Midlife Learning

Hormone Therapy for Menopause

Clinically reviewed and approved by Effica's Health Strategy Team
Content last revised January 14, 2026

Key Facts

Menopausal hormone therapy (MHT) is the most effective therapy for hot flashes, night sweats, and genitourinary symptoms of menopause (GSM).1,2

MHT is generally safe to start in women under 60 years of age or within 10 years of menopause onset if there are no contraindications to therapy.1,2

The type, dose, and duration of MHT should be tailored to your health history, risks, and preferences.1,2

Risks differ depending on age, time since menopause, type of hormones, and formulation used.1,2

Choose how you would like to learn

What to Know About Hormone Therapy

Menopausal hormone therapy (MHT) is the most effective treatment for vasomotor symptoms (hot flashes and night sweats) and for genitourinary symptoms of menopause (GSM), with strong evidence supporting its use for symptom relief and quality-of-life improvement.1,2

MHT is generally considered safe to initiate in women under age 60 or within 10 years of menopause onset, provided there are no contraindications. Starting therapy within this window is associated with a more favorable benefit–risk profile.1-3

Estrogen is the primary hormone responsible for symptom relief, but women with an intact uterus must also use a progestogen to protect against estrogen-induced overgrowth of the uterus lining which can lead to an increased risk of developing endometrial cancer. Women without a uterus can safely use estrogen alone.1,2

MHT can be delivered as systemic or local therapy, depending on the most bothersome symptoms. Systemic therapy treats whole-body symptoms such as hot flashes and helps prevent bone loss, while local (vaginal) therapy treats genital and urinary symptoms only.1,2

Low-dose vaginal menopausal hormone therapy has very low to negligible systemic risk, with minimal absorption into the bloodstream. It has not been shown to increase the risk of breast cancer, cardiovascular disease, stroke, or blood clots.

MHT helps prevent bone loss and reduces fracture risk, making it an important option for symptomatic postmenopausal women at risk of osteoporosis, and a key therapy for those with early or premature menopause.1-3

MHT is recommended for women with premature (<40 years) or early menopause (<45 years) until the average age of natural menopause (51 years old), to reduce long-term risks associated with prolonged estrogen deficiency, including osteoporosis and heart disease.1,2

Risks associated with MHT depend on timing, formulation, and route of administration. Combined systemic estrogen–progestin therapy slightly increases breast cancer risk with longer duration of use, while systemic estrogen-only therapy shows little or no increase in risk.1-31-3

Transdermal estrogen (patches or gels) is associated with lower risks of blood clots and stroke compared with oral estrogen, and is often preferred for women with migraine, high blood pressure, or increased clotting risk.1,2

MHT is not recommended solely for the prevention of heart disease or dementia in women who undergo menopause at the usual age, as large, randomized trials have not shown benefit for these indications. 3

Continue your journey—discover more insights and guidance.

Back To Midlife Learning

A Closer Look at Hormone Therapy

What Is Menopausal Hormone Therapy?

Menopausal hormone therapy (MHT), also called hormone therapy (HT) or hormone replacement therapy (HRT), is the most effective treatment for common menopausal symptoms such as hot flashes, night sweats, and genitourinary symptoms of menopause (GSM)¹˒². These symptoms occur as hormone levels decline during the menopause transition and can significantly affect sleep, sexual health, mood, and overall quality of life.

MHT works by replacing some of the hormones the body no longer produces. For women with a uterus, systemic estrogen therapy must be paired with a form of progesterone or other agent to protect the uterine lining to reduce the risk of endometrial cancer. Women who have had a hysterectomy can safely use systemic estrogen alone.1,2

MHT is considered safe and appropriate for most women under age 60 or within 10 years of menopause onset, provided there are no contraindications¹˒². Timing matters so starting therapy earlier in menopause is associated with a more favorable balance of benefits and risks³. 

The decision to use MHT should always be individualized, taking into account age, time since menopause, symptom severity, medical history, and personal preferences¹˒². 

