Hormone Therapy 101

Hormone Therapy 101: A Guide to HRT in Perimenopause and Menopause

By Dr. Madeleine Clark, ND, MSCP

Few treatments in women's health have been as misunderstood as hormone therapy. For two decades, fear from one large study kept many people from a treatment that could have helped them. The research has moved on a lot since then, and in 2025 the US FDA removed its most prominent warnings from hormone therapy labels.

Here's what hormone therapy is, who it's for, the real risks, and how to decide if it's right for you.

What is hormone therapy?

Menopausal hormone therapy (often called HRT) means prescribing estrogen, usually with a progestogen, to replace hormones that decline during perimenopause and menopause. It's prescribed at an individualized dose to relieve symptoms, improve quality of life and protect long-term health.

What is it used for?

Hormone therapy is the most effective treatment we have for:[1]

• Hot flashes and night sweats

• Vaginal and urinary symptoms (genitourinary syndrome of menopause, or GSM), including dryness, discomfort with sex and recurrent UTIs

• Preventing bone loss and fractures

It's also recommended for people with early menopause (before 45) or premature ovarian insufficiency (before 40), including after surgery or medical treatment, usually until around the average age of menopause (51).[1]

What else can it help with?

• Sleep. It often improves sleep by reducing night sweats, and it may help sleep in other ways too. More in Can't Sleep in Perimenopause? What Actually Helps.

• Mood in perimenopause. It isn't a first-line treatment for depression, but estrogen can improve mood during perimenopause, especially alongside hot flashes.[2] It hasn't shown the same benefit after menopause. More in Depression and Anxiety in Perimenopause.

• Diabetes risk. Women on hormone therapy in large trials developed type 2 diabetes less often. It's a welcome side benefit, not a reason to start it on its own.[1]

What it doesn't do: hormone therapy isn't recommended to prevent dementia or heart disease.[1] Starting it in your 50s doesn't appear to harm memory or the heart, but it isn't a prevention tool for either.

Types of hormone therapy

Estrogen

The main treatment for hot flashes, night sweats and bone protection. It comes as a patch, gel or pill. We usually prefer patches or gels, because estrogen through the skin doesn't appear to raise the risk of blood clots the way pills do.[1]

Progesterone

If you have a uterus, you need a progestogen alongside estrogen to protect the uterine lining. Most often this is micronized progesterone taken at night, since it can make you drowsy, which many people find helps their sleep. In some cases, a hormonal IUD can protect the lining instead.

Vaginal estrogen

A very low dose applied directly to the vagina for GSM symptoms. Very little is absorbed into the bloodstream, so it's an option for many people who can't or don't want to take systemic hormone therapy. More in Is Vaginal Estrogen Safe?

Testosterone

There's good evidence for testosterone for low sexual desire that causes distress in postmenopausal women.[3] No testosterone product is approved for women in Canada, so it's prescribed off-label, by physicians and nurse practitioners (naturopathic doctors can't prescribe it). We can help you decide whether it's worth exploring and refer you.

What are the risks?

For most healthy people under 60 or within 10 years of menopause, the benefits of hormone therapy outweigh the risks.[1] The risks are real, but smaller than most people think, and they depend on your age, your health history and the type of hormone therapy.

• Breast cancer. Estrogen combined with a progestogen carries a small increase in risk, mainly with longer use: less than 1 extra case per 1,000 women per year of use.[1] Estrogen on its own, in people without a uterus, didn't increase breast cancer risk in the largest trial.[4]

• Blood clots and stroke. Higher with estrogen pills, especially over 60. Patches and gels don't appear to carry the same clot risk.[1]

• Timing matters. Starting after 60, or more than 10 years after your last period, carries more risk.

Hormone therapy may not be right for you if you have a history of breast cancer or another hormone-sensitive cancer, a blood clot, stroke or heart attack, active liver disease, or unexplained vaginal bleeding. Smoking and uncontrolled high blood pressure raise the risk too. Even then, there are usually other options.

What about the WHI study?

In 2002, results from the Women's Health Initiative (WHI) linked hormone therapy to breast cancer, heart disease and stroke.[5] Prescriptions dropped sharply almost overnight.

