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July 13, 2026
Birgitta Dunckel
Hormone replacement therapy during menopause: What are the benefits and risks? Here's what current guidelines and the latest evidence recommend.
With
Dr. Petra Eisenmann
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More than nine million women in Germany are currently going through menopause. About one in three experiences symptoms such as hot flashes, sleep disturbances, mood swings, or heart palpitations, which can significantly affect daily life and functioning. On average, this phase of life lasts about seven years, and for some women considerably longer.
According to the consistent assessment of national and international professional societies, hormone replacement therapy (HRT) is the most effective treatment for severe menopausal symptoms. Nevertheless, many women decide against it, often out of concern about potential risks.
This is largely due to the widely discussed Women's Health Initiative (WHI) study from 2002. Its initial findings caused widespread uncertainty around the world and permanently changed the way hormone replacement therapy was approached. Today, however, the body of evidence is interpreted in a far more nuanced way.
Modern guidelines take into account factors such as the patient's age, the timing of treatment initiation, and the type of hormones used. For many healthy women under 60, or within ten years of the onset of menopause, the benefits of treatment are therefore considered to outweigh the risks in cases of severe symptoms. This position is supported by, among others, the German S3 guideline "Peri- and Postmenopause," The Menopause Society, and the International Menopause Society.
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During menopause, the production of female sex hormones – particularly estrogen – gradually declines. This can trigger a wide range of symptoms.
Hormone replacement therapy partially compensates for this hormonal decline. The goal, however, is not to restore hormone levels to those of younger years. Rather, the aim is to relieve symptoms and improve quality of life. A prerequisite is that the symptoms are genuinely related to menopause and that other causes have been ruled out.
Few medical topics have sparked as much controversy in recent decades as hormone replacement therapy. The turning point was the Women's Health Initiative (WHI), a large US study whose initial results were published in 2002.
At the time, researchers reported an increased risk of breast cancer, strokes, heart attacks, and thromboses in women receiving a combined therapy of estrogen and progestogen. The study was subsequently terminated early. Millions of women worldwide discontinued their hormone therapy, and many doctors became considerably more cautious about prescribing it.
Today, the WHI is viewed in a far more nuanced light. For example, participants were on average 63 years old at the start of the study and were often already many years past menopause – that is, they began treatment considerably later than is typical today. Numerous follow-up analyses and additional studies have since shown that age, pre-existing conditions, the type of preparation used, and the timing of treatment initiation all have a decisive influence on the balance of benefits and risks.
For this reason, professional societies now recommend drawing a clear distinction between women who begin therapy early and those who are older patients.
"HRT has undergone several changes and developments in recent years," explains Dr. Petra Eisenmann, a gynecologist at the Munich group practice Pranner15, who guides many affected women through this process. "The focus is on individualized therapy.
The risks and benefits have been reassessed. Hormones are now administered transdermally – for example as gels or patches – tailored to each woman's individual needs. Compared to earlier preparations, transdermal application carries a lower thrombogenic risk."
For women with pronounced menopausal symptoms, hormone replacement therapy is today regarded as the most effective available treatment. This is the consensus of the German S3 guideline, The Menopause Society, and the International Menopause Society. It is particularly effective against vasomotor symptoms such as hot flashes and night sweats. It can also relieve a range of other symptoms and help prevent certain conditions associated with estrogen deficiency.
The most important benefits include:
Hot flashes are among the most common menopausal symptoms and can significantly affect quality of life. Studies show that hormone replacement therapy can substantially reduce their frequency and intensity. According to current guidelines, it is the most effective treatment available for pronounced vasomotor symptoms.
Many women report sleeping better while on HRT. This is not only because nighttime hot flashes diminish, but also because disrupted sleep patterns often stabilize. As a result, concentration, performance, and overall well-being frequently improve as well.
As estrogen levels decline, bone loss accelerates. This significantly increases the risk of osteoporosis and fractures after menopause. Hormone replacement therapy can help slow this bone loss and reduce the risk of osteoporotic fractures. Guidelines therefore recommend it particularly for women with an elevated risk of osteoporosis who also have menopausal symptoms.
Estrogen deficiency can lead to vaginal dryness, pain during intercourse, and recurrent urinary tract infections. Depending on the symptoms, both systemic and low-dose local estrogen preparations may be appropriate. The latter are also considered a suitable option for many women when systemic hormone therapy is not required.
For a long time, hormone replacement therapy was broadly considered a risk to the heart and blood vessels. Today, that assessment is considerably more nuanced.
Current guidelines indicate that women who begin HRT before the age of 60 or within ten years of the onset of menopause do not face an increased cardiovascular risk. Some studies even suggest that early initiation of therapy may be associated with a lower risk of coronary heart disease and reduced overall mortality. However, this potential benefit does not apply to women who begin hormone therapy much later.
In discussions about menopause, there is growing talk of bioidentical hormones. "Bioidentical hormones have the same chemical structure as the body's own hormones," explains Dr. Petra Eisenmann.
