Menopause hormone therapy is the most effective treatment for hot flashes and night sweats. For healthy women within 10 years of their last period or under age 60, benefits usually outweigh risks when you personalize the dose, choose the right route, and monitor with labs. Low-dose transdermal estradiol plus oral micronized progesterone is commonly preferred for safety. If hormones aren’t for you, effective nonhormonal prescriptions exist, including fezolinetant and low-dose paroxetine. We also address weight, sleep, mood, libido, bone, heart, brain, and gut.
Why HRT is back in the spotlight
Good data now separates past media fear from modern practice. Position statements from The Menopause Society and major medical groups agree: for most symptomatic women within 10 years of menopause, hormone therapy meaningfully improves quality of life and protects bone, with a favorable safety profile when tailored.
A wave of attention also comes from mainstream coverage that finally names symptoms many women were told to “tough out.” That visibility is overdue. Our goal here is clear, evidence-based steps so you can decide confidently.
Who should consider menopause hormone therapy
You may be a good candidate if you are:
- Under 60 or within 10 years of your final menstrual period, with moderate to severe hot flashes or night sweats that affect sleep, focus, or work.
- Experiencing genitourinary syndrome of menopause: vaginal dryness, pain with sex, urinary urgency, or recurrent UTIs. Local vaginal estrogen is highly effective and very low risk.
- At risk of bone loss and fractures. Systemic estrogen reduces bone turnover and preserves density; local estrogen helps urogenital tissues.
Who should avoid or delay hormones
Skip or defer systemic HRT if you have any of the following:
- Personal history of estrogen-dependent cancer without oncology clearance
- Unexplained vaginal bleeding, active liver disease, prior VTE or high clot risk, or high 10-year ASCVD risk
- Age over 70 considering new systemic therapy, based on emerging analyses suggesting higher cardiovascular risk when initiating late in life
When systemic estrogen is not suitable, nonhormonal options can work well.
Estrogen: forms, routes, and smarter dosing
Estrogen choices
- Transdermal 17β-estradiol patch, gel, or spray
- Oral estradiol or conjugated estrogens
Why route matters
- Oral estrogen passes through the liver first and can raise clotting factors and triglycerides. Transdermal bypasses first-pass metabolism and is associated with a lower venous clot risk in observational data. For many, we start with a low-dose patch and titrate.
Starting points we often use
- Transdermal estradiol 25 to 50 mcg per day, reassess symptoms and vitals at 6 to 8 weeks
- If you have a uterus, add progesterone for endometrial protection
Local estrogen for GSM
- Vaginal estradiol tablets, rings, or creams can be used long term at very low systemic absorption, including in many breast cancer survivors after oncology discussion.
Progesterone: why the type matters
If you have a uterus, pair estrogen with a progestogen to protect the uterine lining.
- Micronized progesterone 100 mg nightly continuous, or 200 mg nightly for 12 to 14 days per month if using a cyclic plan.
- Observational cohorts suggest different breast-risk signals across progestogens, with micronized progesterone generally associated with a more favorable profile than several synthetic progestins. Randomized data are limited.
What about bazedoxifene plus conjugated estrogens
- For women with a uterus who cannot or prefer not to use a progestin, bazedoxifene with conjugated estrogens is an FDA-approved combination that treats hot flashes and helps bone while blocking estrogen’s uterine effects. Long-term cardiovascular data are more limited.
Breast cancer, clots, heart, and brain: the real risk picture
Breast cancer
- Risk depends on regimen, duration, and baseline risk. Large analyses show that combination estrogen-progestin regimens increase breast cancer risk with longer use, while estrogen-only regimens in women with prior hysterectomy may lower breast cancer incidence in some trials. Absolute risks are small and individualized.
Clotting
- Oral estrogen is linked with higher venous thromboembolism risk; transdermal estradiol appears lower risk in observational data. We screen personal and family history and thrombophilia when appropriate.
Heart
- Timing matters. Starting HRT near menopause in lower-risk women shows a more favorable cardiovascular profile than starting late, consistent with the “timing hypothesis.” Avoid systemic HRT in women with high 10-year ASCVD risk.
Brain
- HRT is not a dementia treatment. Observational studies suggest possible increased dementia risk with some regimens, especially with longer use, while RCTs in older women also showed higher risk. We avoid initiating systemic HRT late in life and keep brain health strategies focused on sleep, exercise, blood pressure, insulin, and lipids.
Nonhormonal options that actually help
Effective prescription choices for hot flashes and night sweats
- Fezolinetant 45 mg daily, a neurokinin 3 receptor antagonist, FDA-approved for vasomotor symptoms. Monitor liver enzymes because of a 2024 safety communication about rare serious liver injury.
- Paroxetine mesylate 7.5 mg nightly, FDA-approved; other SSRIs/SNRIs and gabapentin have evidence and can help sleep.
- Cognitive behavioral therapy and certain mind-body approaches have modest benefit.
We combine these with sleep, temperature, and alcohol/caffeine strategies that make a noticeable difference.
