There isn’t one honest yes-or-no answer to “is HRT safe?” Cleveland Clinic’s published information ties the safety conversation to when treatment starts and to personal medical history [1]. The source reports that the stated increase in breast cancer risk is less than 1 in 1,000 and typically does not increase until after five years of use [1]. Hormone therapy comes in systemic and local forms, so the appointment should identify which form is being discussed and which symptom it is meant to treat [1].
What does HRT mean?
Hormone replacement therapy is a treatment for symptoms of menopause that replaces hormones the body stops producing [1]. Cleveland Clinic lists hormone therapy for hot flashes and night sweats, vaginal dryness and painful intercourse, mood disturbance and depression, insomnia, and urinary incontinence [1].
Perimenopause is the transitional period before menopause, during which estrogen levels start to decrease [3]. Cleveland Clinic lists irregular periods, heavier or lighter periods, mood changes including irritability and depression, low libido, hot flashes, night sweats, vaginal dryness with discomfort during sex, urinary urgency, and trouble sleeping among its symptoms [3].
Perimenopause usually starts in the mid-40s and may begin as early as the mid-30s or as late as the mid-50s [3]. Menopause is reached when there has been no menstrual period for 12 months in a row [3].
Cleveland Clinic says perimenopause is usually identified from symptoms, age, medical history, and a physical exam. Follicle-stimulating hormone testing can help, but hormone levels rise and fall erratically during perimenopause [3].
What forms of HRT are listed?
Systemic hormone therapy forms listed by Cleveland Clinic include pills taken by mouth, a skin patch, a gel applied to the skin, and a spray applied to the arm [1]. Local forms include a vaginal ring, vaginal cream, and vaginal tablets [1].
Ask which form is being discussed and which symptom the treatment is intended to address. Cleveland Clinic lists hormone therapy for hot flashes and night sweats, vaginal dryness and painful intercourse, mood disturbance and depression, insomnia, and urinary incontinence [1].
When does timing affect risk?
Cleveland Clinic reports that risks are generally lower when hormone therapy starts before age 60 or within 10 years of menopause [1]. The same source reports an increased risk of heart disease when hormone therapy begins 10 years after menopause starts [1].
The menopause date matters because menopause is reached after 12 months in a row without a menstrual period [3]. Record the date of your last menstrual period and whether you have reached that point [3].
Which medical history should be reviewed?
Cleveland Clinic says hormone therapy is generally not used by people with a history of breast, ovarian, or uterine cancer, abnormal vaginal bleeding, blood clots, stroke or heart attack, pregnancy, or gallbladder or liver disease [1].
Before the appointment, mark whether any of these apply to you. Use the specific wording when you describe your history: breast, ovarian, or uterine cancer; abnormal vaginal bleeding; blood clot; stroke; heart attack; pregnancy; gallbladder disease; or liver disease [1].
What breast cancer risk figure is published?
Cleveland Clinic states that the increase in breast cancer risk is less than 1 in 1,000 and typically does not increase until after five years of use [1]. The same source says most people take hormone therapy for five years or less [1].
Ask which treatment form the discussion concerns and which breast cancer risk information applies to it.
What bleeding should be part of the conversation?
During perimenopause, menstrual cycles can become longer or shorter than usual, and bleeding can be heavier or lighter than normal [3]. Abnormal vaginal bleeding is also on Cleveland Clinic’s list of histories in which hormone therapy is generally not used [1].
Cleveland Clinic lists periods lasting longer than seven days, soaking through a pad or tampon every hour for several hours, needing to wear more than one pad at a time, changing pads in the middle of the night, and passing blood clots the size of a quarter or larger several times a day as signs of heavy menstrual bleeding [3].
Soaking at least two pads or tampons per hour and keeping that up across two to three consecutive hours is the level Cleveland Clinic says calls for prompt professional evaluation [3]. If this is happening, record the number of pads or tampons and the number of consecutive hours, then use those words when contacting a provider.
Cleveland Clinic also says to contact a provider about bleeding that is very heavy, soaks a pad every one to two hours, lasts longer than usual, happens between periods, follows sex, or occurs when periods come less than 21 days apart [3].
What is the current Menopause Society statement?
The Menopause Society lists its 2022 statement as the current hormone therapy position statement [2]. The society also lists a 2023 nonhormone therapy position statement for hot flashes and night sweats [2].
Ask which position statement is being used in the discussion and whether the conversation concerns hormone therapy or nonhormone treatment.
What nonhormonal approaches are listed?
Cleveland Clinic lists dietary changes, exercise, cognitive behavioral therapy, antidepressants, and gabapentin as nonhormonal approaches for menopause symptoms [3].
Ask which listed nonhormonal approaches are being discussed for the symptom you want treated.
Use this appointment-question checklist
Bring these questions and history points to the hormone therapy conversation.
| Question or history to bring | My notes |
|---|---|
| What symptom am I asking treatment to address? | |
| Are the symptoms hot flashes, night sweats, vaginal dryness, painful intercourse, mood disturbance, insomnia, or urinary incontinence? [1] | |
| Is the treatment systemic or local? [1] | |
| Is the form a pill, patch, gel, spray, vaginal ring, vaginal cream, or vaginal tablet? [1] | |
| What was the date of my last menstrual period? | |
| Have I gone 12 months in a row without a period? [3] | |
| Have I had abnormal vaginal bleeding? [1] | |
| Have I had breast, ovarian, or uterine cancer? [1] | |
| Have I had a blood clot, stroke, or heart attack? [1] | |
| Could I be pregnant? [1] | |
| Have I had gallbladder or liver disease? [1] | |
| Does the timing fall before age 60 or within 10 years of menopause? [1] | |
| Which breast cancer risk figure applies to this treatment form? [1] | |
| Which Menopause Society position statement supports this discussion? [2] | |
| Which nonhormonal approaches are listed for this symptom? [3] |
What to do next
- Record the symptom you want treated and the date of your last menstrual period [1][3].
- Mark each personal-history item that applies to you: breast, ovarian, or uterine cancer; abnormal vaginal bleeding; blood clot; stroke; heart attack; pregnancy; gallbladder disease; or liver disease [1].
- Ask, “Which form is being discussed, and which symptom is it intended to treat?” [1]
- Ask, “Which breast cancer risk figure applies to this treatment form?” [1]
- Ask, “Which Menopause Society position statement supports this discussion?” [2]
- If bleeding soaks a pad every one to two hours, contact a provider about it [3].
- If you are bleeding through at least two pads or tampons each hour for two to three consecutive hours, seek prompt professional evaluation [3].
Related on Ruby: perimenopause symptoms and what is perimenopause.
Sources
- Cleveland Clinic, Hormone replacement therapy for menopause. https://my.clevelandclinic.org/health/treatments/15245-hormone-therapy-for-menopause-symptoms
- The Menopause Society, position statements index. https://menopause.org/professional-resources/position-statements
- Cleveland Clinic, Perimenopause. https://my.clevelandclinic.org/health/diseases/21608-perimenopause