Hormone Therapy

What is hormone therapy?

Hormone therapy (HT) may be prescribed after a woman’s ovaries stop doing their job of producing a natural balance of female hormones.

An HT program may involve using estrogen alone (ET), or an estrogen-progestin (EPT) combination, depending on what is happening in a woman’s life and health.  Women who have undergone a hysterectomy, for example, and have no uterus, are usually given estrogen alone.  Others who still have their uterus are more likely to be prescribed an estrogen-progestin combination.  Progestin has the advantage of providing protection to the lining of the uterus from endometrial cancers.

Hormone therapies can involve a medication taken by mouth, or a skin patch or gel for symptoms such as hot flashes.  Other hormone therapies are applied right where there is a problem – for example, a vaginal cream, tablet or ring, can restores estrogen in the vaginal area and is used when vaginal symptoms are a problem.

HT is usually prescribed for women with moderate to severe menopause symptoms.

Back to top

How will I know that it is time to talk to my physician about hormone therapy?

If you are having symptoms that are bothersome and have not been helped by some of the lifestyle changes that you have tried, make an appointment and talk to your doctor.  Your doctor will have a number of strategies to discuss with you, and will help you to find one that is right for your situation.

Back to top

What symptoms does hormone therapy address?

Hormone therapy (HT) may be prescribed to address a number of menopause symptoms, and is based on a careful assessment of a women’s health status and the seriousness of her symptoms. We do know that:

  • Some menopause problems (such as hot flashes and vaginal dryness) are almost entirely caused by the drop in hormones, so they can be greatly relieved by hormone therapy.
  • Sexual changes, fatigue or sleep disturbance and memory changes are often the result of multiple factors and therefore the impact of hormones varies among women.
  • Estrogen protects skin from thinning and wrinkling, but physicians do not recommend HT for this purpose alone.

Back to top

What are the risks associated with hormone therapy?

The risks associated with hormone therapy (HT) depend very much on a woman’s personal health status. Your overall health, your family history and your age can have an impact on the risks you need to think about.  As well, ongoing health research is providing new insights all of the time.  So assessing risk needs to be done with the support and guidance of a health professional.  Still, research and experience does tell us that women who take hormone therapy may face:

  • A small increase in the risk of deep vein thrombosis, or blood clots in the veins.
  • A risk of stroke for some older women, especially those with high blood pressure.
  • A greater potential incidence of heart disease for women over 60 years of age.
  • An increased risk of breast cancer for women who use HT for a long time.

When considering hormone therapy and the risks, it is important to remember that while hormone therapy is usually offered to women to give them a better quality of life, for some diseases, HT actually reduces risks and offers protection.

Recent research shows that women who started hormone therapy around the time of menopause can reduce their risk of heart disease by about 40 per cent, but doctors don’t currently recommend HT as a means to address that issue alone.

Risk Factors for Breast Cancer

Risk Factors for Breast Cancer
Factor Baseline breast cancers* per 1,000 women Additional cancers per 1,000 women Total cancers per 1,000 women
No HT use (baseline) 45 0 45
5 years of HT use 45 2 47
10 years of HT use 45 6 51
15 years of HT use 45 12 57
Alcohol consumption
(2 drinks per day)
45 27 72
Lack of regular exercise
(<4 hours/week)
45 27 72
Late menopause
(10-year delay)
45 13 58
Body mass index
(10 kg/m2 increase)
45 14 59
Weight gain after menopause
(>=20 kg)
45 45 90

*Baseline or basic risk applies to all women and is due to factors that cannot be controlled (e.g., aging, gender)

Back to top

What is the difference between hormone therapy and hormone replacement therapy?

Although the terms are used interchangeably, there is actually a difference between hormone therapy (HT) and hormone replacement therapy (HRT).  Hormone therapy refers to the treatment doctors prescribe to help replace some of the hormones that are naturally diminishing in a woman’s body during perimenopause and menopause.  Hormone replacement therapy (HRT) describes the treatment prescribed when women have had a hysterectomy, or have their ovaries removed, and the doctor wants to completely replace the hormone levels usually produced by the ovaries.

Back to top

How long can I use hormone therapy and how will I know when to stop?

