What are the basics of starting hormone replacement therapy?

Hormone replacement therapy (HRT) has gotten a bad rap since the Women’s Health Initiative showed that there was a slight increase in the number of older women getting breast cancer and heart disease. However, fifteen years later, the consensus is that for women under the age of 60 who are experiencing menopausal symptoms, hormone therapy may relieve symptoms without a significant increase in risk of heart disease and cancer. It should be noted that no one thinks prescribing HRT for chronic conditions like osteoporosis is beneficial.

What women might benefit from HRT? 
Menopausal symptoms include hot flashes, joint aches/pains, and vaginal atrophy/dyspareunia. The evidence supports using HRT in women <60 years of age. The risk of adverse effects increases with age.

NB: alternative treatments for hot flashes include bedtime gabapentin and a variety of SSRI/SNRIs. Paroxetine and citalopram can be considered (paroxetine is the only SSRI/SNRI FDA approved for treatment of hot flashes, but should not be used in women taking tamoxifen due to cytochrome p450 metabolism). Bazedoxifene/conjugated estrogen is a SERM combination therapy with estrogen that has been shown to be effective but also carries increased risk of VTE. Black cohosh is NOT supported. For women with milder symptoms, simply adjusting the thermostat or changing clothes may be acceptable, or cognitive-behavioral therapy.

NB: women who only have vaginal atrophy and dyspareunia can use estrogen cream instead of taking systemic therapy like pills or patches.

What are the contraindications to prescribing HRT? 


  • history of breast cancer
  • unexplained vaginal bleeding
  • high-risk endometrial cancer
  • Cardiovascular disease risk (CVD risk) >10% by JACC calculator or known CAD
  • previous venous thromboembolic event
  • previous stroke or TIA
  • active liver disease, i.e. cirrhosis


  • hypertriglyceridemia
  • active gallbladder disease
  • hypercoagulable conditions like FVL, without known history of clot
  • migraine with aura is not a contraindication, but you might consider transdermal estrogen instead of oral (same for women with obesity)

What doses of estrogen should I prescribe? 

NB: estrogens come in creams, rings, vaginal formulations, patches, and pills. When thinking about dosing, remember to check for medication interactions as estrogen is metabolized by the liver. Women taking estrogen should also be counseled to avoid or limit alcohol intake for this reason.

  • Transdermal estrogen (the patch) can be started at 0.025 mg/day
  • Low-dose estrogen (pill) can be started at 0.5 mg/day

Check in after 1 month and titrate up for symptoms

Why the progestin, too? 

All women with a uterus should also receive progestin to prevent the increased risk of endometrial cancer from endometrial hyperplasia. (Women who have undergone hysterectomy do not need to take a progestin.) Oral micronized progesterone, which sometimes is called a “minipill.” Progesterone may cause nausea, bloating, and breakthrough bleeding that women can’t tolerate–in these cases, try continuous progesterone therapy, or consider an IUD or switching to a SERM/conjugated estrogen.