Many patients with menopause symptoms are still undertreated in primary care, and symptoms are not always systematically documented or addressed.¹ One contributor is persistent concern shaped by the 2002 Women’s Health Initiative (WHI) findings, which have since been interpreted in a more individualized, age- and timing-dependent way.^2,3 Contemporary guidance supports menopausal hormone therapy as an appropriate option for many healthy, symptomatic patients who are younger than 60 years or within 10 years of menopause onset, while also emphasizing that hormone therapy should not be used broadly for chronic disease prevention.^3,5,7 The FDA has also approved labeling changes for several menopausal hormone therapy products to better clarify benefit-risk considerations.⁴

We recognize that hot flashes, night sweats, sleep disruption, mood changes, vaginal dryness, pain with intercourse, urinary symptoms, and sexual discomfort can profoundly affect quality of life.^5,7,11,20 SSRIs and SNRIs can help some patients, but they typically provide mild to moderate improvement in vasomotor symptoms and are not equivalent to systemic hormone therapy for appropriately selected candidates.⁶ Hormone therapy remains the most effective treatment for vasomotor symptoms such as hot flashes and night sweats.^5,6,7 We offer evidence-based hormone therapy using FDA-approved estradiol and progesterone options when appropriate, rather than defaulting to compounded or proprietary subscription-based products marketed as inherently safer despite lack of evidence that they are safer or more effective than FDA-approved options.^8,9,10

Vaginal Estrogen

For genitourinary syndrome of menopause (GSM), including vaginal dryness, painful intercourse, urinary urgency or frequency, and recurrent urinary symptoms, low-dose vaginal estrogen is an effective treatment option for moderate to severe symptoms and generally produces low systemic estradiol exposure compared with systemic hormone therapy.^11,12 Available forms include:

• Vaginal estrogen creams, including estradiol cream; conjugated estrogen cream is another FDA-approved option.^10,11
• Vaginal estradiol tablets or inserts.^10,11
• Low-dose vaginal estrogen rings, some of which provide continuous local estrogen therapy for approximately 90 days.^10,11

Low-dose vaginal estrogen can be used without systemic hormone therapy when GSM is the primary concern, and a progestogen is generally not required with low-dose local vaginal estrogen.¹¹ For most patients, low-dose vaginal estrogen has few contraindications, but patients with a history of estrogen-dependent cancer should use shared decision-making with their clinician and oncology team when appropriate.¹³

Systemic Estrogen

For systemic vasomotor symptoms, especially hot flashes and night sweats, systemic estrogen therapy is the most effective treatment available for appropriately selected patients.^5,6,7 It may also improve sleep disruption related to vasomotor symptoms and overall menopause-related quality of life.^5,7 Some patients report improvement in concentration or “brain fog” when night sweats and sleep disruption improve, but hormone therapy is not guaranteed as a treatment to prevent or treat dementia or as a general cognitive-enhancement therapy.⁷

We generally prefer transdermal estradiol, such as patches, gels, or sprays, over oral estrogen when clinically appropriate because observational evidence and biologic data suggest lower venous thromboembolism (VTE) risk than oral estrogen.^5,14,15 Oral estrogen undergoes first-pass metabolism through the liver and may increase prothrombotic markers, while transdermal estrogen has little or no effect on these markers.¹⁴ Available transdermal options include:

• Estradiol patches, including once-weekly and twice-weekly patch systems.¹⁰
• Estradiol gels applied to the skin.¹⁰
• Estradiol sprays applied to the skin.¹⁰

Progesterone

For patients who still have a uterus, a progestogen must be added to systemic estrogen to protect the endometrial lining and reduce the risk of estrogen-induced endometrial hyperplasia and endometrial cancer.^5,16,19 We prefer oral micronized progesterone, such as Prometrium or generic micronized progesterone, when clinically appropriate.^4,16 Adequately dosed oral micronized progesterone can provide endometrial protection, may improve some sleep outcomes, and may have a more favorable thrombotic profile than some synthetic progestins, though risks vary by patient, dose, route, and progestogen type.^16,17,18 We do not rely on compounded transdermal progesterone for endometrial protection because evidence does not support it for that purpose.¹⁶ Progesterone is available in combination patches with estrogen though there is a substantial price difference versus separate medications.

For patients who have had a hysterectomy, progesterone is usually not needed with systemic estrogen unless there is a specific clinical reason.^5,19

Our Approach

• Genitourinary symptoms only: Vaginal estrogen alone.^11,13
• Systemic symptoms with intact uterus: Transdermal estradiol plus oral micronized progesterone when clinically appropriate.^5,14,16
• Systemic symptoms, post-hysterectomy: Transdermal estradiol alone in most cases.^5,19
• Combination needs: Both vaginal and systemic therapy can be used when GSM persists alongside systemic symptoms.^5,11

Timing and Safety

Hormone therapy generally has the most favorable benefit-risk profile when initiated before age 60 or within 10 years of menopause onset, often described as the “window of opportunity.”^5,7 We screen for contraindications and higher-risk features, including unexplained vaginal bleeding, prior estrogen-sensitive cancer such as breast cancer, active liver disease, prior coronary heart disease, stroke, myocardial infarction, VTE, or known high-risk thrombophilia.^5,19