Health care professionals in Canada, armed with new research, can help women decide whether some type of hormone therapy (HT) will help them manage their menopause symptoms.  The kind of HT, and the length of time you take HT, are both things you need to talk over with your doctor. They will also have information about alternative therapies, and the impact of lifestyle issues such as diet, exercise, alcohol, smoking and caffeine, and what course of treatment will work best for you.

The Society of Obstetricians and Gynaecologists of Canada (SOGC) supports the recommendations of the 2006 Menopause Consensus Report, and the Menopause and Osteoporosis Update 2009 that hormone therapy may safely be prescribed for the duration necessary to address menopause-related problems.

Back to top

I have heard that some women take “The Pill” (contraceptive medication) during perimenopause.  Is that a form of hormone therapy?

Low dose oral contraceptives are commonly prescribed to help women with perimenopausal symptoms.  They do contain hormones, but in a greater amount than is usually found in hormone therapy.

Back to top

Can hormone therapy assist with my urinary incontinence?

In some cases, physicians may decide that hormone therapy (HT) will help a woman with urinary incontinence.  Your doctor will need to assess your situation and determine if HT will help you.

Back to top

Does my risk for breast cancer go up if I take hormone therapy? 

There is an increased risk of breast cancer for women who have used combined HT for more than five years.  This increase is of a similar magnitude to other common risk factors for breast cancer, such as your age of puberty, being older than age 30 when you have your first child, or being overweight.  The good news is that the absolute risk for any one person is small, and the risk returns to normal soon after stopping HT.

Risk Factors for Breast Cancer

Risk Factors for Breast Cancer
Factor Baseline breast cancers* per 1,000 women Additional cancers per 1,000 women Total cancers per 1,000 women
No HT use (baseline) 45 0 45
5 years of HT use 45 2 47
10 years of HT use 45 6 51
15 years of HT use 45 12 57
Alcohol consumption
(2 drinks per day)
45 27 72
Lack of regular exercise
(<4 hours/week)
45 27 72
Late menopause
(10-year delay)
45 13 58
Body mass index
(10 kg/m2 increase)
45 14 59
Weight gain after menopause
(>=20 kg)
45 45 90

*Baseline or basic risk applies to all women and is due to factors that cannot be controlled (e.g., aging, gender)

And since all women face an increased risk of breast cancer as they age, you should participate in regular breast cancer screening programs to enhance your chances for early detection. 

And finally, quit smoking!  Women who smoke increase their risk of all types of cancer, including breast cancer.

Back to top

What about other cancers?

Women with a history of early stage (stage I) low grade (grade 1 or 2) endometrial cancer may take hormone therapy (HT) to control distressing symptoms such as night sweats and hot flashes.

Combined HT use (progestin and estrogen) is associated with a reduced risk of colorectal cancer and a possible small increase in the risk of ovarian cancer.  These effects are very small, however, should not affect decisions about HT use to deal with distressing menopause symptoms

A relationship between HT use and cancers of the vulva, cervix and vagina has not been found, though more research is required.

Back to top

If I have had any type of cancer in the past, should I consider hormone therapy?

With the exception of meningioma (brain tumours), breast and widespread (metastatic) endometrial cancer, there is no biological evidence that hormone therapy (HT) may increase the risk of recurrence.  Thrombosis risk should be assessed as some cancers are known to increase the risk of venous thromboemolic disease (VTE).

Women with a family history of breast cancer are no more likely to experience breast cancer if they chose to use HT to control menopause symptoms.

Back to top

If I have had a hysterectomy can I still consider hormone therapy for menopause symptoms?

A hysterectomy is often called “surgical menopause” since it stops menstruation immediately.  Still, if ovaries are intact, women who have had a hysterectomy may still need relief from some menopausal symptoms.  Women who have undergone a hysterectomy and have no uterus are usually given estrogen alone since they no longer need the protection from endometrial cancers (cancer of the lining of the uterus) offered by progestin.  Estrogen alone also has a lower risk of breast cancer in long-term HT users than the combination of estrogen and progestin.

Back to top

Does my risk of heart disease go up if I am prescribed hormone therapy?

Recent research is showing that women who started hormone therapy (HT) around the time of their menopause can reduce their risk of heart disease by about 40 per cent.  There appears to be a window of opportunity to benefit — just as women reach menopause. Notwithstanding this encouraging research HT is not currently recommended as a means to address heart disease alone.

