Signs That You Need Hormone Replacement Therapy: A Comprehensive Guide

Key Takeaways

• HRT is used for menopause symptoms and gender-affirming care.
• HRT is available in tablets, pellets, patches, sprays, and gels.
• HRT may alleviate certain menopause symptoms, reduce the risk of certain conditions (like osteoporosis), and improve one’s overall quality of life.
• HRT can trigger side effects and may increase the risk of breast cancer, stroke, and blood clots.
• Receiving a personalized HRT plan from an endocrinologist or OB/GYN may help prevent complications.

Hormone replacement therapy, or HRT, is widely used for people experiencing menopause, as well as individuals who are receiving gender affirming hormone care. You may want to consider HRT for menopause symptoms, like hot flashes, night sweats, mood swings, low libido, and vaginal atrophy. Some transgender individuals or nonbinary people may opt for HRT to more closely align with their gender identity or to decrease certain sex characteristics.

HRT therapy works by increasing estrogen levels in the body and comes in tablet, patch, pellet, spray, and gel form. Estrogen promotes balanced blood sugar levels, healthy circulation, bone mass, hydrated skin, brain function, and more. Progesterone is also often included in HRT to reduce the risk of adverse effects, like certain cancers.

In transgender or nonbinary individuals, HRT can take two to five years before any physical effects are seen, although some people may experience changes much sooner. In those experiencing menopause symptoms, HRT may take up to three months to fully work.

In this article, we’ll go over why someone may want to consider HRT, as well as how it works, what to expect from treatment, and potential side effects.

Signs Indicating the Need for HRT

You may consider HRT if hormonal imbalances affect your physical and mental health. Low estrogen causes tissue to become thinner and drier, potentially leading to bladder infections, incontinence, and vaginal atrophy. It can also increase the risk of osteoporosis and heart disease, in some cases.

Signs That You May Need HRT for Menopause

You may benefit from HRT if you’re experiencing persistent symptoms of menopause, such as:

• Disrupted or poor-quality sleep
• Muscle, joint, or body aches
• Hot flashes and night sweats
• Irritability
• Forgetfulness
• Anxiety or depression
• Poor concentration
• Painful intercourse
• Urinary incontinence
• Low libido

Can I check my estrogen level at home?

You can check your estrogen level with an at-home hormone test kit. This typically involves a quick finger prick sample, which is mailed to a lab for testing.

Related reading: Winona Menopause Review - Is It Worth It for HRT?

When to Consider Gender-Affirming HRT

As a transgender or nonbinary individual, you may benefit from HRT if you’re:

• Experiencing discomfort and/or diminished mental health because your gender identity differs from your sex assigned at birth
• Wanting your sex-related physical characteristics to better align with who you are

How Hormone Replacement Therapy Works

Gender-affirming hormone replacement therapy for transgender women or nonbinary individuals may involve taking estrogen and anti-androgen medications, like spironolactone. Estrogen reduces testosterone production and triggers the development of certain characteristics, including:

• Fat distribution on the hips
• Reduced size of the penis and testicles
• Reduced muscle bulk
• Slowed growth of facial and body hair
• Slowed balding (in the case of androgenic alopecia)
• Tender and potentially larger breasts

The purpose of gender-affirming hormone therapy is to achieve characteristics that more closely align with your gender identity.

HRT for menopause works by restoring levels of estrogen and progesterone after the ovaries stop producing these hormones. This has been found to reduce menopause symptoms, including hot flashes, night sweats, bone loss, vaginal dryness, and mood changes.

What Is the Best Age to Start HRT?

Given that gender transition is a highly personal process, there’s no “right” or “best” time to start gender-affirming HRT. It depends on your individual goals, preferences, and gender identity. A qualified endocrinologist can help you determine if and when to start.

In regards to HRT for menopause, consider that individuals who start HRT at age 60 or older, or over 10 years from the onset of menopause are at the greatest risk for complications. According to the North American Menopause Society, the benefits of estrogen therapy outweigh the risks for healthy people under age 60 or within 10 years of menopause onset.

How Long After Starting HRT Do You Feel a Difference?

