Starting HRT: When to Start and What to Expect

Changes in ovarian function that occur during the menopause transition can cause uncomfortable symptoms that impact daily life. Hormone replacement therapy (HRT) can help women manage symptoms of perimenopause and menopause by increasing levels of sex steroid hormones that fluctuate during this phase of life.

The timing of when a woman starts HRT may influence the potential benefits and risks of treatment.⁽¹⁾ Knowing the signs of when it may be beneficial to start HRT is equally as important as knowing what to expect in the weeks and months after starting treatment.

What is hormone replacement therapy (HRT)?

HRT is a treatment that supplements hormone levels in a woman’s body that decline throughout different stages of menopause. These natural physiological changes can cause a variety of symptoms affecting physical, psychological, and sexual well-being.

HRT may be prescribed for some women during this stage of life because it’s considered the most effective treatment for menopausal hot flashes, night sweats, and vulvovaginal symptoms. Treatment may also reduce the risk of osteoporosis, which increases during menopause due to hormonal changes that cause a loss of bone mineral density.⁽¹⁾

Depending on individual health needs, HRT may involve supplementation of different hormones, such as

• Estrogen

• Progesterone

• DHEA (to increase testosterone levels)

For women with an intact uterus, progesterone is typically prescribed with estrogen to protect against endometrial hyperplasia and endometrial cancer. HRT formulations may be made with synthetic or bioidentical hormones, the latter of which are identical to the chemical structure of the body’s natural hormones. With compounded bioidentical hormones, there’s also potential for individualized dosing.⁽¹⁾

Estrogen is the primary hormone in HRT and may be prescribed in the following dosages:⁽¹⁾⁽²⁾

• Ultra-low dose

• Low dose

• Standard dose

Treatment options include systemic HRT (affecting the whole body) or localized HRT (treating specific areas of the body). Treatment can be administered in the following forms:⁽¹⁾⁽³⁾

• Systemic oral medications: tablets or capsules

• Systemic transdermal HRT: patches, sprays, gels, or body creams

• Topical localized products: vaginal creams or facial creams with tretinoin

• Systemic or localized vaginal rings

When to Start Hormone Replacement Therapy

Women go through the menopause transition at different ages and may, therefore, start HRT at different times. The majority of women enter perimenopause between the ages of 45 and 55, with most reaching menopause at the average age of 52.⁽⁴⁾ Women who are experiencing symptoms of perimenopause or menopause, such as hot flashes, vaginal dryness, or low libido, are encouraged to consult with a doctor about the possibility of starting HRT

Because some forms of HRT may increase the risk of blood clots, coronary heart disease, or breast cancer in higher-risk patients, HRT may not be recommended for those with certain health conditions. However, these side effects are rare, and recommendations from The Menopause Society state that risks may be lower when HRT is initiated before the age of 60 or within 10 years of entering the menopause transition.⁽¹⁾

Postmenopausal women can still benefit from HRT, although the risk of adverse effects may be higher if they begin treatment after the age of 60 or more than 10 years after the onset of menopause.⁽¹⁾ A doctor will consider factors like age, menopause status, symptom severity, and medical history when determining if HRT is recommended for a patient.

What to Expect When Starting HRT

Some women may experience the following side effects after starting HRT:⁽¹⁾

• Breast tenderness

• Nausea

• Weight gain

• Bloating

• Fluid retention 

• Mood changes

• Headaches

• Breakthrough bleeding 

It’s recommended to start with the lowest effective dose to reduce potential side effects. If side effects do not resolve, a doctor may recommend adjusting the formulation, dosage, or route of administration. For example, a patient experiencing nausea may respond more favorably to a transdermal patch than an oral capsule or tablet.⁽⁵⁾

How quickly women experience improvement in menopausal symptoms can vary. Some patients may feel the effects within two weeks, while it may take a few months for others to see the benefits of HRT.

Periods and Bleeding After Starting HRT

Some women may experience breakthrough bleeding in the months after starting HRT. This may involve changes in bleeding frequency or duration and may be referred to as unexpected bleeding, unscheduled bleeding, or abnormal bleeding. Research shows the differences between breakthrough bleeding related to HRT use and menstrual bleeding. Two-thirds of the uterine lining is shed during menstruation, while only the upper layer of the uterine lining is shed in cases of HRT-related bleeding.⁽⁶⁾Why uterine bleeding may occur with HRT use isn’t entirely clear, although it may be influenced by dose, formulation, and route of administration. Breakthrough bleeding tends to be less common with oral HRT than with transdermal HRT. However, some women may be more prone to abnormal bleeding with oral HRT if they’re new users, perimenopausal, diagnosed with certain gastrointestinal disorders, and/or taking certain medications.⁽⁶⁾⁽⁷⁾Age and time since menopause may also influence the risk of breakthrough bleeding after starting HRT. Research suggests that uterine bleeding may be less common among postmenopausal women compared to perimenopausal women.⁽⁷⁾ 

Breakthrough bleeding tends to improve over time with HRT use. However, women who experience bleeding or spotting that persists for six months or more after starting HRT should consult with their doctor.⁽¹⁾⁽⁶⁾

What if HRT isn't working or is causing issues?

It’s recommended that women continue HRT for as long as needed to effectively treat symptoms and improve quality of life. However, there are cases in which a woman and her doctor may decide to discontinue treatment. This may be due to unpleasant side effects, no improvement in symptoms, or the development of health issues that increase the risk of adverse effects with HRT. A doctor may first try adjusting the medication depending on what’s causing the issue.⁽¹⁾⁽⁸⁾Recommendations to continue or discontinue HRT should be individualized. Stopping HRT may produce side effects, including hot flashes or an accelerated loss of bone mineral density. Although there’s little evidence regarding the most effective way to go about stopping HRT, a doctor may sometimes recommend gradually tapering off the medication.⁽¹⁾

The Importance of Communicating Treatment Goals to a Doctor

If a woman has entered the menopause transition and is experiencing bothersome symptoms, she may be eligible for HRT. While there’s no set age at which it’s recommended to start treatment, the risk of adverse effects may be lower for menopausal women who start HRT at an earlier age or soon after menopause onset. However, the timing of initiating HRT is unique to each person and should ultimately be decided upon with a doctor.

A healthcare provider can help women understand what to expect when starting HRT. With regular checkups, they can monitor the effectiveness of treatment and make adjustments as needed. Women can also take charge of their menopausal healthcare by communicating their health needs and treatment preferences to their doctor.

If you’re interested in learning more about HRT, take Winona’s eligibility quiz to see if HRT may be right for you.