“We’ve learned a lot in the last 10 years on risks and benefits, newer drugs have entered the market, and that made us look back at the data,” Pier said. “This is a challenging review process, and making sure we have the highest quality recommendations takes time.”
Hormone therapy replaces declining levels of estrogen and, for some patients, adds progesterone or a related hormone. Treatments come in pills, patches, sprays, gels, and vaginal rings, delivering hormones into the bloodstream to relieve menopause symptoms.
One of the oldest drugs, Premarin, contains estrogen derived from the urine of pregnant horses. Newer treatments often use estradiol, a form of estrogen manufactured from plant-based materials.
Menopause typically occurs around age 50, when menstrual periods permanently stop, but symptoms can begin years earlier and linger for years afterward. Surgery, chemotherapy, or radiation can also trigger menopause earlier.
ACOG says half to nearly all women in menopause have symptoms such as hot flashes, mood swings, night sweats, irregular periods, brain fog, and physical or skin changes. Between 16 and 66 percent report sleep disruption, and more than a third of perimenopausal and postmenopausal women worldwide report symptoms of depression.
The federal government this month announced steps to expand menopause treatment options, including efforts to remove broad FDA boxed warnings from hormone therapies and approving generic versions of Premarin, an estrogen medication, and the first generic hormone therapy patch, Climara Pro. The FDA has also approved a new non-hormonal drug for hot flashes, while federal health officials are promoting vaginal estrogen treatment and expanding breast cancer screening initiatives.
Is hormone therapy safe?
Yes, and for most women, it should often be the first option.
“It’s not really new, but it’s more formal,” said Dr. Deborah Susan Kwolek, a primary care physician who leads the Mass General Women’s Health and Sex and Gender Medicine Program and is a Menopause Society certified practitioner. “We have ways to treat these symptoms.”
She pointed out that both ACOG and the American College of Physicians now call hormone therapy first-line treatment. It gives doctors “permission to not be afraid of prescribing.”
The fear traces to the early 2000s, when a Women’s Health Initiative study linked hormone therapy to higher risks of stroke and breast cancer. Pier said the new analyses, which break the risks down by age, show the risks associated with HRT were found to be highest in women older than 60.
For women under 60, or within 10 years of their first menopausal symptoms, he said, the risk is “exceptionally low.” That timing is the central message.
“This is where we can really guide our patients,” he said.
What if you can’t take hormones?
Doctors say antidepressants like SSRIs and SNRIs are typically recommended for women who can’t or don’t want to take hormonal drugs.
The new guidelines also add a new FDA-approved option of nonhormonal drugs called neurokinin receptor antagonists that target hot flashes in the brain.
For mood symptoms, the guidelines conditionally recommend cognitive behavioral therapy. Kwolek said herbal supplements lack enough evidence to be recommended.
Women with complicated histories, such as breast cancer survivors or those with clotting disorders, should bring them up with their doctor early, Pier said. The guidelines flag that tamoxifen can interact with some antidepressants. He also noted that some non-hormonal drugs ease hot flashes and sleep problems but not vaginal dryness or irritation.
If your doctor is dismissive, Kwolek suggests looking for a clinician with the Menopause Society’s “MSCP” designation. There aren’t enough of them, she said, but the Menopause Society’s website has a directory.
What about the estrogen shortage?
Patients are still feeling it.
Kwolek said estrogen patches remain in short supply and she expects it to “get worse before it gets better.” Most estrogen products are generic, and she doesn’t see a big financial incentive for manufacturers to ramp up.
Her advice is not to go without. Many women can switch for a while to pills, a spray, or vaginal forms, and go back to the patch when it’s available.
What about testosterone/peptides?
Testosterone has become a social media favorite, and Kwolek said patients are asking for it. She prescribes it sometimes but doesn’t push it.
“The data is not convincing,” she said. It may boost sexual desire for some women, but she said the evidence for other claims, like building muscle, is weak. There is also no FDA-approved testosterone product for women, so prescriptions rely on off-label use and extra paperwork.
Pier said more patients are trying it without consulting a doctor.
“We’re seeing patients who come in with misinformation or have been to facilities that provide off-label testosterone or other hormones, and we need to combat that with data,” he said.
Kwolek said more women are also asking about peptides, which have become trendy among women navigating menopause. Often marketed for sleep, weight loss, libido, and longevity, these treatments have not been FDA-approved for menopause.
“If I give you a prescription, I’m confident this will help you,” she said. “If I recommend a supplement, I don’t know if it’ll help or hurt you.”
What about perimenopause?
Perimenopause, the years of irregular periods and shifting symptoms before menopause, isn’t the focus of these guidelines. Kwolek, who sees many perimenopausal patients, said the term has become trendy.
She said hormones are only part of the picture for women in their 40s and 50s who typically come to the hospital exhausted, moody, and sleeping badly. They often also care for kids and aging parents, work, and look for answers or quick fixes.
“Twenty years ago, people weren’t coming in saying, I’ve got perimenopause,” she said. “You might have aches and pains from playing tennis too much, or your kids are keeping you up, or your parents are sick. The 40s and 50s sandwich generation is stretched thin.”
Heavy periods can also cause iron deficiency and fatigue. For some perimenopausal patients, she prescribes contraception to manage symptoms.
Sarah Rahal can be reached at sarah.rahal@globe.com. Follow her on X @SarahRahal_ or Instagram @sarah.rahal.