Systemic vs Local Hormone Therapy

MHT can be delivered in two main ways: 

Systemic MHT (pills, patches, gels) circulates through the bloodstream and treats whole-body symptoms such as hot flashes, night sweats, sleep disturbance, and bone loss¹˒².

Local (vaginal) MHT treats symptoms limited to the vaginal and urinary tissues, such as dryness, irritation, pain with sex, and urinary urgency. These products deliver very small doses of hormone directly to local tissues and do not meaningfully enter the bloodstream, so they do not relieve hot flashes or protect bones¹˒².

Benefits of Hormone Therapy

When used appropriately, MHT offers several important benefits: 

  • Considered the most effective treatment for hot flashes and night sweats, improving sleep and quality of life¹˒² 

  • Highly effective relief of genitourinary symptoms, especially with vaginal estrogen products¹˒² 

  • Prevention of bone loss and fractures, particularly in women at higher osteoporosis risk¹,³ 

  • Protection against long-term health risks in women with premature or early menopause, when used until the average age of natural menopause¹˒² 

Concerns about MHT largely stem from early reports from the Women’s Health Initiative (WHI), which included mostly women over age 60 who were many years past menopause⁸. More recent analyses show that age and timing are critical when assessing risk³. 

  • Combined systemic estrogen-progestin therapy slightly increases breast cancer risk with long-term use (about 1 additional case per 1,000 women per year after five years).¹˒² 

  • Systemic estrogen-only therapy has little or no increase in breast cancer risk.¹˒² 

  • Risks of blood clots, stroke, and heart disease are much lower when MHT is started before age 60 or within 10 years of menopause³ 

  • Transdermal estrogen delivery (patches or gels) is associated with lower clotting risk than oral estrogen delivery¹˒² 

  • MHT is not recommended solely to prevent heart disease or dementia in women who undergo menopause at the usual age³. 

Vaginal Hormone Therapy: A Different Risk Profile

Low-dose vaginal menopausal hormone therapy has a very low to negligible systemic risk. Since absorption into the bloodstream is minimal, circulating estrogen levels generally remain within the normal postmenopausal, very low range. Large studies show no increased risk of breast cancer, heart disease, stroke, or blood clots with vaginal estrogen use⁹. 

For this reason, vaginal hormone therapy is considered a safe and effective treatment for vaginal and urinary symptoms, even for many women who are not candidates for systemic hormone therapy ⁹. 

Most side effects of systemic MHT, such as breast tenderness, bloating, headache or mild nausea, are dose-related and often improve over time¹˒² Rarely systemic MHT can cause blood clots therefore urgent medical attention should be sought if you experience pain in your legs or chest, numbness or swelling in legs or arms, sudden loss/change in vision, severe headache, or unexplained shortness of breath.  

Vaginal products are generally very well tolerated but may occasionally cause local irritation or discharge. 

Regular follow-up with a healthcare provider is essential. Annual reviews help ensure the lowest effective dose is being used and allow reassessment of benefits and risks as health needs change¹˒². There is no fixed limit on duration of therapy, however, continued use should be revisited yearly to ensure it is still appropriate and safe. 

Summary

Menopausal hormone therapy can be life-changing for women with bothersome menopausal symptoms. When started at the right time and tailored to the individual, MHT can offer substantial benefits with manageable risks. Vaginal hormone therapy stands out as a safe, low-risk option for treating genitourinary symptoms. The best outcomes come from informed, shared decision-making with a healthcare provider who understands your personal health profile.

Here's the full picture

Menopausal Hormone Therapy (MHT), also known as Hormone Replacement Therapy (HRT) or Hormone Therapy (HT), is the most effective treatment for hot flashes, night sweats, and the vaginal and urinary symptoms of menopause. As women approach menopause, natural estrogen levels begin to drop, which can trigger uncomfortable symptoms that significantly impact quality of life.  MHT works by supplementing some of the hormones, like estrogen and progesterone, that the body no longer produces after menopause.  

