For months, some people wake up soaked in sweat night after night and, during the day too, find their face suddenly flushing hot so they have to stop what they are doing. When hormone therapy comes up, worries such as “Could it give me breast cancer?” or “Once I start, will I have to keep taking it?” often come first. Rather than recommending or discouraging treatment, this article sets out, step by step, what is worth checking together before you decide.
What symptoms can menopause bring?
The best-known are hot flushes, when heat suddenly rises, and night sweats, but the range is wide and can include sleep, mood, and vaginal and urinary discomfort. Which symptoms appear and how strong they are differ from person to person, and they can begin during the menopausal transition, while periods are still coming.
- Heat and sweating: Heat rushes to the face, neck or chest, or sweating wakes you at night.
- Sleep and mood: You may wake often or find it hard to fall back asleep, and your mood may become low or irritable.
- Physical discomfort: Some people describe aching joints and muscles.
- Vagina and urination: Vaginal dryness can make sex painful, or urinating can become uncomfortable.
- Changes in periods: Cycles become irregular and then gradually stop.
The UK NICE guideline regards menopause as having occurred when someone aged 45 or over who is not using hormonal contraception has had no period for at least 12 months. In this age group the judgement is often based on symptoms and changes in periods, so a hormone blood test is not always needed. On the other hand, if hot flushes appear for the first time long after menopause, other causes such as thyroid disease or medicines you are taking are also checked.
What is hormone therapy used for?
Its main purpose is to reduce menopausal symptoms that interfere with daily life and sleep. The 2022 position statement of the North American Menopause Society (now The Menopause Society) and the 2025 guidelines of the Korean Society of Menopause regard hormone therapy as the most effective treatment for hot flushes, night sweats and menopause-related vaginal and urinary symptoms, and also describe its effect in preventing bone loss after menopause. However, how much it helps differs from person to person.
It is also worth being clear about what it is not for. The North American Menopause Society does not recommend using hormone therapy to prevent dementia or cognitive decline, and the Korean Society of Menopause does not recommend using it solely to prevent heart disease.
How does systemic treatment differ from local vaginal treatment?
Systemic treatment acts throughout the body to address symptoms such as hot flushes and sweating, while local vaginal treatment focuses on symptoms of the vagina, vulva and the area around the urethra. Where to start depends on which symptom troubles you most.
| Category | Systemic hormone therapy | Local vaginal oestrogen |
|---|---|---|
| Main symptoms addressed | Hot flushes and night sweats, and the sleep problems they cause | Vaginal dryness, pain during sex, some urinary discomfort |
| How it is used | Tablets, skin patches, gels and so on | Low-dose products placed in the vagina, such as tablets, creams or rings |
| If you have a uterus | As a rule, used together with a progestogen | A separate progestogen is generally not used |
| Absorption into the whole body | Acts throughout the body by design | Very small amount absorbed compared with systemic treatment |
If someone with a uterus uses oestrogen alone as systemic treatment, the lining of the uterus can thicken and the risk of endometrial cancer can increase. For this reason a progestogen is used alongside it, or another combined preparation that protects the uterine lining is chosen. If you have had your uterus removed, oestrogen-only treatment is considered.
Tablets and treatments absorbed through the skin differ in blood clot risk. The NICE guideline states that the risk of venous blood clots increases with oral hormone therapy but not with treatment through the skin. This is why treatment through the skin is considered first for people at higher risk of blood clots, those with obesity or high blood pressure, and those who smoke.
If you only have vaginal symptoms, you can start with vaginal moisturisers and lubricants or local vaginal oestrogen without systemic treatment. If you have been treated for breast cancer, non-hormonal methods are used first, and local oestrogen is decided on together with the medical team treating your breast cancer.
What is checked before starting?
Your medical history, an examination and tests are used to check whether your symptoms are likely to be helped by treatment and whether there are conditions in which it should not be used. Based on the items the Korean Society of Menopause’s 2025 guidelines list for assessment before starting, these are:
- Medical and family history Breast or endometrial cancer, blood clots, stroke or heart disease, liver or gallbladder disease, migraine, diabetes or high blood pressure, depression, and smoking and drinking are checked. Please also mention if anyone in your family has had breast cancer or blood clots.
- Recent periods and bleeding When your last period was, and whether you have had bleeding between periods or after menopause, are checked.
- Examination Height, weight and blood pressure are measured, and the pelvis, breasts and thyroid are examined.
