What Menopause Hormone Therapy Actually Treats — and What It Doesn't

Hormone therapy has a small number of indications where the evidence is strong, and a much larger number of uses where it is not. The 2022 position statement of The North American Menopause Society — an advisory panel review of the literature, graded by strength of evidence — puts it plainly: hormone therapy "remains the most effective treatment for vasomotor symptoms (VMS) and the genitourinary syndrome of menopause and has been shown to prevent bone loss and fracture."[1]

Knowing what is on that list, and what is not, is most of the decision.

The indications the evidence supports

Vasomotor symptoms. Hot flushes and night sweats. This is the primary indication and the one with the strongest evidence behind it.

Genitourinary syndrome of menopause. Vaginal dryness, irritation, painful sex, and associated urinary symptoms. Worth knowing: for these symptoms alone, in women without another reason to take systemic hormones, the panel recommends low-dose vaginal estrogen or other local options rather than systemic therapy.[1] Local symptoms can often be treated locally.

Prevention of bone loss and fracture. An established effect, not a theoretical one.

The variable that changes the answer

The panel's recommendation is not a single verdict. It splits on timing, and the split is sharp:

• Under 60, or within 10 years of menopause onset, with no contraindications — the benefit-risk ratio is favorable for treating bothersome vasomotor symptoms and preventing bone loss.[1]
• More than 10 years from menopause onset, or over 60 — the balance "appears less favorable because of the greater absolute risks of coronary heart disease, stroke, venous thromboembolism, and dementia."[1]

The reason is partly that those absolute risks rise with age regardless of hormones, so the same relative effect lands on a larger baseline. The WHI data behind that reasoning is worth reading directly, because it is more equivocal than either camp usually admits.

What changes the risk, beyond timing

The panel is explicit that hormone therapy is not one thing: risks "differ depending on type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is used."[1]

Route is the one with the clearest evidence attached to a specific outcome. Oral estrogen passes through the liver before reaching general circulation and raises venous clot risk; transdermal estrogen has not been shown to. See oral versus transdermal estrogen for the numbers.

If you have a uterus, estrogen alone is not appropriate. A progestogen is required to protect the endometrium.[2] This is not a preference or an optimisation — unopposed estrogen raises the risk of endometrial hyperplasia and cancer. Which progestogen, at what dose, and by which route are questions with their own evidence, and they are worth asking your prescriber specifically rather than accepting "and a progesterone" as a complete answer.

What is not on the list

This is where most marketing departs from the evidence.

The panel's favorable-balance statement covers bothersome vasomotor symptoms and prevention of bone loss. It does not extend to energy, mood, cognition, weight, or general "hormone optimisation." Longer courses of therapy, the panel says, "should be for documented indications such as persistent VMS, with shared decision-making and periodic reevaluation."[1]

Symptoms outside that list are real and worth treating. They are just not, on this evidence, reasons to start hormone therapy — and treating them by that route means a workup that never happened. Persistent fatigue or cognitive change deserves its own assessment: thyroid, iron, sleep, mood.

The same pattern holds for testosterone in women, where the evidence supports exactly one indication and no product is approved for female use. That is covered separately in testosterone therapy for women.

Frequently asked questions

Is hormone therapy safe? That question has no general answer, which is the honest response rather than an evasive one. The panel's framing is a benefit-risk ratio that is favorable under 60 or within 10 years of menopause, and less favorable outside that window. Safety depends on which risks apply to you.

How long can I stay on it? The panel does not set a stopping date. It asks for longer durations to be tied to a documented indication such as persistent vasomotor symptoms, with periodic reevaluation of whether continuing still makes sense.[1]

I only have vaginal symptoms. Do I need systemic hormones? Probably not. For genitourinary symptoms not relieved by over-the-counter options, in women without another indication for systemic therapy, the recommendation is low-dose vaginal estrogen or other local treatments.[1]

Does hormone therapy prevent heart disease? It is not recommended for that purpose. Coronary heart disease appears in the position statement among the risks that make the balance less favorable in older women and those further from menopause.[1]

I'm perimenopausal, not postmenopausal. Does this apply? The evidence summarised here is about postmenopausal women. Perimenopause has its own considerations, and it is worth being specific with your clinician about where you are.

Getting the order right

Two questions come before the prescription: are the symptoms ones hormone therapy is shown to treat, and where do you sit relative to that under-60-or-within-10-years line. Route and progestogen follow from there.

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References

2 sources

1. The North American Menopause Society 2022 Hormone Therapy Position Statement Advisory Panel. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767–794. doi:10.1097/GME.0000000000002028 · PMID 35797481
2. Stute P, Neulen J, Wildt L. The impact of micronized progesterone on the endometrium: a systematic review. Climacteric. 2016;19(4):316–328. doi:10.1080/13697137.2016.1187123 · PMID 27277331