The estrogen component of MHT is the main hormone that relieves symptoms, but when used alone it can cause the lining of the uterus to thicken, which leads to an increased risk of developing endometrial cancer. For this reason, women with a uterus must also take a form of progesterone or other agent to protect the uterus lining, to minimize the risk of endometrial overgrowth and development of cancerous cells.  Women who have had a hysterectomy (surgical removal of the uterus) can safely take systemic estrogen alone.1,2 

The term “Systemic” MHT refers to therapy that affects the whole body rather than one specific area. With systemic hormone therapy, hormones circulate through the bloodstream, allowing relief of widespread menopausal symptoms and providing protection against some long-term health risks, such as osteoporosis. Since the entire body is exposed to hormones, systemic MHT carries potential risks such as blood clots, stroke, or breast cancer in some individuals, so overall health history and risk factors must be carefully considered.1,2 

“Local” MHT refers to vaginal hormone products that act solely within the vaginal, vulvar and pelvic floor tissues to reduce genital and urinary symptoms such as vaginal dryness, irritation, painful intercourse, and urinary urgency.  Local MHT does not enter the bloodstream in any significant amount, so it’s not helpful to reduce systemic symptoms such as hot flashes and night sweats and is associated with minimal systemic risk. Local MHT is generally considered safe for long-term use, even in many individuals who may not be candidates for systemic hormone therapy.1,2 

Not sure if hormone therapy is right for you? Take Effica’s Clarity Quiz to understand your symptoms and options.

Start Clarity Quiz

Purpose of MHT

MHT is used primarily to treat disruptive symptoms such as hot flashes, night sweats, difficulty sleeping, mood changes, and vaginal dryness or pain with sex. It also helps prevent bone loss and fractures, and it may be especially important for women who enter menopause early (before age 45) or prematurely (before age 40), since they face higher long-term risks of osteoporosis, heart disease, and cognitive decline if left untreated.1,2 In cases where menopause arrives early, MHT is usually recommended until the age of natural menopause, which is around 51. 

These indications for MHT represent the conditions with the strongest evidence supporting use. While MHT is sometimes prescribed off label for other menopausal symptoms such as joint pain, brain fog, or cognitive changes, the evidence for these uses is less robust and requires individualized assessment with your healthcare provider.  MHT is also not recommended for the prevention of heart disease or cognitive decline in women who go through menopause at the usual age, because large randomized controlled trials, have shown that MHT does not reduce the risk of coronary heart disease, stroke, or dementia when used solely for these purposes.3 

In Canada, a wide variety of products are available. These include pills, skin patches and gels, vaginal creams, inserts, tablets, rings, or intrauterine devices (or IUDs).4

Genitourinary symptoms like vaginal dryness, urinary urgency, and discomfort with intercourse respond best to local menopausal hormone therapy.  Vaginal hormones are used for local symptoms in the vagina and bladder but do not treat hot flashes or protect bones. Local estrogen does not usually require additional progesterone therapy, as a negligible amount of hormone is absorbed into the bloodstream which greatly reduces your risk for problems typically associated with systemic therapy.1,2 Local menopausal hormone therapy products available in Canada:

  • Vaginal creams: Conjugated estrogen cream (Premarin®), estrone cream (Estragyn®)
  • Vaginal tablets: estradiol tablets (Vagifem®)
  • Vaginal ring: estradiol ring (Estring®)
  • Vaginal inserts: Estradiol (Imvexxy®)
  • Vaginal ovule: dehydroepiandrosterone (DHEA) or prasterone (Intrarosa®)

Patients who suffer from menopausal symptoms unrelated to genitourinary issues often get more effective relief from systemic hormone therapy. These treatments affect the whole body and are typically prescribed as oral tablets, transdermal patches, or gels.1,2 Systemic MHT products available in Canada: 

