HRT Long-Term — Supporting Her Treatment Decisions

Hormone replacement therapy (HRT) provides the hormones — primarily estrogen and, for women with a uterus, progesterone — that the ovaries no longer produce after menopause. It comes in many forms: patches, gels, sprays, pills, vaginal rings, and combinations thereof. The primary purpose is symptom relief: HRT is the most effective treatment for hot flashes, night sweats, sleep disruption, vaginal dryness, and the mood and cognitive symptoms associated with estrogen decline. It reduces vasomotor symptoms by 75% or more in most women. Beyond symptom relief, HRT offers several protective benefits when started in the appropriate window. It preserves bone density, reducing fracture risk. It may reduce cardiovascular risk when started within 10 years of menopause (the 'timing hypothesis'). It treats and prevents genitourinary syndrome of menopause. And emerging evidence suggests potential neuroprotective benefits. Modern HRT is highly individualized. Body-identical hormones (estradiol and micronized progesterone), transdermal delivery (patches and gels that bypass the liver), and personalized dosing have made current HRT regimens significantly safer than what was studied in the early 2000s. Understanding what HRT is — and isn't — helps you engage meaningfully when she's weighing her options.

The safety profile of HRT is far more favorable than most people believe, largely because public perception was shaped by the 2002 Women's Health Initiative (WHI) headlines, which were misleading in context and application. Here's what the current evidence actually shows: The WHI studied a specific population (average age 63, many with pre-existing health conditions) using a specific formulation (oral conjugated equine estrogen plus synthetic progestin). The results — a small increase in breast cancer risk in the estrogen-plus-progestin arm — were extrapolated to all women, all ages, and all formulations. That extrapolation was scientifically inappropriate. Subsequent analysis and decades of follow-up have clarified the picture: Estrogen-only HRT (for women without a uterus) does NOT increase breast cancer risk. In the WHI follow-up, it actually reduced breast cancer incidence. The combination of estrogen plus micronized progesterone (body-identical, not synthetic progestin) appears to carry a lower breast cancer risk than the synthetic progestin used in the WHI. Any increase in breast cancer risk with combination HRT is small — comparable to the risk increase from drinking 2+ glasses of wine daily or being obese. Cardiovascular protection is seen when HRT is started within 10 years of menopause. All-cause mortality is not increased, and may be decreased, in women who start HRT in the appropriate window. For most symptomatic women under 60 or within 10 years of menopause, the benefits of HRT — symptom relief, bone protection, cardiovascular protection, quality of life — outweigh the risks. Individual risk assessment matters, and she should discuss her specific profile with a menopause-informed provider.

This is one of the most debated questions in menopause medicine, and the answer has shifted significantly in recent years. The old dogma was 'lowest dose, shortest duration,' driven by the initial WHI findings. Current guidance is more nuanced and individualized. NAMS and the British Menopause Society now state that there is no arbitrary time limit for HRT. The decision to continue should be based on ongoing individualized assessment of benefits versus risks, revisited annually with her healthcare provider. For many women, the benefits of continuing HRT — persistent symptom relief, bone protection, cardiovascular maintenance, quality of life — continue to outweigh the risks well beyond the commonly cited 5-year mark. Some women take HRT for decades and do well. The key is ongoing medical supervision and periodic reassessment. Stopping HRT deserves careful consideration too. Abrupt cessation can cause return of vasomotor symptoms in up to 50% of women. A gradual taper is typically recommended. Genitourinary symptoms will return after stopping systemic HRT unless local vaginal estrogen is continued — and most experts recommend continuing vaginal estrogen indefinitely for symptomatic women, as the risks are minimal and the benefits are significant. Ultimately, this is a conversation between her and her healthcare provider, not a decision to be made by guidelines alone. Her symptoms, her risk factors, her quality of life, and her preferences all matter.

This is frustratingly common. Despite strong evidence supporting HRT for appropriate candidates, many physicians remain reluctant to prescribe it — a lingering effect of the 2002 WHI headlines. Studies show that medical education still dedicates inadequate time to menopause: most OB-GYN residencies include fewer than 7 hours of menopause-specific training. Primary care physicians often receive even less. The result is a generation of healthcare providers who may be uncomfortable with HRT, unsure of current guidelines, or unaware of the nuanced evidence that has emerged in the last two decades. If her doctor dismisses her request for HRT without a specific, evidence-based reason related to her individual risk profile, that's a red flag. A blanket 'HRT is dangerous' or 'just try supplements' from a doctor doesn't reflect current medical consensus. She has every right to seek a second opinion from a menopause-informed provider. NAMS maintains a directory of certified menopause practitioners at menopause.org. The British Menopause Society, the International Menopause Society, and telehealth menopause clinics are also resources. Your role as her partner may be to validate her frustration with medical dismissal and encourage her to advocate for herself or find a provider who will take her symptoms seriously.

If she's on HRT, practical and emotional support makes the experience smoother. HRT often requires a period of adjustment — finding the right formulation (pill, patch, gel, spray), the right dose, and the right combination of estrogen and progesterone for her body. This process can take 2–3 months, during which she may experience side effects like breast tenderness, bloating, or headaches before things settle. Your patience during this adjustment period matters. Ask how she's feeling, notice changes (positive or negative), and encourage her to communicate with her doctor about anything that doesn't feel right. If she's using patches, she may need help applying them to her back. If she takes progesterone at bedtime, understanding that it makes her drowsy helps you adjust evening routines. Keep track of prescription refills if that's helpful — running out of HRT can cause a rapid return of symptoms. Some women feel conflicted about taking HRT, even when it's helping. Cultural messaging about hormones being 'unnatural,' pressure from friends or family, or residual fear from outdated headlines can create doubt. If she expresses ambivalence, listen without judgment and gently point to the evidence: 'How do you feel on it? If it's helping, that matters.' Celebrate improvements. If she's sleeping better, having fewer hot flashes, or feeling more like herself, name it: 'You seem more comfortable lately. I'm glad the treatment is working.' That acknowledgment reinforces her decision and validates her experience.