health Initiative (WHI) reported that a specific type of HRT increased the risk of heart disease, stroke, blood clots, and breast cancer in women over 60 [1]. Prescriptions dropped almost overnight.
The issue was that WHI studied only one formulation, and most participants were well past menopause. Later research showed the risks are much lower for women under 60 or those who start within 10 years of menopause [2], [3]. This “timing hypothesis” suggests earlier use can bring more benefits and fewer risks, including a reduced chance of heart disease [4]-[6].
A 2015 review also found HRT does not increase overall mortality and may protect the heart when started early [7]. Because of this, major U.S. medical groups, including ACOG and NAMS, now support HRT for managing menopause symptoms when treatment is personalized [8].
While not every practitioner is up to date on the latest research, more women are coming in with informed questions. Plus, online clinics like Midi and Evernow make it easier for you to consider HRT options.
Symptoms that push women to consider HRT
From sleepless nights and mood swings to weight gain, the ripple effects of estrogen loss are hard to ignore. Here are the main symptoms that lead women to explore HRT as a treatment option.
Hot flashes and night sweats
The most common reason women start systemic HRT is to get relief from hot flashes and night sweats, clinically known as vasomotor symptoms [9].
The difference can be life-changing. A Cochrane review of 24 randomized controlled trials found that HRT, whether estrogen alone or combined with progesterone, reduced the number of weekly hot flashes by 75% and made them 87% less intense [10]. Since hot flashes can linger for many years, having an option that works can make a real difference day to day [11].
Vaginal and urinary symptoms
HRT also addresses other changes that can feel as disruptive, like vaginal dryness, irritation, pain during sex, and repeated UTIs. These fall under what’s known as genitourinary syndrome of menopause (GSM). Local vaginal estrogen is especially effective and is often the go-to when symptoms are limited to the vaginal and urinary area [9].
Sleep and mood
By easing night sweats, HRT can help you sleep better and may also support mood, particularly for depression and anxiety symptoms in perimenopausal and early postmenopausal women [9], [12]. That's not surprising, since estrogen plays a role in regulating your mood.
Metabolic shifts: Can HRT help with weight loss?
Lower estrogen levels can also slow metabolism, which is why many perimenopausal and menopausal women notice weight gain during this time, even without major changes in their diet or routine. Since every woman's body is different, and the effects of HRT are so personalized, it's no surprise that weight changes raise a lot of questions.
For some, HRT may help stabilize weight, while women who are sensitive to estrogen may find themselves asking, "Why am I gaining weight on HRT?" Others wonder if HRT helps with weight loss, and the truth is nuanced. It depends on factors like when you start treatment and your body's metabolism.
What HRT does and when to consider it
Hormone replacement therapy replenishes the estrogen, and sometimes progesterone, that your body naturally produces. If you still have a uterus, estrogen is typically combined with progesterone to reduce the risk of endometrial cancer. If you’ve had a hysterectomy (your uterus removed), you generally do not need progesterone and may benefit from estrogen-only therapy.
HRT supports your health as hormone levels change by easing symptoms caused by estrogen deficiency, such as hot flashes, mood swings, night sweats, brain fog, and weight gain [9]. Ultimately, it helps restore hormone levels to a range your body is more familiar with.
Understanding your levels isn’t always straightforward. Hormones fluctuate from day to day and don’t always reflect how severe your symptoms feel, so blood, saliva, or urine testing isn’t always reliable. That’s why most clinical guidelines recommend symptom-based dosing, using the lowest effective dose to manage symptoms rather than relying solely on lab results [10].
HRT timeline: Best time to start and see results
The best time to start hormone replacement therapy is different for every woman — your HRT timeline depends on factors like age, symptoms, and overall health. Many start during perimenopause, when changes begin to affect daily life. That might mean losing sleep, avoiding intimacy, skipping activities you enjoy, or not feeling like yourself.
Menopause happens on average around age 51, but the transition can begin in your late 30s or early 40s. Even after menopause, timing still matters. Research shows HRT is safest for women under 60 or within 10 years of their last period.
You might wonder, “How long does it take for HRT to work?” Everyone’s experience is a little different. Some women feel a lift in mood within days, while improvements like fewer hot flashes or better sleep may take weeks. Full benefits can take a few months, depending on the type of hormones, dosage, and your body’s response. Some positive effects only show up on medical tests, like bone scans and cholesterol panels. If you notice signs HRT is not working for you, like persistent hot flashes and night sweats, check in with your healthcare provider to talk through what’s going on and see if dosing changes might help.
Types of HRT
From pills to patches, each type of HRT works a little differently in your body. Some, like oral estrogen, pass through the liver first, while others, like patches or gels, enter the bloodstream directly. There’s also the option between FDA-approved products and compounded formulas that you might want to discuss with your practitioner.
Oral vs transdermal estrogen
When you take estrogen in pill form, it has to pass through your liver first. This process can raise levels of the sex hormone-binding globulin (which can lower libido), as well as triglycerides and C-reactive protein, a marker of inflammation.