  • Oral tablets: estradiol (Estrace®), conjugated estrogen (Premarin®), micronized progesterone (Prometrium®), medroxyprogesterone (Provera®) taken daily or cyclically
  • Transdermal gels: estradiol (Estrogel®, Divigel)®applied daily
  • Transdermal patches: estradiol (Estradot®, Climara®) applied once or twice weekly
  • Combination products: estradiol/norethindrone patch (Estalis®), estradiol/norethindrone ®), estradiol/drosperinone ®), estradiol/progesterone tablet (Bijuva®)

There are certain advantages to different delivery and administration methods.  Transdermal (drug delivery through the skin) products are often considered safer options for women with risk factors such as high blood pressure, clotting risks, or migraines.1,2   Oral tablets also have advantages such as familiar administration method, once daily dosing, reliable absorption patterns and often covered by most drug plans.

There are two newer types of MHT medications that allow systemic hormone effects to be prescribed without requiring a separate prescription for progesterone. Both are available as oral tablets in Canada.

  • Duavive® is a Tissue Selective Estrogen Complex (TSEC). Each oral tablet contains 0.45 mg conjugated equine estrogen (CEE) and 20 mg bazedoxifene (BZA).  Bazedoxifene blocks the estrogen receptors in the breast and uterus, so the estrogen component cannot stimulate those tissues. It also selectively binds to estrogen receptors in bones to help make them stronger. 
  • Tibolone (Tibella®) is a Selective Tissue Estrogenic Activity Regulator (STEAR) that doesn’t contain any actual hormones. Instead, it is a synthetic steroid medication that breaks down into three substances that mimic estrogen, progesterone, and testosterone in the body.

Other hormone options that may be used around the time of menopause include combined hormonal contraceptives (birth control pills) and the levonorgestrel-releasing intrauterine device (IUD), such as Mirena®. Combined hormonal contraceptives can be particularly helpful during perimenopause, as they not only ease symptoms like hot flashes but also regulate menstrual cycles, reduce heavy or painful periods, and provide reliable contraception.5 The hormonal IUD releases a form of progesterone, which can help control heavy bleeding, provide contraception and may also be used in combination with estrogen therapy to protect the lining of the uterus.6 

Some products, such as compounded “bioidentical” hormone therapy, are marketed as more natural, however, these products are not regulated by Health Canada and are not proven to be safer or more effective than approved prescription therapies.1,7  Most commercially available Health Canada approved products (those containing estradiol or micronized progesterone) are also bioidentical, meaning they are structurally identical to those produced in a woman’s body. 

Personalization is key! The right choice of hormone therapy for you depends on your age and time since menopause, symptom severity, personal and family medical history, individual risk factors, personal preferences for delivery method, and lifestyle factors. Work with your healthcare provider to create a personalized treatment plan that maximizes benefits while minimizing risks for your unique situation. 

MHT is considered safe to start if you are under 60 years old or less than 10 years post-menopausal and have no contraindications to MHT. It is the most effective treatment for hot flashes and night sweats, which affect up to 80% of women during menopause, and it significantly improves sleep and overall quality of life.1,2 

It effectively relieves genitourinary symptoms of menopause, including vaginal dryness, painful intercourse, and recurrent urinary tract infections, with local vaginal estrogen products offering targeted relief.1,2 

Systemic MHT helps prevent bone loss and reduces the risk of fractures in postmenopausal women, making it an important additional benefit for those at high risk of osteoporosis who have bothersome menopausal symptoms.1-3 

In women who experience premature or early menopause (before age 40 or 45), systemic MHT provides protection against the long-term consequences of estrogen deficiency, such as cardiovascular disease, osteoporosis, and cognitive decline, until they reach the natural age of menopause.1,2  

MHT made headlines in 2002 after the Women’s Health Initiative (WHI) reported that it increased the risks of breast cancer, heart disease, and stroke.8  However, most of the women in that study were over 60 and many years past menopause, which is not the group most likely to benefit from MHT.  Today, experts emphasize that timing matters with the safest window to start MHT being before age 60 or within a decade of menopause3 and to target treating disruptive symptoms rather than starting MHT as a preventive health measure. Your health care practitioner can help walk you through your personal health profile, so you can decide whether systemic hormones are right for you. 

