Detailed definition
Hormone replacement therapy is the most effective treatment for moderate-to-severe vasomotor symptoms and is approved by the FDA for vasomotor symptoms, GSM, and prevention of postmenopausal osteoporosis. Modern HRT comes in many forms: estradiol patches, gels, sprays, oral tablets, vaginal rings, vaginal tablets and creams; oral or vaginal micronized progesterone; combination patches; and synthetic progestin-containing products. Transdermal estradiol is preferred over oral when feasible because it bypasses first-pass hepatic metabolism, avoiding the modest increase in venous thromboembolism risk seen with oral estrogen. For women with a uterus, a progestogen is required to protect the endometrium; bioidentical micronized progesterone (Prometrium) is widely used both for endometrial protection and for its sleep-promoting allopregnanolone metabolite when dosed at bedtime. The 2022 NAMS Position Statement supports HRT as the most effective treatment for VMS and GSM and concludes the benefit-risk profile is favorable for women under 60 or within 10 years of menopause without contraindications.
Why it matters in menopause
For most healthy women under 60 with menopausal symptoms, HRT remains the most effective evidence-based treatment. The risk picture for women starting HRT in the timing window with bioidentical transdermal estradiol differs substantially from the picture conveyed by 2002 WHI headlines, which used older oral conjugated equine estrogens plus medroxyprogesterone in older women.