- Tests These include blood tests such as liver and kidney function, haemoglobin, fasting blood sugar and cholesterol, as well as a mammogram, bone density scan and cervical cancer screening. Considering the situation in Korea, the Korean Society of Menopause also recommends a pelvic ultrasound.
- Medicines and products you are taking Please mention not only prescription medicines but also any health supplements or herbal medicines you are taking for menopause.
If you have results from a recent national health screening or breast and uterine check-ups, bringing them can help avoid repeating tests. If you are unsure which check-ups you had and when, read Should you have an OB-GYN checkup even without symptoms? first.
What changes with age and time since menopause?
If it is started before age 60 or within 10 years of menopause and there are no contraindications, the benefits are judged to outweigh the risks for treating bothersome hot flushes and preventing bone loss. This is the assessment of the North American Menopause Society’s 2022 position statement, and the Korean Society of Menopause guidelines follow the same direction. If it is first started after age 60 or more than 10 years after menopause, the absolute risks of coronary heart disease, stroke, venous blood clots and dementia are higher, so the balance of benefits and risks becomes less favourable.
Risks also vary with the type and combination of medicine, the dose, how long it is used and the route by which it is given.
| Risk to check | What the guidelines summarise |
|---|---|
| Breast cancer | With oestrogen and progestogen used together, the risk rises the longer it is used; it falls after stopping but remains for at least 10 years. With oestrogen alone, there is very little or no increase (NICE). |
| Blood clots | Increased with tablets but not with treatment through the skin (NICE). The Korean Society of Menopause explains that the risk is especially high in the first year after starting. |
| Uterine lining | If you have a uterus and use oestrogen alone, the risk increases, so a progestogen is used alongside it. |
| Gallbladder disease | Studies have found more gallbladder disease during use, so this is also explained. |
The actual size of these risks depends on the risk factors you already have. That is why the explanation can differ from person to person even for the same medicine, and in consultation the figures are discussed in terms of your own age and medical history. At the same time, there is no rule that treatment must be stopped across the board on reaching 60 or 65. If symptoms continue, the risks are weighed again to decide whether to carry on.
What side effects can occur?
Headaches, breast pain or tenderness, nausea, a feeling of swelling, mood changes and unexpected bleeding are relatively common. In many cases they ease within a few weeks to a few months; if they do not, the dose, the type of medicine or the way it is used can be changed. Menopausal symptoms and side effects can be similar and hard to tell apart, so keep a note of any changes.
If you have a uterus, irregular bleeding is common in the first 6 months of systemic treatment, or within 3 months of changing the dose or medicine. If bleeding continues after this period, becomes heavier, or newly appears after a time without bleeding, you need to see a doctor. How the cause of bleeding is investigated is covered in detail in Abnormal vaginal bleeding: how is the cause found during a clinic visit?.
When is treatment checked again after starting?
The NICE guideline recommends checking effectiveness and any problems 3 months after starting, and then reassessing once a year. If treatment is not working well enough or there are side effects, it is checked sooner.
At every reassessment, the benefits and risks of continuing are discussed again from the beginning. The focus is on how much the symptoms have eased, whether there is any new bleeding or discomfort, and whether any illness or change in medicines has come up in the meantime. Rather than changing the dose or duration yourself, please adjust it together during a consultation.
When stopping, you can choose between reducing gradually and stopping all at once. Reducing gradually may help limit symptoms coming back in the short term, but over the longer term there is said to be no difference between the two approaches. It is common for symptoms to return after stopping, and you can discuss it again if that happens.
What options are there if hormones are not suitable?
If you cannot or would rather not use hormones, options such as non-hormonal medicines, cognitive behavioural therapy, and vaginal moisturisers and lubricants are chosen to suit your symptoms. The size of the effect may differ from hormone therapy, so what you hope for is discussed together.
- Non-hormonal medicines: The Korean Society of Menopause guidelines explain that some antidepressants (SSRIs and SNRIs) and gabapentin can reduce hot flushes to some extent. Each medicine has side effects and medicines it should not be taken with, so these are checked before prescribing.
- Cognitive behavioural therapy: The NICE guideline presents menopause-specific cognitive behavioural therapy as a treatment option for hot flushes. It can be used together with hormone therapy, or be an alternative for people who do not use hormones.
- Managing vaginal symptoms: For dryness and pain during sex, vaginal moisturisers and lubricants can be tried first.
- Lifestyle: Maintaining muscle strength through exercise and looking after bone health help whether or not you have treatment.
What is discussed together in a consultation is summarised in LILEAP’s menopause and climacteric care guide, and managing vaginal dryness and pain during sex in the vaginal dryness care guide.