What types of hormone therapy can help with hot flashes and other menopause symptoms?
Medications that deliver estrogen into your bloodstream can help relieve bodywide symptoms related to menopause. You can take a pill or wear a patch, but those aren’t the only FDA-approved options.
Menopause marks the one-year anniversary of your final menstrual period. If you use hormonal birth control or don’t have a uterus, menopause may not have a noticeable marker. But menopause will happen just the same. Whether the milestone is still ahead or in the rearview mirror, symptoms related to menopause can stretch on for miles.
Many people experience symptoms during this time, including hot flashes, night sweats, mood changes, and interrupted sleep. Genitourinary Syndrome of Menopause is also common and may include vaginal dryness or pain, peeing problems, and trouble enjoying sex.
Hormone therapy with estrogen can help relieve bothersome symptoms that occur during and after the menopause transition. But note, only medications that deliver estrogen into your bloodstream can relieve bodywide symptoms like hot flashes. This type of medication is called systemic hormone therapy. Most forms of systemic hormone therapy treat both bodywide and genitourinary symptoms caused by menopause.
✨ Low-dose vaginal estrogen treatment doesn’t treat hot flashes, but it’s very effective (and preferred) if you only have Genitourinary Syndrome of Menopause. Learn why low-dose vaginal estrogen is a very safe option in this TNG post by nerdy girl physician Dr. Alexandra Hall.
Your clinician can help you decide whether or not to start menopause hormone therapy and how long to continue. Knowing which options are available can help you have the conversation to find a treatment that’s right for you. But first, a note on uterine protection.
➡️ If you have a uterus, don’t forget a progestogen
Systemic estrogen hormone therapy needs to be taken with an adequate dose of a progestogen. This second hormone protects your uterus from estrogen. Taking systemic forms of estrogen alone can cause your uterine lining to get too thick (a condition called endometrial hyperplasia). Over time, systemic estrogen without a progestogen could lead to uterine cancer. According to the National Cancer Institute, the risk of uterine cancer is at least doubled after using estrogen alone for five years.
✨ Estrogen-only hormone therapy: If you take estrogen-only systemic hormone therapy and have a uterus, then your clinician will prescribe a progestogen medication separately. Oral progesterone (Prometrium) and medroxyprogesterone (Provera) are both FDA-approved for this purpose, but they come with different risks. Progestin intrauterine devices (IUDs) like Mirena act as long-term birth control and also provide uterine protection. Ask your clinician to help you weigh the risks and benefits of each to help you decide which progestogen option is best for you.
✨ Estrogen-progestogen hormone therapy: Some combination hormone therapies include estrogen, usually with a progestin (a synthetic form of progesterone). These products are convenient since both medications come in one pill or patch. However, combination products come in fewer medication types and dosages, so some people may prefer to take these hormones separately.
Below, we cover the FDA-approved types of systemic hormone therapy for menopausal symptoms. These medications contain estrogen, usually in the form of estradiol (the same form of estrogen made by the ovaries).
➡️ Transdermal (through the skin)
Transdermal hormone therapy delivers estrogen through the skin and into the bloodstream. There are three different medication forms.
✅ Skin patches
Active ingredient: Most patches contain estradiol only. Some patches, such as Combipatch or Climara Pro, contain estradiol with a progestin.
General use: One patch is applied to the skin. Depending on the specific patch product, patches need to be replaced either once-weekly or twice-weekly (such as Monday and Thursday).
- Patches are placed on the stomach (below your belly button). Some patches can also be worn on the upper part of the butt cheeks. Read your product’s instructions carefully.
- When you change out patches, the new patch should be applied to a different skin area than where the last patch was placed.
- You can wear the patch while showering or swimming.
Dosages: Each patch contains a specific dose listed as the daily amount of estrogen released into the body.
- Patches come in many strengths. The standard daily dose range is 25 to 100 micrograms (0.025 to 0.1 milligrams).
