HRT in Women — Foundations

Is progestogen required to protect the endometrium with estrogen therapy?

Systemic estrogen in women with a uterus requires adequate progestogen exposure to prevent endometrial hyperplasia. Micronized progesterone and progestins differ in metabolic and VTE profiles.

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What is the evidence for treating genitourinary syndrome of menopause?

Low-dose vaginal estrogen effectively treats vaginal dryness, dyspareunia, and urinary symptoms of genitourinary syndrome of menopause with minimal systemic exposure. Regular reassessment of endometrial safety applies at higher cumulative doses.

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Does menopausal hormone therapy prevent osteoporosis and fractures?

Estrogen-based therapy reduces bone loss and fracture risk in postmenopausal women, with benefit most established during early postmenopause. Guidelines support HRT for fracture prevention primarily when indicated for vasomotor symptoms or in high-risk women.

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What therapies are most effective for vasomotor symptoms in perimenopause?

Systemic hormone therapy remains the most effective treatment for moderate-to-severe vasomotor symptoms across the menopause transition. When estrogen is declined or contraindicated, evidence-supported non-hormonal options—including fezolinetant and selected SSRIs/SNRIs—reduce symptoms, though with generally smaller effect than estrogen.

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Does hormone replacement therapy increase venous thromboembolism risk?

Oral estrogen increases venous thromboembolism risk compared with no therapy. Transdermal estrogen appears to carry lower thrombotic risk in observational studies and is often preferred in women at elevated VTE risk.

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Does low-dose vaginal estrogen carry significant systemic risks?

Low-dose vaginal estrogen for genitourinary syndrome of menopause achieves local benefit with minimal systemic absorption in most women. Progestogen is generally not required for endometrial protection at standard low doses.

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Is transdermal estrogen preferred over oral estrogen in menopause?

Transdermal estrogen avoids first-pass hepatic effects and is associated with lower venous thromboembolism risk than oral routes in observational data. It is often preferred in women with elevated thrombotic or metabolic risk.

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How long should menopausal hormone therapy be continued?

Duration should be individualized based on symptom control, indication, and evolving risks. Many guidelines support continued use with annual reassessment rather than arbitrary stopping ages when benefits outweigh risks for that patient.

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Does hormone therapy prevent cognitive decline or dementia?

WHI and subsequent analyses do not support HRT for dementia prevention when initiated in older postmenopausal women. Early-initiation cognitive studies are mixed and do not establish routine neuroprotection.

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