Later analyses told a more nuanced story:

• Participants averaged 63 years old, many more than a decade past menopause. That's not who usually starts hormone therapy today.

• The estrogen-alone group had lower breast cancer rates, not higher.[4]

• After nearly 20 years of follow-up, hormone therapy didn't increase overall death rates.[6]

That's why current guidance focuses on starting hormone therapy at the right time for the right person.

What changed in 2025 and 2026?

In November 2025, the US FDA announced it would remove the boxed warnings about heart disease, breast cancer and probable dementia from hormone therapy labels. The first updated labels were approved in February 2026.[7] The Canadian Menopause Society welcomed the change, saying the old warning had discouraged women and clinicians from even discussing hormone therapy.[8]

That decision applies to US labels. Canadian product labels are regulated separately by Health Canada, so the information that comes with your prescription here may still include the older warnings.

How is it taken, and for how long?

• Estrogen: usually a patch or gel

• Progesterone: usually a capsule at night, if you have a uterus

• Vaginal estrogen: a cream, tablet or ring, for vaginal and urinary symptoms

There's no set time limit. Some people use it for a few years, some longer. We review it regularly, looking at how well your symptoms are controlled, any side effects, and how your health risks change over time.

Is hormone therapy birth control?

No. If you're still in perimenopause, you need contraception until menopause is confirmed. A hormonal IUD can do double duty: it prevents pregnancy and protects the uterine lining. More in Oral Contraceptive Pill vs. Hormone Therapy.

Wondering if hormone therapy is right for you? We'll walk through your symptoms, history and personal risks so you can make an informed choice. Book a free 15-minute meet and greet.

If hormone therapy isn't for you

There are good options for people who can't take hormone therapy or prefer not to:

• Non-hormonal prescription medications for hot flashes, sleep and mood

• Cognitive behavioural therapy, for insomnia and for coping with hot flashes

• Lifestyle foundations: movement (especially strength training), nutrition, sleep, alcohol and stress

• Targeted supplements, chosen for your specific symptoms

• Acupuncture. See what the research actually shows

Related reading

• Perimenopause: Symptoms, Stages and What Actually Helps

• Hot Flashes Explained

• Genitourinary Syndrome of Menopause (GSM): What You Need to Know

• Osteoporosis

Is HRT right for you?

Dr. Madeleine Clark, ND, MSCP prescribes hormone therapy as part of whole-person menopause care, alongside lifestyle, nutrition and supplements, so you can choose what fits.

Book a free 15-minute meet and greet →

We see patients in Toronto and virtually across Ontario.

This article is for general education and isn't a substitute for personalized medical advice.

References (click to expand) ▾

1. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767-794.
2. Maki PM, Kornstein SG, Joffe H, et al. Guidelines for the evaluation and treatment of perimenopausal depression: summary and recommendations. Menopause. 2018;25(10):1069-1085.
3. Davis SR, Baber R, Panay N, et al. Global consensus position statement on the use of testosterone therapy for women. Journal of Clinical Endocrinology & Metabolism. 2019;104(10):4660-4666.
4. Chlebowski RT, Anderson GL, Aragaki AK, et al. Association of menopausal hormone therapy with breast cancer incidence and mortality during long-term follow-up of the Women's Health Initiative randomized clinical trials. JAMA. 2020;324(4):369-380.
5. Writing Group for the Women's Health Initiative Investigators (Rossouw JE, et al.). Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA. 2002;288(3):321-333.
6. Manson JE, Aragaki AK, Rossouw JE, et al. Menopausal hormone therapy and long-term all-cause and cause-specific mortality: the Women's Health Initiative randomized trials. JAMA. 2017;318(10):927-938.
7. US Food and Drug Administration. FDA approves labeling changes to menopausal hormone therapy products. February 12, 2026.
8. Canadian Menopause Society. Canadian Menopause Society welcomes FDA decision to remove "Black Box" warning from menopausal hormone therapy labels. November 12, 2025.
9. Vinogradova Y, Coupland C, Hippisley-Cox J. Use of hormone replacement therapy and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases. BMJ. 2019;364:k4810.