"Simply put: they perform the same function and bind to the same receptors as endogenous hormones. The most common bioidentical hormones include estradiol, estriol, DHEA, progesterone, and testosterone. Synthetic hormones, by contrast, do not correspond to the body's own hormones and are produced in the laboratory. They are used, for example, in the contraceptive pill."
Professional societies caution, however, that bioidentical does not automatically mean safer or risk-free. What matters is the individual selection of preparations, the dosage, and regular medical monitoring. Approved bioidentical hormones such as estradiol or micronized progesterone are well supported by scientific research and are widely used today.
Professional societies take a different view of individually compounded preparations made in pharmacies, known as "compounded bioidentical hormones." To date, sufficient data on their efficacy, safety, and consistent quality are lacking.
Hormone replacement therapy is tailored to each woman's individual symptoms and health situation. Estrogens are available as tablets, gels, sprays, or patches, and today they are frequently applied to the skin. According to current guidelines, this so-called transdermal therapy is associated with a lower risk of thrombosis than orally administered estrogens.
If the uterus is still present, estrogen therapy is generally combined with a progestogen to protect the uterine lining. For predominantly local symptoms such as vaginal dryness, low-dose estrogen preparations applied as a cream, vaginal tablet, or vaginal ring are often sufficient.
Even though hormone replacement therapy is assessed far more carefully today than it was 20 years ago, it is not suitable for every woman. An individual benefit-risk assessment should therefore always be carried out before starting treatment.
Breast cancer risk is one of the most common concerns among women. It does indeed depend, among other factors, on the duration of treatment and the combination of hormones used. The landmark Lancet meta-analysis from 2019 prompted an update to the German S3 guideline.
Long-term combined therapy with estrogen and progestogen may slightly increase the risk of breast cancer. However, the absolute risk remains low and must be viewed in the context of other contributing factors such as obesity, alcohol consumption, and physical inactivity. There are also indications that the risk may differ depending on the progestogen used.
Estrogens can increase the risk of venous thrombosis. This applies particularly to orally administered preparations and to women with relevant pre-existing conditions or a hereditary clotting disorder.
Based on current evidence, this risk is lower with transdermal preparations such as gels or patches than with tablets, which is why they are now more commonly preferred.
The effects of HRT on the heart and blood vessels depend critically on when treatment is started. Women who begin HRT many years after menopause have a less favorable benefit-risk profile than those who begin treatment early. For this reason, current guidelines recommend starting therapy as early as possible when HRT is medically indicated.
"Among others, for patients with breast cancer or a history of clotting disorders," says Dr. Petra Eisenmann.
An overview of the most important contraindications:
Whether hormone replacement therapy is an option should therefore always be determined through a thorough gynecological consultation that takes the individual's medical history into account.
The duration of hormone replacement therapy depends on the individual's symptoms and overall health situation. In the past, it was often recommended to end treatment as early as possible. Today, professional societies take a more nuanced view.
As a general principle: HRT should be used at the lowest effective dose and for only as long as medically necessary.
Dr. Petra Eisenmann explains: "According to the guideline, HRT is beneficial for 5–7 years within the 'window of opportunity,' that is, up to age 60. After this window, the risk of breast cancer for hormone-dependent tumors increases. This is also partly attributable to the age of the users and not solely to the use of HRT."
Hormone replacement therapy has undergone a fundamental transformation over the past two decades. While it was long regarded as risky following the publication of the WHI study, current guidelines and long-term data now paint a considerably more nuanced picture.
For healthy women with pronounced menopausal symptoms who begin HRT before the age of 60 or within ten years of the onset of menopause, the benefits are today generally considered to outweigh the risks. Modern preparations – particularly transdermal estrogens combined with individually selected progestogens – make a personalized treatment approach with a favorable benefit-risk profile possible.
Nonetheless, hormone replacement therapy remains an individual decision. The question of which preparations are suitable, and whether treatment is appropriate at all, should always be discussed with an experienced gynecologist.
Many women worry about gaining weight as a result of hormone replacement therapy. However, scientific studies have not been able to demonstrate that HRT generally leads to weight gain.
Rather, metabolismchanges during menopause independently of hormone therapy. As a result, many women find it easier to gain weight, and fat tends to accumulate more often in the abdominal area. HRT cannot prevent these natural changes, but it does not cause them either.
In principle, yes — but starting therapy late requires careful consideration. According to current guidelines, the benefit-risk ratio is most favorable when treatment begins before the age of 60 or within ten years of the onset of menopause.
When HRT is started considerably later, risks such as cardiovascular disease or stroke may increase. Whether treatment is still advisable in such cases should be discussed individually with a gynecologist.
Yes. Falling estrogen levels accelerate bone loss after menopause and raise the risk of osteoporosis and fractures. Hormone replacement therapy can effectively slow this bone loss and reduce the risk of fractures.
Not necessarily. Although bioidentical hormones share the same chemical structure as the body's own hormones, this does not automatically make them safer or free of side effects. What matters most is the correct dosage, the choice of preparation, and regular medical monitoring.
Approved bioidentical hormones such as estradiol and micronized progesterone are well researched. Caution is warranted, however, with individually compounded hormone mixtures prepared in pharmacies, for which only limited scientific data are currently available.
