Common Menopause Hormone Therapy Side Effects And How to Manage Them

Hormone therapy is a common treatment for women experiencing symptoms of perimenopause and menopause, with benefits well-supported by current science. If you’re on social media, you’re probably used to hearing a LOT about its perks (of which there are many!) but, like any medication, hormone therapy can come with side effects. We’re taking a look at the most common side effects, how to mitigate them, and what’s cause for concern.

Hormone therapy 101

Our ovaries are responsible for the production of a few key hormones, including estrogen and progesterone. During perimenopause, production begins to fluctuate and progressively decline, which can cause a whole host of symptoms.

Menopause hormone therapy or MHT (previously referred to as hormone replacement therapy/HRT) involves taking a supplemental form of estrogen and/or progesterone to treat those symptoms, and can look like:

1. Estrogen therapy alone. Estrogen-only therapy is commonly used for women who have had a hysterectomy.
2. Combination estrogen and progesterone therapy. If you have a uterus, your hormone therapy regimen will typically involve a combination of estrogen and an additional medication to protect your uterus, like progesterone. If someone who has a uterus uses estrogen alone for a long period of time without progesterone (or other uterine protection), it can cause thickening of the uterine lining, which can increase the risk of endometrial cancer, a type of uterine cancer.

Hormone therapy is proven to help with vasomotor symptoms of menopause (hot flashes and night sweats). For some people, it might help with additional menopausal symptoms like mood swings, brain fog, and low energy. It’s also recommended for women who experience early menopause, and others who have a significant risk of osteoporosis.

Local vaginal estrogen is another form of MHT, prescribed specifically for vaginal symptoms like UTIs and vaginal dryness. Unlike the types of systemic hormone therapy listed above, the actual dose of estrogen is much lower and it doesn’t enter into the bloodstream when applied as directed. Therefore, it doesn’t come with the same side effect risks. So, for the purposes of this discussion, we’re focusing on systemic MHT side effects.

READ MORE: Is Vaginal Estrogen Safe? What The Science Says.

What are the most common side effects of systemic hormone therapy?

You may notice that some of these side effects overlap with actual symptoms of menopause. Annoying, we know, but makes sense —hormones influence our entire body! The good news is, most of these improve after a few months, and in the meantime, there are adjustments you can make at home.

1. Vaginal bleeding

Irregular bleeding and spotting is common when first beginning menopause hormone therapy, and it typically subsides in 3–6 months. Different types of hormone therapy are associated with different bleeding patterns:

Sequential hormone therapy: This is a regimen sometimes considered for women who are still menstruating. It involves taking estrogen every day, and progesterone for part of the month, to mimic a natural period. (Sort of like the “sugar” pill week in an oral birth control pack). With this type of hormone therapy, irregular bleeding can be common when starting out.

Continuous hormone therapy: This is when you take estrogen and progesterone together every day. With this type of hormone therapy, light spotting is not uncommon in the beginning.

2. Headaches

Estrogen is usually the main driver when it comes to hormone-related headaches. In fact, many people experience new or worsening migraine headaches in particular during perimenopause, and MHT can be very helpful.

But, like we said earlier, side effects of hormone therapy can overlap with menopause symptoms, and some people do experience headaches or migraines when starting MHT. For most patients, they’ll settle down within a few months as the brain adjusts to the new hormone levels. In the meantime, the following micro-adjustments can make a big difference:

• Staying hydrated
• Maintaining regular meals
• Keeping caffeine intake steady (we’re looking at you 4pm latte treat)
• Prioritizing sleep
• Over-the-counter pain medication

3. Nausea

Nausea is most commonly associated with estrogen. Oral estrogen in particular tends to cause more nausea than the estradiol patch or gel because it goes through the liver first. Similar to headaches, nausea often improves as the body adapts over a few months. What helps?

• Taking oral estrogen with food or at bedtime
• Opting for smaller, more frequent meals
• Avoiding strong smells or trigger foods.

4. Bloating

Oral progesterone is the culprit for most people who experience bloating with MHT, but it typically improves within a few months. Probiotics can sometimes help, but for people who are particularly sensitive, they can potentially make things worse, so we recommend starting slow. What else helps?