Transdermal estrogen, like patches, gels, or sprays, bypasses the liver, so it doesn’t have those downsides. Because of this, topical HRT is preferred for women with obesity, high triglycerides, or low sex drive [11].
HRT pellets
Some women choose HRT pellets, which are small implants placed under the skin that release hormones over time. They’re usually compounded, so they aren’t FDA-regulated, and they may not be covered by insurance.
Compounded bioidentical hormone therapy vs standard HRT
Standard HRT includes FDA-approved options such as oral or transdermal estrogen and progesterone, which come in set doses with strict quality control. Many of these are also bioidentical, meaning the hormones are structurally the same as the ones your body naturally makes. Examples include transdermal estradiol and micronized progesterone.
Pros and cons of bioidentical hormones
You may have also heard of compounded bioidentical hormone therapy (CBHT), often marketed as a more natural alternative. Like standard bioidentical options, these hormones are usually made from plant sources such as soy or yams. The difference is that CBHT is mixed in compounding pharmacies for custom prescriptions and is not regulated by the FDA. This means there is less oversight of dose, purity, and quality.
For these reasons, major medical organizations don’t recommend CBHT as a first-line therapy. If you are considering it, work with a knowledgeable provider and choose a pharmacy that verifies quality through third-party testing [10].
Understanding HRT risks
As mentioned earlier, HRT is considered safe for many women when started before age 60 or within 10 years of menopause. Still, it’s not without risks. Oral estrogen can slightly increase the risk of blood clots and stroke, particularly for women with certain risk factors, like smoking or a higher body weight. Transdermal estrogen, such as patches or gels, has a lower clotting risk because it bypasses the liver [12].
Combined estrogen-progesterone therapy may slightly raise the risk of breast cancer after several years, while estrogen-only therapy for women without a uterus may not. Gallbladder problems are also more common with oral HRT [8]. If you notice any side effects, such as unusual bleeding or leg pain, talk to your doctor right away.
It’s also worth thinking about the risks of not taking HRT if you’re a candidate for it. Untreated menopausal symptoms like hot flashes, sleep disruption, and vaginal dryness can affect quality of life for years. Long-term estrogen deficiency may also contribute to bone loss and a higher risk of fractures, as well as changes in heart and metabolic health for some women.
Your practitioner can help you weigh the benefits and the potential downsides.
How HRT impacts your vaginal microbiome
Estrogen plays a key role in regulating your vaginal microbiome [13]. During menopause, your levels drop, disrupting this delicate ecosystem [14]. Your vaginal pH rises, and helpful Lactobacillus bacteria decline. Sometimes, disruptive microbes take their place, increasing the risk of discomfort, dryness, burning, infections, odor changes, and painful sex linked to GSM [15], [16].
Hormone replacement therapy may reverse many of these negative changes. Studies show that it helps rebuild Lactobacillus dominance, lowers pH, and reduces the presence of potentially disruptive bacteria such as Prevotella and Escherichia-Shigella [17]-[21]. The result is a vaginal microbiome that more closely resembles that of a premenopausal woman. For many women, that also means relief from their GSM symptoms.
These shifts are especially pronounced in those who started with lower Lactobacillus levels (like those with a CST 4 community type, which is more diverse and less protective). If you already had a Lactobacillus-dominant microbiome before starting HRT, the changes may be more subtle [18], [20].
While both oral and vaginal estrogen can support these microbiome changes, most of the research has focused on local treatments, like vaginal creams, tablets, or rings [17]-[21].
HRT and your gut microbiome
Menopause can also shift the makeup of your gut microbiome in similar ways. Beneficial gut bacteria and beta-glucuronidase (a microbial enzyme involved in estrogen metabolism) often decline, while disruptive species tend to increase [22]-[26].
While we’re still learning exactly how HRT affects the gut, early research points to some promising shifts, especially in areas linked to inflammation, hormone recycling, and microbial balance.
In one study of women with premature ovarian insufficiency (POI), a condition where the ovaries stop making hormones like estrogen before age 40, HRT helped lower a potentially unfriendly bacteria called Eggerthella compared to women who didn’t take HRT [27].
And in postmenopausal women, HRT was linked to a more balanced gut microbiome in the upper small intestine. Women not on HRT had higher levels of Proteobacteria (often linked to inflammation), lower levels of Bacteroidetes, and reduced microbial diversity. Meanwhile, those on HRT had a gut microbiome with more Prevotella and fewer Escherichia and Klebsiella, similar to what’s seen during the reproductive years [28].
Finding what works for you
HRT isn’t about turning back the clock; it’s about feeling better as your body changes. The right hormone replacement therapy can help you feel more like yourself again, easing symptoms that throw off your day, helping you sleep better, and supporting your overall well-being.
HRT isn’t the answer for everyone, but it’s worth exploring if menopause is affecting your quality of life. If you do give it a try, it’s always a good idea to keep track of your symptoms so you can spot any signs HRT is not working, and share them with your practitioner.
For women who want a fuller picture of what’s happening during this stage, our Gut Health and Vaginal Health tests now include a menopause metric for those 35 and older, giving you insights, clarity, and personalized steps to support you in this transitional time.
