Is HRT Right For Me?

Hormone therapy (HRT) is the gold standard for treatment of hot flashes, night sweats and other pesky menopausal symptoms that can bedevil women at midlife. But not everyone is a candidate for the therapy experts consider most effective.

Who should not use hormone replacement therapy?

Hormone replacement therapy (HRT) is not recommended for certain women due to increased health risks. You should avoid HRT if you have:

• A current or past history of breast, ovarian, or uterine cancer
• A history of blood clots, including deep vein thrombosis (DVT) or pulmonary embolism
• Certain inherited clotting disorders
• Liver disease or abnormal liver function
• A history of stroke or heart attack
• Uncontrolled high blood pressure

Why is HRT not safe for these conditions?

Oral estrogen can increase clotting factors in the blood, raising the risk of new or recurrent blood clots. In women with certain cancers or cardiovascular conditions, hormone therapy may also worsen outcomes or increase the risk of complications.

If you have any of these conditions, talk to your doctor about non-hormonal options for managing menopause symptoms.

That doesn’t mean these groups must forego relief altogether.

Grettel Garcia, M.D., an internist with the University of Miami Health System who specializes in menopause, says there are plenty of non-hormonal alternatives that can manage The Change.

“Hormone therapy is the most effective treatment,” Dr. Garcia explains, “but it’s not the only one. If a woman can’t use or chooses not to use hormones, she still has several options. The idea is to match the treatment to the woman and her health history.”

Non-hormonal alternatives range from U.S. Food and Drug Administration-approved medications to lifestyle changes, behavioral therapies, and even herbal remedies.

However, not all remedies are equally effective, and some may not work at all.

The Menopause Society issued a position statement in 2023 to help make sense of the ads — and wild claims — flooding social media and various websites.

As Dr. Garcia explains, all treatments “should be based on evidence,” but not everyone bases their choices on science.

What’s more, the range and severity of symptoms vary among ethnic and racial groups, even from one woman to another. For example, Black women experience the most severe symptoms for the longest time — up to 10 years, significantly longer than their white counterparts. They reach menopause earlier than white and Asian women, too. The same holds true for Hispanic women.

There’s a lot of room for personalization, a lot of nuances in treatment,” Dr. Garcia adds. “It’s not a one-size, one-dose fits all.”

Treating menopausal symptoms can be challenging because the hormonal changes associated with the transition affect many areas of well-being, from mood to temperature regulation, from sleep to sexuality. Women’s health experts often find that a combination of therapies is most effective.

Non-hormonal menopause treatments were back in the news recently when the FDA approved Lynkuet, a daily pill that treats hot flashes. Also known by its generic name, elinzanetant, it’s the second medication on the market to target brain pathways involved in body temperature regulation.

For women who can’t use or prefer not to use hormone therapy, Dr. Garcia offers several alternatives.

More recommendations can be found in a 2023 position statement issued by The Menopause Society.

• Neurokinin Receptor Antagonists. Lynkuet, the most recently approved oral medication, blocks two types of neurokinins. These particular chemical messengers send signals to your nerves that trigger hot flashes and night sweats. Another once-daily tablet, Veozah (generic name fezolinetat), was approved in 2023. It blocks one kind of neurokinin. Though these oral medications help stabilize temperature dysregulation and improve sleep quality, they’re not as effective for mood swings and other menopausal symptoms, Dr. Garcia adds.
• Vaginal relief moisturizers. Non-hormonal lubricants, sometimes known by their commercial names, such as K-Y and Replens, are easy to use and offset the vaginal dryness and discomfort that many menopausal women feel, particularly during intercourse.
• Low-dose antidepressants. There is only one medication, Paroxetine, that is FDA-approved for vasomotor symptoms. However, clinicians also use off-label drugs, such as citalopram (Celexa), venlafaxine (Effexor), and escitalopram (Lexapro) for the relief of symptoms.
• Behavior and lifestyle changes. Probably the most recommended therapy is Cognitive Behavioral Therapy (CBT), used in the management of menopause-related sleep and anxiety issues. Hypnosis has also been found to reduce hot flashes in some studies.

While there may be other popular alternatives, most mind-body therapies lack evidence of effectiveness.

The Menopause Society discounts some products and techniques that claim to alleviate hot flashes, night sweats and other menopausal symptoms, without the science to prove it. For example, no clinical trials back up claims that exercise and yoga, dietary modifications or avoiding “triggers” such as certain foods can alleviate symptoms. Evidence on supplements is also insufficient, as is the use of certain natural remedies, such as soy products, flaxseed and black cohosh.

To manage menopausal symptoms, the key is to seek guidance from clinicians well-versed in the subject. “There’s a lot more awareness now around menopause,” Dr. Garcia adds. “Talking to your doctor [about concerns and symptoms] helps women make better informed choices. The more we talk about it, the more we empower women.”

Written by Ana Veciana-Suarez. Medically reviewed by Grettel Garcia, M.D.

Tags: alternatives to HRT for hot flashes, Dr. Grettel Garcia, menopause symptom relief options, menopause without hormone therapy