• Hydration!
• Simethicone (an over-the-counter medicine that can help with gas and bloating)
• Ginger tea

READ MORE: What To Look For When Selecting a Supplement

5. Breast tenderness

Breast pain and tenderness can be a particularly uncomfortable side effect of estrogen and progesterone therapy. If you experience new breast pain or tenderness upon starting MHT, we recommend:

• Wearing a supportive, well-fitted bra
• Limiting salt intake, which can increase fluid retention
• Over-the-counter pain relievers like ibuprofen and/or acetaminophen

RELATED: Mammograms During Menopause: Type, Frequency, What To Expect & More

When to talk to your clinician

If you’re taking MHT, you’re hopefully already seeing a clinician, and it’s important to keep them informed of any side effects you’re experiencing. But what if you’re in between appointments? Should you wait it out until your next visit, or try to see them sooner?

This can be a tricky judgment call. As we mentioned, most of these symptoms occur upon initiation or adjustment of dosage and resolve within a few weeks. But, if any side effects seem to be worsening or aren’t getting better with time, it’s worth reaching out to your healthcare provider or moving up that appointment. Ultimately, you know your body best.

It can also be helpful to keep a log of when you’re experiencing symptoms to share with your provider, so that they have the full picture and can rule out other potential causes. If what you’re experiencing is a result of MHT, adjusting the dose or switching the formulation can sometimes do the trick.

Serious health risks are rare

Today, The Menopause Society considers MHT to be safe and effective for most women, especially when started prior to age 60 or within 10 years of menopause.

Current research suggests that the benefits far outweigh the risks for most people, but for a small number of women, MHT can increase risk of the following conditions:

• Blood clots
• Breast cancer
• Heart attack
• Stroke
• Gallbladder disease

Again, the actual incidence of these conditions as a direct result of hormone therapy is rare. A qualified women’s health specialist will take into account things like family medical history and preexisting health conditions, such as liver disease and some types of cancer, when making prescribing decisions.

Why medication formulation matters

Not all hormone therapy products are created equally. FDA-approved medications, which we prescribe at Elektra, have been subject to rigorous testing standards and are produced with meticulous attention to dosing and safety. Compounded medications, on the other hand — especially ones purchased directly from the internet — are not regulated by the FDA. This can mean products include filler ingredients and inconsistent dosing, which may put patients at increased risk of side effects.

FAQs

Will hormone therapy cause weight gain?

Weight is a common concern around this time, but significant weight gain from hormone therapy specifically is rare. Factors like sleep, genetics, and cardiometabolic shifts as a result of aging are much more influential. Sleep hygiene, a balanced diet, and regular exercise can be very effective. For prolonged weight challenges or metabolic dysfunction, GLP-1s are also an option.

But I’ve heard that hormone therapy causes breast cancer. Is this true?

As we discussed earlier, serious side effects from MHT are rare. That said, the misconception that hormone therapy causes breast cancer or dramatically increases breast cancer risk for all women has been particularly hard to dispel.

In 2002, a large study suggested that MHT can lead to a significantly increased risk of breast cancer and heart disease. The media hyped the findings and alarmed the public, including women and their clinicians. In the years since then, comprehensive reevaluation of the research has led to a better understanding of the original findings.

Hundreds of follow-up studies and clinical trials have been conducted by reputable institutions on the safety and efficacy of MHT for treating menopause symptoms. Today, The Menopause Society considers MHT to be safe and effective for most women. For perimenopausal and postmenopausal women taking MHT, it’s important to stay up-to-date with regular breast cancer screening.

How long should a woman be on hormone replacement therapy?

Previously, the recommendation for MHT prescribing was the most low dose possible for the shortest amount of time, to maximize benefit from treatment while limiting risk of side effects. While this approach is still typically recommended, the guidelines have been revised in recent years to accommodate more individualized prescribing — including longer duration.

For instance, many women experience hot flashes and night sweats due to fluctuating hormone levels in perimenopause, but some continue to experience them postmenopause. It’s well-established that hormone therapy is THE gold standard for vasomotor symptoms. In fact, a retrospective analysis presented at the 2024 Annual Meeting of The Menopause Society found that hot flashes were a major reason that the participating cohort of women continued MHT into their 70s, and even 80s.

The reality is, symptoms of menopause can significantly impact quality of life, and they are unfortunately not easily mapped over a specific number of years. The highly variable nature of menopause requires an individualized approach to treatment, which is why working with a healthcare professional trained specifically in menopause (like Elektra’s clinicians!) is so important.

READ MORE:

• Elektra’s Take: Is Bioidentical Hormone Therapy Safer for Menopausal Women?
• Progesterone vs Progestin: What’s The Difference?
• Surgical Menopause Symptoms: What To Expect After a Hysterectomy
• 5 Non-Hormonal Treatment Options For Hot Flashes
• Bone Loss and Osteoporosis in Menopause

This information is for general educational purposes, and should not be used as a substitute for medical advice, diagnosis, or treatment of any health condition or problem.