Starting with: You feel like you have PMS all the time.
If a male friend or partner wrote off your PERFECTLY NORMAL emotional reaction to hormones, you might feel the urge to punch him in the throat. Just because you’ve begun to sob at life insurance commercials, haven’t slept well in weeks and feel like your body might burst into flames without warning—which, let’s face it, is upsetting—that doesn’t mean you shouldn’t be taken seriously, right? How dismissive! But two things can be true at the same time: You deserve to be taken seriously AND your perfectly normal emotional reactions may, in fact, be due to hormones (no need to tell him he’s right.) So what are the signs you might need hormone therapy?
The short answer: If you have symptoms that are more than little annoyances, that get in the way of feeling good and functioning well, that’s a pretty good indication.
Let’s face it: we’re not talking about a garden-variety cold that goes away in a couple of weeks. The average menopause transition—i.e., from perimenopause to one year after your last period— takes about seven years, according to the National Institute on Aging.
It’s hard to know exactly how many women have symptoms that get in the way of their functioning, but we do know that 54% of women find them disruptive enough to seek treatment, according to research (1). During that time, over 80% of women have hot flashes, for instance, according to the Journal of Midlife Health (2).
“With women often living until their mid-90s, many spend 40 percent of their life post-menopause,” says JoAnn Pinkerton, M.D., director of the Midlife Health Center at the University of Virginia Health in Charlottesville and executive director emerita of the Menopause Society.
Joanne Pinkerton, M.D., is the Mamie A. Jessup Professor of Obstetrics and Gynecology and division director of Midlife Health at the University of Virginia. She has published in more than 90 peer-reviewed journals and has frequently been the principal investigator in research on treating vasomotor symptoms with hormonal and non-hormonal therapies.
Stephanie Faubion, M.D., is the Director of the Center for Women’s Health at the Mayo Clinic in Jacksonville, FL, and Rochester, MN. Dr. Faubion’s research encompasses sex- and gender-based differences in disease, menopause, hormone therapy, healthy aging, and sexual health and dysfunction in women.
Perimenopause and menopause often hit just when you’re at the top of your career, and possibly sandwiched between caring for your kids and your parents. So you need to be sharp. That’s not easy when you feel like a sleep-deprived, brain-fogged spontaneous-combustion engine. “Menopause is a major health issue that’s under-addressed and under-treated,” says Pinkerton.
But it doesn’t have to be that way. For many women, hormone therapy (HT)—also known as menopause hormone therapy (MHT)—can make all the difference. “We don’t call it HRT [hormone replacement therapy] anymore,” explains Stephanie Faubion, M.D., director of the Mayo Clinic Center for Women’s Health in Rochester, MN, and medical director of the Menopause Society. After all, you’re not “replacing” your hormones, and it’s perfectly natural that they’re fluctuating now. “We’re not trying to get your hormones back to where they were before menopause. Instead, we’re trying to manage symptoms effectively, which can often be accomplished with lower doses of hormone therapy. The goal is to help women through this universal transition without suffering.”
Menopause 101 is something all women should be taught at informal but mandatory classes held at wine bars for our convenience. Since it isn’t, you might have questions about the best time to start hormone therapy.
Menopause, for some women, can be a bear. Every day, about 6,000 American women reach menopause. By the year 2030, more than a billion women around the world will be menopausal or postmenopausal. That’s a lot of women’s PERFECTLY NORMAL reactions being dismissed as merely hormonal (but we digress).
The point is, menopause is a natural, everyday event, but you still might have symptoms that bother you or get in the way of your everyday life.
“I always like to say that menopause is the reverse of puberty,” explains Pinkerton. It starts when your levels of the hormones estrogen and progesterone begin to drop, eventually causing your monthly periods to stop and your childbearing years to come to an end.
Perimenopause. This phase usually begins around the age of 47. As your levels of the hormones estrogen and progesterone fluctuate, you may notice your cycles are becoming irregular, shorter, or even longer, and your menstrual flow may be heavier or lighter. You may start having hot flashes, mood changes, and sleep disturbances.
Menopause. You’ll only realize you’ve reached menopause when you look back. If it’s been a full year since your last period, you’re officially in menopause.
Postmenopause. Welcome to the rest of your life, when you can spend your tampon money on a flashy red convertible (why should midlife men get all the horsepower?) and swim without fear of shark attacks (that’s a myth, by the way.) No more monthly periods. No more pregnancies. For many women, it’s a good thing.
Still, throughout the transition, you may not appreciate some of the symptoms that you’re starting to notice (4).
Here are some clues that menopause is around the corner. This is just a partial list–dozens of symptoms can be attributed to “the change,” as people used to call it when they for some reason couldn’t just say “menopause. (Or you might be one of the around 15 percent of lucky women with no menopause symptoms at all.)
How can two hormones—estrogen and progesterone—cause so much trouble? Turns out, they affect just about every part of your body, from your reproductive system to your heart and blood vessels to your skin, hair, and urinary tract—even your brain. So it’s not just symptoms like those above: According to the National Osteoporosis Foundation, your bones are affected by menopause, too. That drop in estrogen can cause women to lose up to 20 percent of their bone density during this period, making falls and fractures more common.
To make matters worse, the calendar is catching up with you. In your postmenopause years, you’re more prone to conditions like heart disease and thin bones anyway. Menopause may not be causing all your troubles, but everything might be happening at the same time. Some days, it just seems like the universe wants to remind you that you’re mortal.