- Your prescriber will usually start you on a lower dose and then increase your dose up to the maximum recommended amount if needed for symptom relief.
Benefits:
- You only need to remember your dose once or twice weekly.
- Patches are easy to take with when traveling.
- They’re inexpensive and widely available in generic forms.
Drawbacks:
- The adhesives (glues) in patches may cause skin irritation in some people.
- Finding an area of skin free from irritation or rashes where the patch can be applied may be difficult for some people.
✅ Topical skin spray
Active ingredient: estradiol
General use: The cone-shape applicator is pressed to the skin of the inside part of your forearm (near your elbow) and then the spray pump bottle is pressed.
- Additional sprays should be applied to non-overlapping sites on your skin.
- You’ll need to wait at least 2 minutes before covering the sprayed area with clothing.
- Waiting at least an hour before getting the skin area wet is also recommended.
Dosages:
- Each spray product has specific dosing recommendations listed by the number of sprays per day.
- Most people start with a lower dose. If needed for symptom relief, the dose may be gradually increased up to the maximum, waiting at least a week between dose increases to give the lower dose time to work.
- Evamist is the only spray option available in the U.S. Its dosing is 1 to 3 sprays per day. In the UK, Lenzetto is the trade name for an available estradiol spray used for menopause.
Benefits:
- Dosing is flexible and can be adjusted without needing a new prescription.
- Using the spray is mess-free and doesn’t get on your hands.
- Quick drying — topical sprays dry faster than gel forms.
Drawbacks:
- Evamist is only approved to treat bodywide menopausal symptoms (not vulva or vaginal symptoms).
- Spray bottles may be less convenient to carry when traveling.
- Some pharmacies might not have it in stock.
- May cost more than pills or patches.
- There’s a chance people or pets could be exposed to estradiol if they have direct close contact with your forearm where the spray was applied. It’s possible that estradiol could get into their bodies and cause hormonal effects.
✅ Topical skin gel
Active ingredient: estradiol
General use: Apply one pump of gel (or entire contents of single-use packets) to your skin, rubbing the gel in with fingers. Wash hands right away after applying. Follow your product’s instructions carefully.
- Elestrin and Estrogel are multi-use pump bottles. These gels are applied to the arm, although Elestrin should only be applied to the upper portion of the arm.
- Divigel comes in single-use packets and is applied to the upper thighs.
- With gels, a longer waiting period is usually needed before covering the applied area with clothing (up to 5 minutes) and getting the skin area wet (at least 2 hours).
Dosages: The amount of estradiol in each pump or packet varies. For example, Estrogel contains more estradiol per pump than Elestrin. The single-use Divigel packets, however, are available in many different strengths.
Benefits:
- Single-use packets are easy to carry when traveling.
- Topical gels have more products to choose from compared with the topical spray form.
Drawbacks:
- Only Estrogel is approved to also treat vulva and vaginal symptoms related to menopause.
- May be messier to apply than spray.
- Some pharmacies might not have your product in stock.
- May cost more than pills or patches
- People or pets could be exposed to estradiol if they have direct close contact to your skin where the gel was applied. It’s possible that estradiol could get into their bodies and cause hormonal effects.
➡️ Oral tablets
Active ingredient: The active ingredients depend on the specific medication.
✅ Estrogen-only oral tablets contain estradiol (Estrace) or conjugated estrogens (Premarin).
✅ Estrogen plus progestin oral tablets contain estradiol, ethinyl estradiol, or conjugated estrogens with a progestin (progestin type varies by product).
✅ Estrogen plus progesterone oral capsules (Bijuva) contain estradiol and progesterone.
✅ Duavee is an estrogen hormone therapy option for someone who has a uterus but is unable to tolerate progestins or progesterone. Each tablet contains conjugated estrogens with bazedoxifene (a medication that protects the uterus from estrogen).
