Hormone replacement therapy
Also known as: HRT, menopausal hormone therapy, MHT
Medically reviewed by Hormone Journal Editorial Team · Last reviewed 2026-05-17
Hormone replacement therapy (HRT) uses estrogen, progestogens, or both to relieve menopausal symptoms and reduce bone loss after the body's own hormone production declines.
What it is
Hormone replacement therapy (HRT) — also called menopausal hormone therapy (MHT) — uses estrogen, progestogens (progesterone-like medicines), or a combination of both to replace hormones the ovaries stop producing at menopause. It is the most effective treatment available for moderate-to-severe vasomotor symptoms (hot flashes, night sweats) and is also FDA-approved to prevent postmenopausal osteoporosis (bone thinning).
Causes and mechanism
At menopause, the ovaries sharply reduce output of estradiol (the main form of estrogen) and progesterone. Falling estrogen disrupts the brain's temperature-regulation center, triggering hot flashes and night sweats. It also accelerates bone loss and can thin vaginal and urinary tissues. HRT restores circulating estrogen to levels that suppress these effects. In people who still have a uterus, a progestogen must be added because estrogen alone thickens the uterine lining and raises the risk of endometrial cancer (cancer of the uterus lining).
Symptoms and diagnosis
HRT is considered when menopause symptoms are moderate to severe and affect quality of life. Common indications include:
- Hot flashes and night sweats (vasomotor symptoms)
- Vaginal dryness, pain with sex, or recurrent urinary symptoms (genitourinary syndrome of menopause)
- Accelerated bone loss or early osteoporosis
- Premature menopause (before age 40) or early menopause (before age 45)
Diagnosis of menopause is clinical — 12 consecutive months without a period — though blood tests (FSH, estradiol) can help in ambiguous cases, such as perimenopause or surgical menopause.
Treatment options
Systemic HRT (pill, patch, gel, spray, or vaginal ring) circulates estrogen throughout the body and treats both vasomotor and bone symptoms. Patches, gels, and sprays deliver estrogen through the skin (transdermally), bypassing the liver; some evidence suggests transdermal routes carry a lower blood-clot risk than oral pills, though head-to-head trial data are limited.
Low-dose vaginal estrogen (cream, tablet, suppository, or ring) acts locally on vaginal and urinary tissue with minimal systemic absorption; it does not reliably treat hot flashes or protect bone.
Progestogen options include synthetic progestins (e.g., medroxyprogesterone acetate) and micronized progesterone. Some observational data suggest micronized progesterone may carry a lower breast-cancer risk than certain synthetic progestins, but the evidence is not definitive and guidelines do not yet rank one above the other for most patients.
Non-hormonal alternatives exist for those who cannot or prefer not to use HRT: the SNRI fezolinetant (FDA-approved 2023 specifically for vasomotor symptoms), other SNRIs/SSRIs, gabapentin, and cognitive behavioral therapy show modest benefit in trials.
When to see a clinician
Seek evaluation if hot flashes or night sweats disrupt sleep or daily function, if vaginal symptoms affect sexual health or cause recurrent infections, or if a bone-density scan shows significant loss. Starting HRT before age 60 or within 10 years of menopause is associated with a more favorable benefit-risk profile according to current guidelines from ACOG, the Menopause Society, and NICE. People with a personal history of estrogen-receptor-positive breast cancer, unexplained vaginal bleeding, active blood clots, or recent stroke or heart attack are generally not candidates for systemic HRT. Review your regimen with a clinician at least annually, as the optimal duration varies by individual risk.
FAQs
What is the difference between HRT and bioidentical hormone therapy?
Bioidentical hormones have a chemical structure identical to hormones made by the body. Some FDA-approved products — such as micronized progesterone and estradiol patches — are bioidentical. Compounded bioidentical hormones, mixed by a pharmacy to a custom dose, are not FDA-approved and have not been tested in large safety trials. Major professional bodies including ACOG and the Menopause Society caution that compounded products carry unknown risks and should not be assumed safer than regulated options.
Does HRT cause breast cancer?
The risk depends on the type and duration of HRT. The Women's Health Initiative trial found that combined estrogen-plus-progestin therapy was associated with a small absolute increase in breast cancer risk — roughly 8 additional cases per 10,000 women per year of use. Estrogen-only therapy (for those without a uterus) was not associated with increased breast cancer risk in that trial. Risk appears to return toward baseline within a few years of stopping. Individual risk factors such as family history, obesity, and alcohol use also matter and should be discussed with a clinician.
How long can you stay on HRT?
There is no universal time limit. Current guidance from the Menopause Society states that duration should be individualized based on ongoing symptoms, bone-health needs, and personal risk factors, reviewed at least once a year. Some women with premature menopause are advised to continue HRT at least until the average age of natural menopause (around 51) to protect bone and cardiovascular health. For women who start HRT after age 60 or more than 10 years past menopause, the risk-benefit balance shifts and closer monitoring is warranted.
Is HRT covered by insurance?
In the United States, most FDA-approved HRT formulations are covered under commercial insurance and Medicare Part D, though cost-sharing varies by plan and formulary tier. Generic estradiol patches and pills are typically the least expensive options, often under $30 per month with insurance. Compounded bioidentical hormones are usually not covered. Patients in the UK receive NHS-prescribed HRT at the standard prescription charge (currently capped at a prepayment certificate rate).
Can HRT help with mood and sleep problems during menopause?
HRT can improve sleep indirectly by reducing night sweats that fragment sleep; direct effects on sleep architecture are less clear. Evidence for mood benefits is strongest in the perimenopause transition, where estrogen may reduce depressive symptoms, but HRT is not a first-line treatment for clinical depression at any age. A 2018 Cochrane review found insufficient evidence to recommend HRT specifically for mood disorders. If mood symptoms are severe or persist after vasomotor symptoms are controlled, a mental health evaluation is appropriate.