You may start to feel a difference within a few weeks of starting HRT for menopause-related symptoms, although this can vary from person to person. Some individuals don’t notice a difference for up to 3 months.

With gender-affirming HRT, it can take up to 5 years before any physical effects are seen, however, this can vary depending on the individual and their specific goals.

How Long Does HRT Stay in Your System After Stopping?

Systemic HRT, meaning the hormones are in your bloodstream, typically leaves your system within a few days. However, this can vary depending on the individual.

Benefits and Types of HRT

Multiple types and forms of HRT are available, with each offering unique benefits. Some people may only be candidates for certain types of HRT, so speak with a qualified endocrinologist or OB/GYN to determine the right type for your needs.

Bioidentical Hormone Therapy

Bioidentical hormone therapy, or bHRT, uses hormones that are chemically identical to those produced in the human body. They’re produced in a lab and derived from plant sources (typically yams or soy). This is in contrast to the hormones conventionally used in HRT, which are derived from animal sources. For context, a common HRT drug, Premarin, is derived from the urine of pregnant horses.

The FDA has approved a few bioidentical hormones, including estradiol (brand names Estrace, Vivelle, and Climara) and progesterone (brand name Prometrium).

The primary benefit of bHRT is that it’s derived from plant sources, which is preferable for many people, especially those following a vegan or vegetarian diet. Additionally, since bioidentical hormones are chemically identical to the body’s natural hormones, they may provide better results for some individuals, although clinical research to support this claim is lacking.

Combination HRT

Combination HRT contains both estrogen and progesterone. It’s generally recommended for people who have a uterus, as progesterone helps reduce the risk of endometrial cancer with estrogen therapy. It can also benefit individuals undergoing gender-affirming HRT through faster feminization, reduced testosterone production, and optimal breast development.

Benefits of combination HRT may include:

• Reduces the risk of endometrial cancer compared to estrogen-only HRT
• Effectively relieves certain menopause symptoms
• Can provide faster, better results for gender-affirming HRT, in some cases

Estrogen-Only HRT

Estrogen-only HRT may be recommended for people who have had their uterus removed in a hysterectomy. These individuals aren’t at risk of endometrial cancer and may safely take estrogen alone. Estrogen-only HRT may reduce the risk of breast cancer in individuals who have had hysterectomies, while combination HRT may cause a small, rare increase in breast cancer risk.

Benefits of estrogen-only HRT may include:

• Effectively relieves certain menopause symptoms
• Reduces the risk of breast cancer in people who have had hysterectomies

Forms of HRT

HRT is available in patches, implants, oral tablets, and topical gels and sprays.

Patches

Patches gradually release hormones through the skin. They’re generally placed on the lower stomach or upper buttock and need to be replaced every few days. Both combination and estrogen-only HRT are available in patch form.

Benefits of patches may include:

• May be more comfortable for people who struggle to swallow pills
• Can provide a more consistent dosage for people who may forget to take pills at the same time each day
• May prevent certain side effects of HRT pills, like indigestion
• Doesn’t increase the risk of blood clots, like tablets do

Implants/Pellets

HRT implants and pellets are inserted under the skin by a physician. They release a consistent dose of hormones throughout the day and night. After 3 to 6 months, the pellet fully dissolves, at which point a new pellet must be inserted.

Benefits may include:

• Provides a more consistent dosage of hormones
• Lasts for 3 to 6 months, which may be more convenient than patches or topical hormones that must regularly be re-applied

Tablets

Hormone tablets are taken by mouth, usually once daily. This is the most common form of HRT.

The biggest benefit of taking tablets is that they are simple and convenient for people who don’t mind taking pills

Gels and Sprays

Topical HRT is available in the form of gels and sprays. Both are absorbed through the skin, usually on the arm or thigh.

Benefits of gels and sprays:

• May be more comfortable and convenient for people who don’t like taking pills
• May prevent certain side effects of systemic HRT, like indigestion
• Doesn't increase the risk of blood clots, like tablets do

What are the long-term benefits of HRT?

