A Guide to Hormone Replacement Therapy for Menopause

Hot flashes. Mood swings. Vaginal dryness. Menopause isn’t for the fainthearted.

And it’s probably not doing any favors for your sex life, either.

Hormone replacement therapy (HRT) can treat symptoms and improve your sex life, but it may not be for everyone. Here’s the scoop on the risks and benefits of HRT.

HRT for menopause

Around the age of 50, as part of the natural aging process, a woman’s body stops making estrogen, her natural hormone levels fall because her ovaries stop making female hormones, and she has no period for 12 months. This is menopause, a broad term that encompasses myriad symptoms: hot flashes, vaginal dryness, decreased bone density (osteoporosis) and moodiness, among others.

Hormone replacement therapy is a medication that contains female hormones—estrogen and progesterone—to treat these side effects. Women in perimenopause, which precedes menopause and is marked by decreasing hormones, can benefit from HRT, too.

Six million American women take estrogen-progesterone hormone therapies. Two common forms of HRT are systemic therapies and low-dose vaginal products. The former, taken as a pill, patch, gel or spray, circulates throughout the body and treats all menopausal symptoms. The latter remains localized, treating only vaginal and urinary menopausal symptoms.

Risks & benefits

In the 1990s, two major studies were conducted that later reported a number of risks of systemic HRT treatments: increased risk of heart disease, stroke, blood clots and breast cancer, with a greater risks-to-benefit ratio in women who start hormone replacement therapy later than age 60 or more than 10 years after the start of menopause.

After these studies were published in the early 2000s, the number of women taking HRTs fell by 66 percent.

More recently, the validity of those two landmark studies has been called into question. In fact, a 2012 study from Denmark found a reduced risk of heart disease in women taking combined hormone replacement therapies for 10 years if they started immediately after the onset of menopause. While the original study from the Women’s Health Initiative has been disproved, experts still agree that it is best to use the minimal amount of HRT for the shortest amount of time to treat symptoms of menopause.

Sexual side effects of menopause

Menopause can devastate a woman’s sex life by bringing on vaginal dryness, itchiness, burning and discomfort during penetration. Many menopausal women experience pain with intercourse due to vaginal atrophy, which is thinning and/or inflammation of the vaginal walls.

Hormonal changes can also alter mood and libido, and cause urinary side effects such as frequent urinary tract infections (UTIs) and incontinence.

A drop in collagen production can change the appearance of women’s skin and hair, which in turn can affect self-confidence. And then there’s insomnia. Who wants to have sex when they’re exhausted?

Managing menopause symptoms

Ironically, engaging in sex may be one of the best treatments for the sexual side effects of menopause. Stimulating the vagina increases blood flow and helps it stay lubricated. But it’s difficult to suggest sex as part of the treatment without addressing the menopausal symptoms that make having sex uncomfortable.

Medications undeniably have a positive effect for women experiencing these symptoms and can have a transformative benefit on their love life. The data suggest that HRT does come with some risks. Overall, however, hormone replacement therapy can be extremely beneficial for some women by decreasing discomfort, reducing the side effects of menopause and possibly even protecting them from heart disease.

Women going through early menopause—brought on by having a hysterectomy, the surgical removal of the reproductive organs, for example—who have estrogen deficiencies or are experiencing a significant negative impact on their sex life may find that the benefits of HRT outweigh the risks.

Hormone replacement therapy use depends on your risk factors, health history and health goals/personal preferences. Minimum use, or taking the lowest dose required, can help minimize risk. Discuss your personal risk-benefit ratio with your doctor, and which medications—more than 50 HRTs are on the market—may be best for you. Be upfront about any sexual health concerns you have.

If HRTs are not a great choice for you, other options exist: Sex therapy, pelvic floor therapy, vaginal dilators, yoga and clitoral devices can all help with discomfort.

Use water-based lubricants to improve comfort during sex. Treatments for insomnia—both medical and behavioral—can help you reboot and feel more energized. Libido and arousal may be helped by non-hormonal medications, such as bupropion and testosterone, though they’re not approved by the Food and Drug Administration (FDA) for that use.

Menopause is one of the many challenges women face in life. Hormone replacement therapy can be a game changer, but it’s not for everyone. Know your options, and choose the one(s) that best protects your health while enabling you to live a comfortable and (sexually!) active life.