Like any therapy, MHT carries some risks. Combined estrogen-progestin therapy slightly increases the risk of breast cancer, adding about one extra case per 1,000 women per year after five years of use. Estrogen-only therapy appears to have little or no increase in breast cancer risk. Risks of stroke, blood clots, and heart disease rise if MHT is started after age 60 or more than ten years after menopause begins, but the risks are much lower when therapy is started earlier. Oral estrogen has a greater effect on clotting than transdermal products, which is why patches and gels are often preferred. MHT may also slightly increase the chance of gallbladder disease. 

The story is different if considering vaginal hormonal therapy alone. Low-dose vaginal menopausal hormone therapy is associated with very low to negligible systemic risk. Since these preparations are applied locally and result in minimal systemic absorption, circulating estrogen levels generally remain within the postmenopausal low range. As a result, vaginal hormone therapy has not been shown to increase the risk of breast cancer, heart disease, stroke, or blood clots in any available evidence. It is considered a safe treatment for genitourinary symptoms of menopause, including vaginal dryness, irritation, pain with sex and urinary urgency, even for many individuals in whom systemic hormone therapy is not recommended.9 

Side effects of MHT

Like all medications, menopausal hormone therapy (MHT) can cause side effects, although many are mild and improve over time as the body adjusts. The most commonly reported symptoms with systemic MHT are breast tenderness, bloating, and fluid retention, which can feel similar to premenstrual symptoms. Some women notice nausea or indigestion, particularly with oral estrogen, though switching to a patch or gel often reduces these effects. Headaches and mood changes may also occur, sometimes linked to the type or dose of progestin being used.1,2 

Irregular or unexpected vaginal bleeding can also happen, especially in the first few months after starting treatment. This usually settles as the body adapts to the hormones, but any persistent or heavy bleeding should be checked by a healthcare provider to rule out other causes. Skin irritation or rash may develop under transdermal patches, while vaginal estrogen creams or tablets may occasionally cause local irritation or vaginal discharge.1,2 

Some women report changes in weight or fluid balance, though large studies show that MHT does not typically cause significant weight gain. Libido may improve in some women due to better relief of vaginal dryness, but others may experience changes in sexual desire depending on how their body responds. 

A rare side effect of systemic estrogen therapy includes an increased risk of blood clots.  Urgent medical attention should be sought if you experience pain in your legs or chest, numbness or swelling in legs or arms, sudden loss/change in vision, severe headache, or unexplained shortness of breath. 

Importantly, many of these side effects can be minimized by adjusting the dose, changing the type of hormone or formulation, or switching to a different route of administration. Regular follow-up with a healthcare provider helps ensure that therapy is both effective and well tolerated. 

When MHT is not recommended

Some women shouldn’t use systemic MHT or may need to stop using it if they begin experiencing undesirable side effects.  Systemic MHT is not appropriate for women with a personal history of breast or estrogen-sensitive cancers, unexplained vaginal bleeding, blood clots, stroke, coronary artery disease, or active liver disease.1,2 If you’re already on MHT, tell your health care practitioner right away if you develop any of these conditions. They may want to change your treatment plan or adjust your dose.

If you start MHT, it is important to meet with your healthcare provider regularly to review your treatment. Annual check-ins allow you to reassess your current health status, check for any adverse effects of therapy, ensure you are using the lowest effective dose, and weigh the risks and benefits of continued therapy. Regular breast screening, blood pressure monitoring, bone, and heart health checks remain essential.1-3 

There is no strict maximum length of time for using MHT. Some women only need it for a few years, while others continue longer if symptoms persist. Women who enter menopause early are strongly encouraged to use it until the average age of menopause. Beyond that, ongoing use should be tailored to individual needs, personal health status, and be carefully reassessed each year. 

Summary

Menopausal Hormone therapy can be a very effective treatment for women who are suffering with symptoms associated with the menopause transition. Every woman’s experience of menopause is unique, and decisions about hormone therapy should be based on symptoms, health history, and personal preference. The best approach is an informed discussion with your healthcare provider to weigh the benefits and risks in your particular situation.