Menopause hormone therapy can relieve these health concerns:
Trouble concentrating? Feeling super-forgetful? Some of it is just plain brain aging. And some of it may be your fluctuating hormone levels–estrogen and progesterone, after all, help your brain stay sharp. Add in sleepless nights and mood swings, and it’s no wonder you’re feeling a little foggy. For many women, says Pinkerton, “hormone therapy can improve brain fog and concentration.”
There could be lots of reaons for this, but two big culprits are hot flashes and night sweats. Studies show that zapping them can help you get a good night’s sleep (3).
Hormone therapy can help with mental health concerns like depression. A recent study found that HT significantly improved symptoms of depression, both with HT alone and combined with antidepressant medication. That’s important because some 62 percent of women reported experiencing depression at this time of life (4).
According to the Menopause Society, HT is the most effective way to treat these symptoms.
The jury is still out on whether HT can aid weight loss, but in one large study, women who took HT during menopause had lower BMIs than those who didn’t (5). But, says Pinkerton, “Hormone therapy is not a magic bullet.” You’ve heard this song before: exercise and eating a healthful, moderate diet is always good advice.
The more trips you make around the sun, the higher your risk for a bunch of health conditions. HRT can help reign some of them in. The United States Preventive Services Task Force, an organization that weighs evidence of and provides recommendations for screenings and treatments, doesn’t recommend that HT be used primarily to treat or prevent illness. That said, if you’re using it for menopause symptoms, HT appears to confer some benefits.
Your risk for both of these goes up after menopause. Oral HT can bump up your risk for blood clots just a smidge. But with a patch, spray, or gel, there’s no increase in risk, especially if you’re under 60.
According to the National Institute on Aging, HT can decrease your resistance to insulin, which can help prevent diabetes. One recent study suggested that it may even slightly reduce your risk of getting diabetes in the first place. If you already have type 2 diabetes, one recent study found that HT confers a “neutral to beneficial impact.” (6)
When women start hormone therapy before the age of 60 and within a few years of menopause, a recent study found that HT reduces cardiovascular disease. (7)
Hormone therapy isn’t one-size-fits-all. Though it’s almost always a combination of estrogen and progesterone, doctors can adjust and tailor the dose and the length of time a woman receives it. They can also offer women lots of different forms of hormone therapy.
“When a woman comes in with menopause symptoms, we talk about what they’ve tried in the past and what their preferences are,” says Pinkerton. “How bothersome are they, for instance—are they having trouble sleeping, having lots of hot flashes? We talk about what form might work best.”
If you’ve been on birth control pills and done well with them, your doctor might try oral HT first, says Pinkerton. “We can also offer transdermal patches—they tend to be safer and more effective, though some people can have allergies or reactions to them. And there are also estradiol pumps and gels—for example, a daily gel in a little package or a systemic ring that you can put into the vagina.” These can help with menopause discomfort.
For most women, yes.
It is confusing, though, because in 2002, HT got some super-bad press that scared people, including many doctors. A major study from the Women’s Health Initiative reported that women taking HT had a higher risk of coronary heart disease, stroke, and breast cancer. That report caused a big drop in the use of hormone therapy, from about 22 percent of women in 1999 to as few as 3 percent in 2010 (8).
Once the commotion died down, though, it was understood that these findings only applied to older women who had hit menopause a long time before the study. The research also didn’t look at a wide range of formulations or delivery systems.
In 2014, scientists launched the Kronos Early Estrogen Prevention Study (KEEPS), to take another look. This time, they enrolled younger participants—700 women with an average age of 53 and a lower risk for cardiovascular and other diseases. Plus, they were all within three years of their last period. During the study, none of the women had a serious heart event, and none experienced cognitive problems or breast cancer (8).
And—hallelujah!—they saw some of their symptoms improve: fewer hot flashes and night sweats, as well as better sleep. The treatment improved their mood as well as their sexual function. They also maintained their bone density and decreased their resistance to insulin.
The bottom line? After rerunning the numbers, scientists came to this conclusion: For healthy women under sixty—and fewer than ten years post-menopause—“the benefits of HT often outweigh the risk,” explains Pinkerton.
If your menopause symptoms are bothering you and getting in the way of your everyday activities, Pinkerton says, you may be a candidate for menopause hormone therapy. It’s not the solution for everyone, though.
A 2023 study published by the journal Circulation suggests that the following women may not be the best candidates for HT (9). That’s because they may already be at risk for these conditions, and HT may exacerbate that risk.
Definitely not, says Faubion. It’s common to put on a few pounds during the years of menopause, but it’s not because of hormone therapy. It may not be due to menopause, either. Midlife weight gain is often due to the fact that our crazy lives make it harder to eat right and exercise enough.
Either way, HT won’t make you gain more, says Pinkerton. “You’re not likely to notice any change in the scale by taking hormone therapy.” Studies show no significant differences in weight between women who take HT and those who don’t (10).
“Women often gain weight as they age, and the hormonal changes your body is going through make it more likely that you’ll notice it in your abdomen. HT can actually help redistribute fat and help you manage weight by improving your sleep—when you don’t get enough sleep, you consume more calories.”
If you start noticing signs that you might need hormone replacement therapy, it’s better to start looking into it sooner rather than later, say the experts. Ideally in the years right around when you reach menopause, talk to your healthcare provider as soon as you start noticing bothersome symptoms.
How long should you continue? That depends. While you’re on menopause hormone therapy, meet with your doctor annually about your symptoms, risks, and benefits. Most women take HT for two to five years to get over the worst of the hot flashes. But some may need it for longer, and for others, there may be no need for an endpoint.
Not a candidate for menopause hormone therapy for women—or choose not to take it? You have options. There are other meds and some “natural” cures, although those don’t have a lot of science behind them, according to Pinkerton. These are:
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