Good question: What are the risks and benefits of HRT for menopause?

Is there any wonder many women find menopause (the point at which at which a person goes 12 months without a menstrual period, marking the end of reproductive years) and perimenopause (the often years-long period of highly variable symptoms preceding menopause) overwhelming?

Navigating the variable, unpredictable, and sometimes – debilitating symptoms¹ that come with this life transition – all while balancing the compounding responsibilities of middle age – can affect physical, emotional and mental health,² finances,³ and overall quality of life.⁴ Relatively few are fully prepared for the change: As recently as 2022, most women reported feeling uninformed about menopause,⁵ and fewer than 1 in 4 said their physicians have proactively brought the topic up.⁶

But evidence suggests the tide might be starting to turn.

“There’s long been stigma around menopause. Women have often felt it’s just something they need to soldier through in silence,” says Cori Lawson-Roberts, Assistant Vice-President, Disability & Group Life at Manulife. “But that’s no longer the case. There is help available, and as awareness grows, more women are seeking it.”  

Consider the recent sharp rise in the use of hormone replacement therapy (HRT) among Canadian women of menopausal and perimenopausal age. Over the past five years, HRT claims among women aged 45 to 54 have increased by 228%, according to Manulife Canada claims data.⁷ This aligns closely with the average age of menopause in Canada, which is 52. The most commonly prescribed menopausal  treatments include estrogen and progesterone preparations to counteract the hormonal changes that happen around menopause.⁸

“Clinicians are becoming more aware of the benefits of treating menopause and perimenopause symptoms as soon as they start,” explains Dr. Farzana Haq, Physician Lead of Women’s Health at Cleveland Clinic Canada, which serves as the Medical Director for Manulife Canada's Group Benefits. “Increasingly, we are intervening with therapies to help women feel better and more like themselves.”

What does this mean for women considering HRT to manage the symptoms of perimenopause or menopause?

Below, Dr. Haq explains why there’s often confusion surrounding HRT, how it can alleviate menopause and perimenopause symptoms and what women should know about the risks and benefits of pursuing this form of treatment.

Dr. Haq: Although hormone replacement therapy (HRT) remains the term most people are familiar with, clinicians are increasingly using the term menopausal hormone treatment (MHT), which many consider a more accurate description of these therapies. HRT can imply that hormones are being restored to premenopausal levels, when in reality treatment is tailored to a woman's symptoms, health profile and goals. Hormone therapy typically refers to estrogen, often combined with some type of progesterone. It’s meant to help alleviate symptoms and confer potential health benefits in response to the decline in hormones that occurs during the perimenopause and menopause transition.

It comes in several forms: There’s localized treatment, such as vaginal estrogen treatment that helps with symptoms like vaginal dryness, urinary frequency and painful intercourse. Then there’s systemic treatment, which can come in both oral and transdermal formulations and is more commonly used to help manage broader symptoms such as hot flashes, night sweats and sleep disruption. Each option comes with its own benefits and risk profile.

Dr. Haq: As women, we have hormone receptors literally all over our bodies, from head to toe – including estrogen and progesterone receptors. Typically, those hormones circulate and impact all our body systems, conferring some overall health protection and contributing to making us generally feel well.

Those hormone levels decline in perimenopause and menopause. This affects our entire bodies, which is why women can experience a myriad of symptoms during this stage of life. One of the hallmark symptoms women in this transition will report is, ‘You know, I'm just not feeling like myself.’ That feeling can be mental and physical. It’s so common that it’s become its own validated symptom,⁹ with its own acronym: NFLM.

Menopausal hormonal treatment is meant to address that drop in hormones while helping to mitigate or treat some of the symptoms that come from it. It can help women to get back to feeling like themselves, or as close to it as possible.

Dr. Haq: I think there are two main reasons. First, menopausal hormonal prescriptions and treatment can be really nuanced. Physicians need to review each individual patient in terms of their symptoms and their underlying health risks to be able to make an assessment as to whether and what options are appropriate. It takes a significant level of training to be able to do that, and, historically, education around menopause in medical training has been minimal. Unless physicians have an interest in this area and have done extra training, they may not have the training and knowledge to prescribe HRT comfortably. 