Labs we run before and during treatment
Baseline
- CBC, CMP, fasting lipids with ApoB, fasting insulin and glucose to calculate HOMA-IR, hs-CRP, TSH with reflex free T4, 25-OH vitamin D, ferritin, B12, Lp(a) once in a lifetime, stool microbiome if GI symptoms
- For women considering HRT: blood pressure, BMI, ASCVD risk estimate, mammography status, and VTE risk screen
Follow-up
- Vital signs and symptom scores at 6 to 8 weeks and every 6 to 12 months thereafter
- Lipids, liver enzymes, and glucose-insulin markers if clinically indicated
Weight, insulin, and GLP-1s
Weight gain in perimenopause is common because of sleep fragmentation, reduced energy expenditure, and insulin resistance. For patients with obesity or overweight plus comorbidities, GLP-1 or GIP-GLP-1 medications can be effective additions to nutrition and resistance training.
Representative outcomes from large RCTs
- Semaglutide 2.4 mg once weekly delivered about 15 percent mean weight loss at 68 weeks with lifestyle support.
- Tirzepatide 5 to 15 mg once weekly delivered about 16 to 22.5 percent mean weight loss at 72 weeks and improved cardiometabolic markers.
- A 2023 cardiovascular outcomes trial with semaglutide showed fewer major CV events in patients with obesity and prior CVD.
We evaluate meds in the context of your hormones, thyroid, sleep, and gut so the plan is coherent.
Libido and testosterone in women
Low desire is multifactorial. For carefully diagnosed hypoactive sexual desire disorder after biopsychosocial assessment, systemic testosterone can help postmenopausal women using standardized dosing and monitoring. This is an off-label therapy in the US. We avoid supraphysiologic dosing and pellets.
Gut, sleep, and recovery
Menopause symptoms amplify when sleep and gut are off. We use:
- Sleep: morning light, consistent rise time, cooldown routine, protein at dinner plus magnesium glycinate if appropriate
- Gut: fiber to 30 g per day, protein to 1.2 to 1.6 g per kg per day, reduce ultra-processed foods that drive vasomotor triggers in some patients
- Training: 2 to 3 days per week of heavy compound lifts plus daily zone 2 walking
A short case example
Client M, age 49, had 12 months of worsening night sweats, 15-pound weight gain, and brain fog. Baseline labs: LDL 146 mg/dL, ApoB 110 mg/dL, fasting insulin 14 µIU/mL, HOMA-IR 3.1. We started transdermal estradiol 25 mcg per day and oral micronized progesterone 100 mg nightly, plus protein targets, creatine 3 g daily, and a push-pull-legs plan. At 8 weeks, sweats down 80 percent, sleep from 5 to 7.5 hours, and focus improved. At 6 months: 6 percent weight loss with diet and training only. We later added semaglutide for 16 weeks, targeting 10 to 12 percent total weight loss.
How we personalize care at 1st Optimal
What we do
- Individual risk scoring for breast, clot, heart, and bone
- Route choice for estrogen to minimize clot risk
- Prefer micronized progesterone for endometrial protection and sleep
- Layer nonhormonal options when hormones are not appropriate
- Integrate GLP-1s, peptides when indicated, gut repair, and strength training
- Measure outcomes that matter: sleep, mood, hot flash frequency, body composition, and labs
Callouts
- Safety first: if you are over 70 or far from menopause onset, we generally avoid starting systemic HRT. Local vaginal estrogen remains a helpful option for urogenital symptoms.
- GSM matters: dryness and pain rarely “go away.” Local therapy is low dose, direct to tissue, and effective.
FAQs
Q1. Is “bioidentical” safer than “synthetic”?
“Bioidentical” just means the molecule matches human hormones. Estradiol and micronized progesterone fit this category. Safety comes from dose, route, timing, and your baseline risks, not marketing terms.
Q2. Do I need blood tests to diagnose menopause?
No. If your cycles have stopped for 12 months and you’re in the typical age range, it’s a clinical diagnosis. We use labs to guide overall metabolic and cardiovascular risk and to troubleshoot symptoms.
Q3. Will HRT cause weight gain?
Estrogen therapy is weight neutral in trials, but better sleep and thermoregulation can make fat loss easier. For significant weight goals, nutrition, training, and sometimes medications are needed.
Q4. Is transdermal estrogen really safer?
For clot risk, observational data are consistent that transdermal estradiol is lower risk than oral estrogen. We still screen, but route matters.
Q5. What if I’ve had breast cancer?
Systemic HRT is usually avoided for hormone receptor-positive disease. For bothersome GSM after nonhormonal measures, low-dose vaginal estrogen may be considered with oncology input.
Q6. Can HRT prevent dementia?
No. Evidence does not support HRT to prevent cognitive decline, and some studies suggest increased dementia risk with certain regimens and durations. Brain health is multifactorial.
Q7. How long can I stay on HRT?
Use the lowest effective dose for the shortest time needed to manage symptoms, with annual risk review. Some women taper after 2 to 5 years; others continue longer with shared decision making.
Q8. What if I cannot or won’t take hormones?
Evidence-based nonhormonal options exist, including fezolinetant and low-dose paroxetine. We also use CBT-i, sleep, and cooling strategies.
Q9. Does progesterone help sleep?
Oral micronized progesterone can improve sleep quality in some women and is required for endometrial protection when using systemic estrogen and you have a uterus.
Q10. What about testosterone for women?
Only for carefully diagnosed hypoactive sexual desire disorder, using standardized low-dose regimens and monitoring. Not for general “energy” or fat loss.