Women’s risk of heart disease increases about ten years later than when men start to have heightened risk. Still, for women that risk does increase after menopause, so it is important to take steps to reduce the risk:

  • Do not smoke.
  • Have your blood pressure checked.
  • Ask your doctor when you should have your blood sugar and cholesterol levels checked.
  • Eat healthfully (See Canada’s Food Guide.)
  • Exercise regularly. As little as 30 minutes of brisk walking three times a week makes a difference.
  • Maintain a healthy weight.

Whether using HT or not, all women need to address their personal risk for heart disease and stroke and take the steps necessary to improve their “heart health”. While there is a slightly elevated risk of heart disease among older women using hormone therapy (ten years after menopause) HT is still an effective and recommended treatment for moderate to severe menopause symptoms. 

Back to top

How does hormone therapy help me if I am at risk of osteoporosis?

Even short-term hormone therapy (HT) use can improve a women’s bone structure, so that other medications can then be used to sustain bone health over the longer-term. The Women’s Health Initiative in the United States, a randomized clinical trial involving menopausal women, found that HT was clearly effective in the prevention of hip fractures, vertebral breaks and other injuries.  The SOGC Consensus Report, and the Menopause and Osteoporosis Update 2009 however, does not recommend HT solely for purposes of addressing osteoporosis.

Back to top

What are some of the side effects of hormone therapy?

Finding the right hormone therapy (HT) may take some time as different combinations and dosages of the key hormones – estrogen and progestin -- are used.  Women may experience some breast tenderness, bloating, nausea and headaches after HT use begins.   Adjustments can be made to deal with these side effects.

Back to top

Will I gain weight while on hormone therapy?

Weight gain is not necessarily a symptom of menopause.  Even though the rate at which our bodies burn energy, and subsequently fat, declines as we age, a healthy diet and a moderate exercise program can usually keep those extra kilos at bay. 

Research studies investigating if women taking hormone therapy (HT) gain more weight that those who do not is fairly conclusive; women on HT gain less than those not taking hormone therapy.  Still, many quit because they believe that hormone therapy is making them gain weight.

Modest weight gain is not necessarily a bad thing, as long as your weight remains in a healthy range. The most important thing is not your weight, but that you are eating healthfully, and getting regular exercise.  Still, if you are struggling with weight issues as you are nearing, or have reached, menopause, consult a health professional who is familiar with your health status and history.

Back to top

Why can’t I have hormone therapy that uses estrogen alone instead of an estrogen-progestin combination?  Isn’t it true that estrogen alone is safer?

Women who still have a uterus, that is, who have not had a hysterectomy, require a balanced amount of estrogen and progestin in their hormone therapy (HT) because progestin provides protection from endometrial cancer (cancer of the lining of the uterus).

Back to top

Does it make a difference if I take hormone therapy orally or by using a transdermal skin patch?  Is the dosage different?  Is one safer than the other?

How hormone therapy (HT) is administered is determined by your health care provider and is based on your unique health situation.  There is a slightly reduced risk of blood clots with the use of the transdermal patch, but research continues to determine if there are any real differences in the effectiveness and safety of therapies taken orally or applied to the skin.

Back to top

Does previous use of birth control pills make a difference when considering hormone therapy?

If you have taken birth control pills it won’t make any difference to the risk of breast cancer if you now decide to take hormone therapy (HT).  It also doesn’t matter if birth control pills were used long-term, or just before the onset of menopause.

Back to top

What is the Society of Obstetricians and Gynaecologists of Canada's position on hormone therapy use?

After carefully reviewing scientific research on hormone therapy from Canada and around the world, Canadian obstetricians and gynaecologists recommend hormone therapy as a safe option for most women who are experiencing a reduction in their quality of life due to the symptoms of menopause. The increased risk for recently menopausal women taking hormone therapy is extremely small.

The Society of Obstetricians and Gynaecologists of Canada (SOCG) published a report in 2006, The Menopause Consensus Report, and the Menopause and Osteoporosis Update 2009, which says that hormone therapy may safely be prescribed in the dose and for the duration necessary to achieve treatment objectives, unless a woman has a specific risk factor for a specific disease or health condition.  The Society recommends that health care providers regularly review the risks and benefits of hormone therapy with their patients. Emerging advice is suggesting that for women under age 60 HT is a safe and reasonable choice.

Back to top

SOGC