General use: Pill forms of menopause hormone therapy all come as once-daily tablets you take by mouth.
Dosages: Doses vary by product and products come in multiple strengths. Your clinician will help you find a dose that’s safest for you and helps with your symptoms.
💡Your clinician will adjust your hormone therapy dose based on your symptoms, rather than hormone blood levels. There’s no “optimal” blood level of estrogen that menopause hormone therapy is used to maintain. What’s more, estrogen levels fluctuate and vary from person to person. Learn more about why hormone blood tests aren’t routinely recommended in this TNG post by nerdy girl and OB-GYN Dr. Katherine Cartwright.
Benefits:
- There are lots of medication types and strengths to choose from.
- Most oral tablets are inexpensive and widely available.
- There are no administration steps to learn.
- Tablets are small and easy to take with you.
Drawbacks:
- Some risks of estrogen, such as blood clots, may be higher when estrogen hormone therapy is taken by mouth.
- Estrogen absorption from the gut may be less consistent and impacted by other medications or conditions, like diarrhea.
💡If you haven’t reached menopause yet, your clinician might instead suggest a low-dose combination birth control pill. They provide pregnancy prevention and contain estrogen that may help with symptoms during perimenopause. Plus, oral contraceptives may help control menstrual bleeding. Your clinician can help weigh the risks and benefits and discuss other birth control options if needed.
➡️ Vaginal rings (Femring)
Note: Only higher-dose vaginal rings like Femring count as systemic forms of hormone therapy that can treat both vaginal symptoms and bodywide ones like hot flashes. Lower-dose vaginal rings like Estring are only approved for vaginal symptoms.
Active ingredient: Estradiol acetate
Dosages: Femring comes in two strengths. Each vaginal ring lasts 90 days and is designed to release a small amount of estrogen each day while it’s inside the vagina.
General use: Using your fingers, place one ring up inside your vagina as far as you can reach. Remove the ring every 90 days and replace it with a new one. Read your product’s instructions carefully.
Benefits:
- Only need to remember to replace it every 3 months.
Drawbacks:
- May be difficult for some people to insert (or remove) properly.
- Rings may fall out during sexual intercourse or if vaginal muscles are weak.
- Only comes in two doses.
- May cost more than a pill or patch.
➡️ Long-acting injection
Active ingredient: Estradiol cypionate (Depo-estradiol) or estradiol valerate (Delestrogen)
General use: Injections are given in a medical setting every 3 to 4 weeks.
Hormone therapy injections aren’t commonly prescribed since easier estrogen dosage forms are available that you can take at home.
➡️ What about compounded hormone therapy?
With so many FDA-approved hormone therapy medications for menopause, there’s rarely a need to use products from compounded pharmacies. Compounded medications may use hormones or formulations that haven’t been widely studied. Plus, there are fewer safeguards to protect you from products that may be contaminated or improperly made.
Finding a treatment that helps your menopause symptoms may take time. In addition to hormone therapies, there are non-hormonal medications and non-medication treatments that may help. It’s also important that your clinician looks into other possible causes if you have symptoms that aren’t getting better.
Just know, you’re not alone. And no, menopause is not a disease. Nearly one billion people living today have gone through menopause. Finding ways for us to be better informed, supported, and included as our bodies change can make the world a better place, one by one.
Stay hormone-informed. Stay aware of options. And know, you’re not alone.
Further reading:
Check out this TNG post by certified nurse practitioner MK Haber: Hot flashes and mood swings in perimenopause! Make ‘em go away!
And this must-read TNG post by health communicator Ashley Sever: Are you caught up? 8 health screenings for women and people assigned female at birth that can’t wait.
Hormone therapy: Four things a Mayo Clinic women’s health specialist wants you to know
4 Things to Know About Early and Premature Menopause
Why Menopause-Friendly Workplaces Are Better For Everybody
It’s time to stop treating menopause like a disease, researchers argue in series of Lancet articles