For many healthy, symptomatic patients in the appropriate timing window, benefits can outweigh risks when treatment is individualized by symptom burden, dose, formulation, route of administration, medical history, and patient preference.^5,7,14,15

We use FDA-approved estradiol and oral micronized progesterone products whenever possible. These are pharmacy-dispensed products with standardized dosing and regulatory oversight, and many are available as generic or branded prescriptions that may be covered by insurance depending on the plan.^8,9,10

Menopause is a normal life stage marked by declining ovarian hormone production, but “natural” does not mean symptoms should be ignored.²⁰ For symptomatic patients, evidence-based hormone therapy can substantially improve quality of life when prescribed thoughtfully, monitored appropriately, and individualized.

References

1. Bevry ML, Stogdill ER, Lea CM, et al. Addressing menopause symptoms in the primary care setting: opportunity to bridge care delivery gaps. Menopause. 2024;31(12):1044-1048. doi:10.1097/GME.0000000000002439
2. Writing Group for the Women’s Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA. 2002;288(3):321-333. doi:10.1001/jama.288.3.321
3. Manson JE, Crandall CJ, Rossouw JE, et al. The Women’s Health Initiative randomized trials and clinical practice: a review. JAMA. 2024;331(20):1748-1760. doi:10.1001/jama.2024.6542
4. US Food and Drug Administration. FDA approves labeling changes to menopausal hormone therapy products. Published February 12, 2026. Accessed June 7, 2026. https://www.fda.gov/news-events/press-announcements/fda-approves-labeling-changes-menopausal-hormone-therapy-products
5. The North American Menopause Society. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767-794. doi:10.1097/GME.0000000000002028
6. The North American Menopause Society. The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause. 2023;30(6):573-590. doi:10.1097/GME.0000000000002200
7. Lumsden MA, Dekkers OM, Faubion SS, et al. European Society of Endocrinology clinical practice guideline for evaluation and management of menopause and the perimenopause. Eur J Endocrinol. 2025;193(4):G49-G81. doi:10.1093/ejendo/lvaf206
8. Endocrine Society. Compounded bioidentical hormone therapy. Published October 2, 2019. Accessed June 7, 2026. https://www.endocrine.org/advocacy/position-statements/compounded-bioidentical-hormone-therapy
9. American College of Obstetricians and Gynecologists. Compounded bioidentical menopausal hormone therapy: ACOG Clinical Consensus No. 6. Obstet Gynecol. 2023;142(5):1266-1273. doi:10.1097/AOG.0000000000005395
10. US Food and Drug Administration. Menopause. Updated December 14, 2023. Accessed June 7, 2026. https://www.fda.gov/consumers/womens-health-topics/menopause
11. The NAMS 2020 GSM Position Statement Editorial Panel. The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause. 2020;27(9):976-992. doi:10.1097/GME.0000000000001609
12. Santen RJ, Mirkin S, Bernick B, Constantine GD. Systemic estradiol levels with low-dose vaginal estrogens. Menopause. 2020;27(3):361-370. doi:10.1097/GME.0000000000001463
13. American College of Obstetricians and Gynecologists. Treatment of urogenital symptoms in individuals with a history of estrogen-dependent breast cancer: Clinical Consensus No. 2. Obstet Gynecol. 2021;138(6):950-960. doi:10.1097/AOG.0000000000004601
14. American College of Obstetricians and Gynecologists. Postmenopausal estrogen therapy: route of administration and risk of venous thromboembolism. Committee Opinion No. 556. Obstet Gynecol. 2013;121(4):887-890. Accessed June 7, 2026. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2013/04/postmenopausal-estrogen-therapy-route-of-administration-and-risk-of-venous-thromboembolism
15. Mohammed K, Abu Dabrh AM, Benkhadra K, et al. Oral vs transdermal estrogen therapy and vascular events: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2015;100(11):4012-4020. doi:10.1210/jc.2015-2237
16. Stute P, Neulen J, Wildt L. The impact of micronized progesterone on the endometrium: a systematic review. Climacteric. 2016;19(4):316-328. doi:10.1080/13697137.2016.1187123
17. Nolan BJ, Liang B, Cheung AS. Efficacy of micronized progesterone for sleep: a systematic review and meta-analysis of randomized controlled trial data. J Clin Endocrinol Metab. 2021;106(4):e942-e951. doi:10.1210/clinem/dgaa873
18. Scarabin PY. Progestogens and venous thromboembolism in menopausal women: an updated oral versus transdermal estrogen meta-analysis. Climacteric. 2018;21(4):341-345. doi:10.1080/13697137.2018.1446931
19. American College of Obstetricians and Gynecologists. Hormone therapy for menopause. Accessed June 7, 2026. https://www.acog.org/womens-health/faqs/hormone-therapy-for-menopause
20. World Health Organization. Menopause. Published October 16, 2024. Accessed June 7, 2026. https://www.who.int/news-room/fact-sheets/detail/menopause