Why are some doctors hesitant to prescribe hormone replacement therapy to menopausal women?

Menopause symptoms — and how severe they are — vary from person to person. But in general, the hormonal changes that happen during menopause bring on a slew of physical and emotional side effects, such as hot flashes, night sweats, vaginal dryness, low libido, sleep disturbances and mood swings.

Despite how common they are, a 2023 study published in Menopause: The Journal of the Menopause Society shows that a high proportion of women experiencing more serious menopausal symptoms remain untreated, with nearly 40% of them having no prescription medication documented at all. The study also found that, even though they were suffering through these symptoms, about 50% of the women surveyed delayed seeking care for more than six months.

Hormone replacement therapy, or HRT (also now referred to as menopausal hormone therapy, or MHT), is an FDA-approved effective treatment designed to alleviate many menopausal symptoms. Yet numerous doctors are hesitant to prescribe it — and many women are worried about taking it.

Here, experts explain why this is so, and how HRT works.

What is HRT and how does it work?

The basic components of HRT are estrogen and progestin, which is a form of progesterone. “The active component responsible for relief of menopausal symptoms — and for the long-term health benefits — is the estrogen,” Dr. Sharon Malone, chief medical adviser at Alloy, a women's health company, tells Yahoo Life. “Progestins are added only to protect the lining of the uterus for those people with intact uteruses.” So women who have undergone a hysterectomy would be offered an estrogen-only remedy.

The North American Menopause Society states that, depending on a patient’s symptoms, medical history and lifestyle, a female can be prescribed:

Systemic therapies, where hormones are released in the bloodstream and travel to the organs and tissues. Products are available in pills, skin patches, gels, injections and sprays and can be used to treat hot flashes, night sweats, vaginal symptoms and osteoporosis.

Local therapies, which target a specific area of the body. Products are available in creams, tablets or vaginal ring and can be used to treat vaginal symptoms, such as pain with sexual intercourse.

Malone explains that estrogens and progestins can be bioidentical — meaning the hormones are identical to the hormones produced by the ovaries — or non-bioidentical. “The term ‘synthetic’ is a misnomer,” she says. “All estrogen products, with the exception of Premarin (made from the urine of pregnant mares), are synthetic, which simply means made in the lab. The same is true for progestins.”

Bioidentical progesterone, often referred to as “natural” progesterone, is also made in the lab and is a modification of a plant-based source — primarily yams — to create the bioidentical progesterone, Malone says.

Who is — and isn’t — a good candidate for HRT? And when is the best time to take it?

It comes down to risk factors. Hormone therapy is typically not recommended for anyone with a personal medical history of breast or uterine cancer, undiagnosed postmenopausal bleeding, active liver disease, heart attack, stroke or diagnosed cardiovascular disease, unprovoked blood clots in legs or lungs or hereditary blood clotting disorders.

That said, Malone points out that not all former breast cancer patients are the same. “There is considerable discussion as to whether women with a history of breast cancer can take HRT,” she says, adding: “It is no longer an absolute contraindication.” The same goes for those who were diagnosed with blood clotting disorders.

As for the right time to start HRT, Dr. Mary Claire Haver, author of The Galveston Diet and founder of the Mary Claire Wellness Clinic, tells Yahoo Life that women should never experience a single menopausal symptom. “This is far from reality,” she says. “Due to lack of training and education in the menopausal transition, many women are expected to wait until their symptoms are severe before a clinician will consider hormone therapy.”

Haver says there are some possible benefits to starting treatment when the symptoms appear. “There are studies to support beginning hormone therapy in perimenopause,” she says, since findings suggest it may decrease symptoms of depression, treat abnormal uterine bleeding, improve bone density and lessen symptoms of genitourinary syndrome — a chronic, progressive condition of the vulva, vagina and lower urinary tract, which occurs during menopause that causes urinary and sexual issues, according to Brigham and Women’s Hospital. These include vaginal dryness as well as itching and burning, painful sex and recurring urinary infections.

Malone says there is a preferred time for postmenopausal women to start hormone therapy. “Preferably HRT/MHT should be started before age 60 or within 10 years of the last period,” she says. “This ‘window of opportunity’ is simply the time frame within which we can unequivocally say that the benefits greatly outweigh the risks.”

Women who do not fall into this time frame can still consider taking hormone therapy, although it requires “a more nuanced discussion of treatment goals and personal health risks,” adds Malone.

Why is HRT controversial?

As with most types of treatments, there are risks and benefits. In 2002, the National Institutes of Health stopped their research on hormone therapy trials — a study known as the Women’s Health Initiative (WHI) — when they found a link between hormone therapy and increased risk of breast cancer, certain types of heart disease and blood clots. As a result, prescriptions for HRT plummeted from approximately 40% to nearly 5%, according to a 2013 article published in The Journal of Clinical Endocrinology & Metabolism.

And it was the same journal article that took a closer look at the 2002 study and reported that subsequent research “clearly showed that younger women and those close to menopause had a very beneficial risk-to-benefit ratio.”

Further studies have shown other possible benefits to HRT, such as reduced risk of type 2 diabetes, reduced risk of bone loss and fracture and lower rates of breast cancer when using estrogen-only therapy. And yet, some practitioners are still hesitant to prescribe hormone therapy.

“The truth of the matter is there has been a decided lack of education on the part of doctors and patients,” states Malone. “A generation of doctors that has come of age since the WHI still believes the headlines from 20 years ago. Medical education has not kept pace with current data, and the study of menopause in medical schools and residency programs has languished.”

She emphasizes the timing of starting HRT is important — and that the findings of older women included in the WHI do not apply to younger women. “Much of what we know now is not new,” says Malone. “The issues with the interpretation of the WHI data were voiced almost immediately but have been drowned out by the words ‘breast cancer.’”

Haver agrees. “Despite recent research suggesting potential benefits, doctors remain cautious about prescribing HRT for several reasons,” she says, including “inadequate understanding” of the causes and effects of menopause and the lack of awareness of modern hormone therapy options.

The variety of symptoms in menopause patients also plays a role. “Menopause symptoms can vary widely among individuals, both in terms of the symptoms experienced and their timing,” says Haver. “The highly individualized nature of symptoms makes it difficult for doctors to establish a standardized approach to diagnosis and treatment.”

She adds that insufficient education and training in medical schools and residency programs, gender bias and stereotyping (labeling it as a “women’s issue” that can be “dismissed or downplayed, leading to the misinterpretation of significant symptoms as emotional or psychological rather than physiological”) and the absence of universally accepted diagnostic criteria and routine screenings all contribute to challenges in identifying, addressing and treating menopause-related issues.

“Furthermore, menopause is dramatically underrepresented in the articles presented to ob-gyns as continuing medical education required for their yearly maintenance of board certification requirements,” says Haver.

The bottom line

Both physicians uttered the same statement: Menopause is inevitable, suffering is not.

“I discuss menopause care with my patients in the form of a toolkit: nutrition, exercise, supplements, pharmacology, stress reduction and sleep optimization,” says Haver. “Everyone deserves the conversation on what science currently recommends so that they can live as long and healthy and as possible — and not just surviving but thriving.”

Treating the symptoms of menopause is much more than just easing the occasional hot flash, says Malone. “It can be a detriment to a woman’s long-term health, with increased cardiovascular disease, hip fractures, urinary symptoms and painful sex,” she says. “Women should not feel as if they are doing something risky or dangerous by choosing HRT/MHT. They will be improving not only the quality but also the quantity of their remaining years.”