HRT can provide several long-term benefits, including:

• A lower risk of osteoporosis and bone fractures
• Healthier nerve cells, which may reduce the risk of dementia and Alzheimer’s disease (particularly if HRT is started in the perimenopause transition, before menopause)
• A lower risk of colorectal cancer
• A higher quality of life

How to Decide If HRT Is Right for You

To decide if HRT is right for you, schedule an appointment with an OB/GYN or endocrinologist in your area or through a trusted telemedicine platform. With many different types of HRT available and several factors affecting which type of HRT is safe for you, professional guidance is key.

With that said, the decision to start HRT is a personal one. Weighing the pros and cons can help you make an informed decision.

Pros and Cons of HRT

Managing Expectations and Risks

Before starting HRT, it’s important to have realistic expectations, as the results can vary from person to person. Your physician can discuss these factors with you:

• Your mood and emotions may fluctuate as your body adjusts to the new hormone levels during this time.
• Your sexual function and libido are likely to change during this time.
• Gender-affirming hormone therapy doesn’t always reduce sperm count in transgender women.
• Breast growth from gender-affirming HRT is often very small.

HRT Side Effects

Potential side effects of HRT with estrogen and progesterone include:

• Headache
• Stomach upset
• Stomach cramps
• Bloating
• Vomiting
• Diarrhea
• Weight fluctuations
• Appetite changes
• Nervousness
• Acne
• Fluid retention
• Breast tenderness or discharge

Possible Complications of HRT

Possible complications of HRT may include breast cancer, blood clots, and stroke.

Breast cancer

A widely known safety risk of HRT for menopause is an increased risk of breast cancer. Clinical research in the early 2000s linked HRT to a higher risk of breast cancer. But, further research has found that this connection is complex, depending on the individual and the type of HRT.

The North American Menopause Society found that the benefits of estrogen therapy outweigh the risks for healthy people under age 60 or within 10 years of menopause onset.

Blood clots

Individuals taking HRT are at an increased risk of blood clots. Both estrogen-only and combination (estrogen and progesterone) HRT carry this risk.

Stroke

HRT can increase the risk of stroke. This risk is higher in people who have already reached menopause when compared to younger individuals.

How to Prevent the Risks and Side Effects of HRT

A few strategies may help ease some side effects from HRT, including:

• Following all of your physician’s instructions closely
• Taking HRT tablets with a meal
• Reporting all side effects to your physician so that they may adjust your dose, as lowering your dose may lessen side effects

To mitigate the risks of HRT, it’s essential to visit your physician for all scheduled follow-ups and report all side effects or unusual symptoms. Additionally, before starting HRT, speaking to a qualified physician for a personalized treatment plan is essential.

The safest course of HRT varies significantly depending on your medical history, family history, current medications, and other factors, making individualization a crucial component of effective HRT.

Additionally, once you start taking hormones, it’s important to talk to your doctor before stopping HRT. It’s usually advised to gradually decrease the dose, rather than stop abruptly, to avoid estrogen withdrawal symptoms.

Frequently Asked Questions (FAQs)

What kind of doctor prescribes hormone replacement therapy?

Obstetricians-gynecologists (Ob/Gyns) and endocrinologists can prescribe hormone replacement therapy.

What is hormone pellet therapy?

Hormone pellet therapy involves inserting a small pellet containing hormones beneath the skin. The pellet gradually releases hormones into the bloodstream until it dissolves, usually within 3 to 6 months.

Does a lack of estrogen cause weight gain?

Low estrogen can lead to weight gain for some individuals, particularly after menopause.

Related reading: Effective Strategies for Losing Weight During Menopause: HRT, GLP-1 Agonists, and Lifestyle Changes

How do I know if I need testosterone with my HRT?

Your physician may recommend testosterone with HRT for menopause to increase libido.

How do you feel when estrogen is too high?

Too high of a dose of estrogen HRT can lead to side effects, like breast tenderness, headaches, fatigue, and mood swings.

What is the best natural replacement for estrogen?

Natural replacements for estrogen include soy, tofu, sesame seeds, and beans. These foods contain phytoestrogens.

Related Reading