If you’d like to read more, please check out other resources we trust:

Society of Obstetricians and Gynaecologists of Canada (Menopause and U)

Canadian Menopause Society- Menopause Hub

The Menopause Foundation of Canada

The Menopause Society

Sharing is caring

Know someone who could use this information? Pass it along.

Copy Link
Link copied!
  1. The 2022 Hormone Therapy Position Statement of The North American Menopause Society” Advisory Panel. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022 Jul 1;29(7):767-794 
  2. Yuksel N, Evaniuk D, Huang L, Malhotra U, Blake J, Wolfman W, Fortier M. Guideline No. 422a: Menopause: Vasomotor Symptoms, Prescription Therapeutic Agents, Complementary and Alternative Medicine, Nutrition, and Lifestyle. J Obstet Gynaecol Can. 2021 Oct;43(10):1188-1204 
  3. Manson JE, Chlebowski RT, Stefanick ML, Aragaki AK, Rossouw JE, Prentice RL, et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women’s Health Initiative randomized trials. JAMA. 2013;310(13):1353-68. 

  4. Canadian Menopause Society- Medication chart https://www.canadianmenopausesociety.org/files/publications/MHT%20Table%202025%20-%20table%201-7%20final.pdf

  5. The Menopause Society (NAMS) Practice Pearl- Contraception in Perimenopause Released January 16, 2025 Barbara A. Soltes, MD, FACOG, MSCP

  6. The Menopause Society (NAMS) Practice Pearl- Use of Progestin-Containing Intrauterine Systems in Hormone Therapy Regimens: What Are the Data? Released July 23, 2025 Amy J Voedisch, MD, MS, MSCP

  7. The Menopause Society (NAMS) Practice Pearl- What Are the Concerns About Custom-Compounded “Bioidentical” Hormone Therapy? Released August 6, 2014 JoAnn V. Pinkerton, MD, NCMP

  8. Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, Jackson RD, Beresford SA, Howard BV, Johnson KC, Kotchen JM, Ockene J; Writing Group for the Women’s Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial. JAMA. 2002 Jul 17;288(3):321-33

  9. Crandall CJ, Hovey KM, Andrews CA, Chlebowski RT, Stefanick ML, Lane DS, Shifren J, Chen C, Kaunitz AM, Cauley JA, Manson JE. Breast cancer, endometrial cancer, and cardiovascular events in participants who used vaginal estrogen in the Women’s Health Initiative Observational Study. Menopause. 2018 Jan;25(1):11-20.

 

  • Nese Yuksel, BSc Pharm, PharmD, FCSHP, MSCP
  • Lindsay Torok-Both, BSc Pharm, ACPR, MSCP
  • Christine Maslanko, BSc Pharm, ACPR, MSCP
  • Victoria Groves, BScN MN, NP, MSCP
  • Susan Poon, BScN, MN, NP
  • Monique Lavoie, BScPh, RPh, CDE, APA, CTHCailee Heggestad, RD
  • Dr. Nan Schuurmans, MD, FRCSC
  • Dr. Catherine Hansen, MD, MPH, FRCSC, FACOG, MSCP
  • Dyan Eybergen, BA, RN, GCert-PM
  • Kayla McKinley, RN, BScN, BSc
  • Nicole Horinek-Castro, RN, BScN
  • Sarah Palen, BScPhm
  • Lunda Mbesha, MHS, BScN RN
  • Ashley Chartier, BSc Pharm, APA
  • Kate Bolohan, RN(EC), NP
  • Lena Ashrf, PharmD (Candidate)

Your first step toward clarity and confidence

Take our free Clarity Quiz—it only takes a few minutes to complete and helps you understand your stage of midlife health. You’ll receive personalized insights and actionable next steps, delivered straight to your inbox.

Take Our Clarity Quiz

Get personalized guidance from licensed clinicians who specialize in menopause care.

See Your Options
Scroll to Top