HRT for Beginners: What Every Woman Should Know Before Deciding
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Hormones & Menopause

HRT for Beginners: What Every Woman Should Know Before Deciding

Dr. Emily RichardsonJan 31, 202610 min read
HRT isn't "one size fits all"—it's the most effective symptom reliever for severe menopause (hot flashes -80%, sleep/mood +70%). But WHI scare lingers (2002 halted early; re-analysis shows nuanced risks). For beginners: pros/cons, types, who benefits, monitoring. Not endorsement—empower informed choice with endo.
Modern data: Lowest dose/shortest time (<5yrs) safe for most <60/under 10yrs post-menopause (Lancet 2019). Bioidentical preferred. Track symptoms/bloods pre/post.
Pros cons HRT menopause decision infographic
Pros cons HRT menopause decision infographic

HRT 101: What It Replaces

Estrogen (E2): Vasomotor, urogenital, bone. Solo for hysterectomy.
Progesterone (P4): Uterus protect vs. hyperplasia.
Testosterone: Libido/energy (off-label low-dose).
Delivery: Transdermal (patch/gel) > oral (liver bypass, clots -80%).

Pros: Symptom Relief + Longevity

  • Hot Flashes/Night Sweats: 75-90% reduction (Cochrane 2022).
  • Bone Protection: Fracture risk -34% (JAMA 2019).
  • Mood/Sleep: Depression risk -50%, insomnia -60% (Menopause 2021).
  • Heart (Timing): <60yo start -30% CVD (Lancet 2019).
  • Brain: Dementia neutral/possible delay early use (Neurology 2022).
  • Libido: T add-on +40% satisfaction.

    • Cons/Risks (Dose/Time Dependent)

  • Breast Cancer: +0.01%/yr oral CEE/MPA; neutral transdermal micronized P4 (BMJ 2019).
  • Clots/Stroke: Oral +doubled (transdermal safe) (Circulation 2020).
  • Gallbladder: Oral +20%.
  • Bleeding: Spotting common first 6mo.
  • Cost/Access: $20-100/mo.
    • Absolute risk low <60yo: Breast +1/1000yr vs baseline 2.5/1000.

    Types Compared

    | Type | Pros | Cons | Best For |
    |------|------|------|----------|
    | Oral Estrogen (CEE/estradiol) | Cheap, easy | Liver first-pass risks | Mild symptoms |
    | Transdermal Patch/Gel | Clot-safe, steady | Skin irritation | CVD family hx |
    | Micronized P4 (oral/vaginal) | Breast-neutral | Drowsy | Uterus intact |
    | Synthetic Progestins (MPA) | Strong endo | Breast risk | Avoid if poss |
    | Bioidentical Compounded | Customized | Unregulated potency | Complex cases |
    | T Gel/Cream | Libido | Acne/hair | Low drive |
    Bioidentical = molecule match (estradiol, micronized P4); compounding variable FDA oversight.

    Who Should Consider HRT

    Yes: Severe VMS (20+/wk), osteoporosis risk, early menopause (<45).
    Maybe: Moderate symptoms + lifestyle fail.
    No: Breast/endometrial ca hx, clots, liver dz, >65yo/10+yrs post.
    Black box: Smoking doubles risks.

    Starting Guide: 12 Steps

  • Symptom Score: >20 Greene Climacteric? Proceed.
  • Labs: FSH>30, E2<50, TSH, lipids baseline.
  • Endo/Gyno Consult: Pelvic exam, mammogram.
  • Lowest Dose: Estradiol 0.025-0.05mg patch.
  • Trial 3mo: Titrate up if needed.
  • Monitor: Bloods 3/6/12mo, mammo yearly.
  • Taper Off: Symptoms gone? Cycle off.
  • Alternatives: If risks high—supps/lifestyle.
    • Step-by-step HRT starter guide for menopause
    Step-by-step HRT starter guide for menopause

    Lifestyle Synergy (Boosts 2x)

  • [Diet Article 10], exercise, stress mgmt cut dose 50%.

    • Myths Busted

  • "Causes cancer": Absolute risk tiny, benefits outweigh symptoms.
  • "Forever": Avg 5yrs.
  • "Bulk": No testosterone = no.

    • 3-Month Starter Protocol

    Mo1: Patch + P4, track flashes.
    Mo2: Add T if libido low.
    Mo3: Reassess labs/symptoms.
    Red Flags: Bleeding >6mo, chest pain—stop/ER.

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