Is hormone therapy for the menopause safe and worthwhile?

Hormone therapy (HT) works best against hot flushes and night sweats. That is robustly established. It also demonstrably slows bone loss after menopause, resulting in fewer hip fractures. Sleep problems caused by hot flushes can improve as well. HT is intended purely as a treatment for symptoms, not to prevent heart disease or other chronic conditions.

The most important risk of combined oestrogen-progestogen therapy, the most commonly used form in women with a uterus, is a higher chance of breast cancer. In the large WHI study that risk was 1.24 times higher during use, and it remained slightly elevated after long-term follow-up. This risk grows with use lasting longer than three to five years. Women without a uterus who use oestrogen alone do not carry this risk. In the WHI study, researchers even observed a slightly reducing effect on breast cancer in that group, although it was not statistically convincing.

Another real risk of oral HT is a higher chance of thrombosis and pulmonary embolism. Transdermal oestrogens, administered via patch or gel, do not carry this increased thrombosis risk. Not even in women who already have an elevated baseline risk. This practical difference is taken into account when choosing a method of administration.

The timing of starting also matters. Women who begin shortly after menopause, around the age of 50 to 59, have better outcomes for heart disease and mortality than women who start much later, more than ten years after menopause. This is called the 'timing effect' or 'window of opportunity'. In women aged 65 and older who used combined HT, the WHI study found an increased risk of dementia. Whether this also applies when starting around the time of menopause is unclear.

For local complaints such as vaginal dryness, pain during sex and urinary problems, collectively known as the genitourinary syndrome of menopause (GSM), low-dose vaginal oestrogens are the first choice. These are applied locally and are much safer than systemic HT. Prefer to avoid oestrogens? Then vaginal DHEA and the oral agent ospemifene are proven effective alternatives, although the evidence is of low to moderate quality. For hot flushes, certain antidepressants such as paroxetine and venlafaxine, and gabapentin, are proven alternatives, though they work less well than oestrogen. Yoga, acupuncture, black cohosh and omega-3 supplements do not clear the bar: there is no consistent evidence that they work better than a placebo.