The second, and probably the biggest, reason is the fallout from the 2002 Women’s Health Initiative (WHI) study  – whose findings are now understood to have important limitations¹²  –  which linked use of HRT with increases in cardiovascular disease, stroke, blood clots and breast cancer. After that study was published, many patients were scared to take HRT, and a lot of physicians were afraid to prescribe it.

There are multiple problems with that study, based on what we know today: For example, the average woman enrolled in it started hormones in her mid-60s – more than a decade after she was menopausal – which is a very different risk category than younger women. Also, the study overstated the risk of breast cancer, as later analyses found no associated increase in mortality. Finally, the type of hormones that they used in that study were different than the first-line treatments favoured by many clinicians now, so we can’t really compare apples to apples.

These are facts I bring up often with my patients, because there’s still a lot of reluctance. It’s so important to look at the data and understand the actual risks.

Dr. Haq: We are very cautious with women who might be at a very high risk of hormone-sensitive cancers. We’re also cautious with women who are at high cardiovascular risk to start with, or women who are older. For example, someone in their 60s with high blood pressure, diabetes and a family history of early heart disease may face different risks from HRT than someone who is younger and otherwise healthy, even if both women have the same symptoms. That’s why it’s so important to conduct a detailed risk assessment before prescribing treatment.

Dr. Haq: We know there can definitely be benefits to mood and cognition.¹³

For a lot of women, HRT helps with sleep¹⁴ – whether because it has a direct impact on sleep, or because we’ve solved for the hot flashes or night sweats that have been waking patients up.

The drop in estrogen during the menopause transition impacts cardiovascular health: It increases LDL, which is bad cholesterol, for example, and it increases arterial stiffness. Introducing hormones during the transition can have cardiovascular benefits in younger menopausal women.¹⁵

We know that HRT can play an important role in bone health, in terms of prevention and treatment for osteoporosis.¹⁶

A drop in estrogen changes body composition: During the transition, women tend to gain weight more easily and accumulate fat, especially around the abdominal area. This can increase the risk of diabetes,¹⁷ cardiovascular disease,¹⁸ fatty liver disease,¹⁹ and even some cancers.²⁰ There’s some evidence²¹ that HRT can provide some benefit against the risks that can come from metabolic and body composition changes during menopause.

Dr. Haq: Primarily, the benefits are symptom relief.

The old-school way physicians would prescribe hormones was to wait until a woman is officially menopausal – that is, the date at which she hasn’t had a menstrual period for 12 months. The problem with that approach is that many women are symptomatic for years leading up to that moment; hormone levels fluctuate and start to decline for five to 10 years prior to that last period.

Thankfully, more physicians are understanding that perimenopause needs to be treated. We’re not waiting until that final period to say, ‘OK, it’s time, your estrogen levels are officially low enough now.’

Dr. Haq: Every woman is different. I have some patients who breeze through menopause and feel great, and others who really suffer, and some who have complicated risk factors.

In my view, every single woman who has had any kind of menopausal or perimenopausal symptoms deserves a conversation about HRT with her doctor: to understand what her underlying risks are, and what the potential benefits might be, so she can make an informed decision. 

Dr. Haq: First, for many women who are symptomatic, the benefits of hormone therapy probably outweigh any risks. Second, as we discussed, there are lots of different treatment options available. And finally, any treatment should be highly individualized, based on conversations with a physician that consider the patient’s physiology and symptoms. 

Learn more: Demystifying menopause, one of the biggest health shifts for women

_{This article is for informational purposes only. It is not intended to diagnose or treat a condition. If you have questions or concerns about your specific situation or are seeking medical advice, contact your medical doctor or your healthcare provider.}

_{A note about gender:}

_{While we use the terms "women," "female," and "men" and "male" in this article, we recognize that these terms are not inclusive of all gender identities and that the health issues addressed here may be relevant to individuals across the gender spectrum.}

_{Cleveland Clinic Canada}

_{Manulife is proud to have Cleveland Clinic Canada on board as Medical Director for our Group Benefits operations. Cleveland Clinic Canada has a wealth of global healthcare expertise and shares our goal to help Canadians live longer, healthier, and better lives. Cleveland Clinic is a nonprofit organization that has been at the forefront of modern medicine since 1921. In recent years, Cleveland Clinic has worked with progressive companies in Canada and around the world to prioritize the health and well – being of their employees, customers, and communities.}