Menopause and Hormone Replacement Therapy (HRT) - Should I or shouldn't I?

Janet is a 57-year-old female who was referred to pelvic floor physical therapy after searching online for solutions to painful intercourse. During her initial examination, her physical therapist asked if she was taking any hormone replacements. Janet’s physician had never brought it up, so she assumed she didn’t need any. Her PT explained that hormone replacement, specifically vaginal estrogen, can be helpful to address pain intercourse concerns in addition to pelvic PT.  

Menopause results in decreased sex hormones that causes changes in the labia major and minora (“outside” and “inside” lips), clitoris, introitus (opening of the vagina), vagina, urethra, and bladder. Women may experience vaginal dryness, burning, irritation, lack of lubrication with arousal, discomfort or pain with intimacy, urinary urgency, and recurrent urinary tract infections (UTIs).1 The healthy, good vaginal bacteria (microbiome) lessen due to lack of estrogen. Most women will live 40% of their lives post-menopause, which means it is vitally important to address concerns with this major life change!1 

Hormone replacement therapy (HRT) can be used to treat symptoms of menopause resulting from the reduction in hormones. HRT can be estrogen and progesterone combined or estrogen only. It can be administered a handful of ways including orally, patch, implant, and topically either on the skin or inside the vagina. Depending on the way HRT is administered to the body, different outcomes can be expected.  

According to the North American Menopause Society (NAMS) and International Menopause Society, vaginal estrogen is considered the first recommendation for symptoms of vulvar, vaginal, and urethral changes that may accompany menopause. 1 Most will agree that women should be treated with the lowest dose and frequency that effectively manages their symptoms. If symptoms are limited to the vulvovaginal area than vaginal treatment is usually recommended as compared to systemic or fuller body treatment like oral medication. Vaginal estrogen has been found to improve vaginal lining (think better vaginal “skin” health), reduce vaginal pH (this is good!), improve comfort with intimacy especially insertion, reduce vaginal dryness, and improve urethral/bladder symptoms, such as urinary urgency and frequency, with minimal to no side effects. 1 Also, women who are peri-menopausal and post-menopausal should be recommended to use vaginal estrogen to reduce the risk of UTIs, especially those that have suffered from recurring infections.2 Keep in mind, oral or other systemic estrogen therapy, such as the patch, have not been shown to reduce UTI. In most cases, you can use vaginal estrogen in addition to other forms of estrogen therapy if needed.2  

Hormone replacement therapy can have other benefits. For example, cardiovascular disease (CVD) is the number one cause of death for women in the U.S.3 Estrogen provides a protective effect against CVD by keep our blood vessels healthy. This protective benefit stops after menopause when estrogen declines and CVD risk increases. When hormone replacement therapy is used in women less than 60 years old and/or less than 10 years since menopause, it significantly reduces mortality and cardiovascular disease. It also reduces menopausal symptoms, reduces new onset diabetes, prevents osteoporosis and bone fracture, improves quality of life, and is cost effective. Negative reactions to hormone replacement therapy, such as breast cancer and stroke, are rare. In fact, less than 10 in every 10,000 women with experience an adverse reaction which is comparable to medications such as statins, aspirin, and calcium channel blockers.3 

For those who are worried about gaining or maintaining strength in menopause, hormone therapy has been found to reduce the loss of muscle power and size as compared to women who were not on hormone therapy.4 

Many women I work with are concerned about the risks of hormone replacement therapy, especially with a history of breast cancer. This is a valid concern since breast cancer is the most common cancer in U.S. women.5 According to NAMS (North American Menopause Society) and the International Society for the Study of Women’s Sexual health, women with breast cancer or at high risk of developing breast cancer should be offered non-hormonal therapies initially. These could include lubricants, moisturizers, dilator therapy, and pelvic floor physical therapy as first treatment approaches. However, both The American College of Obstetricians and Gynecologists and The American Society of Clinical Oncology consider vaginal estrogen, specifically low dose, to be an appropriate treatment option when non-hormonal treatments fail even in “patients with a history of estrogen-dependent breast cancer”.5 The reason for this is most forms of vaginal estrogen allow for the amount in the blood to remain within a normal, menopausal range.6 Basically, if estrogen is applied vaginally, it will stay more vaginally.6 

So, if you are in perimenopause or post-menopause, discuss the benefits of adding hormone replacement therapy with your medical provider, especially if you are experiencing any vaginal or urethral symptoms like dryness, leakage or frequent UTIs. Also, don’t be surprised if your pelvic floor therapist brings up this type of treatment – it can be a wonderful addition to your treatment plan to address your concerns! 

Written by Jordan Schmidt, PT, DPT 

References 

1. Kagan, R., Kellogg-Spadt, S., & Parish, S. J. (2019). Practical Treatment Considerations in the Management of Genitourinary Syndrome of Menopause. Drugs & aging, 36(10), 897–908. https://doi.org/10.1007/s40266-019-00700-w 

1. Anger J, Lee U, Ackerman AL, et al. Recurrent uncomplicated urinary tract infections in women: AUA/CUA/Sufu guideline. Journal of Urology. 2019;202(2):282-289. doi:10.1097/ju.0000000000000296 

1. Hodis, H. N., & Mack, W. J. (2022). Menopausal Hormone Replacement Therapy and Reduction of All-Cause Mortality and Cardiovascular Disease: It Is About Time and Timing. Cancer journal (Sudbury, Mass.), 28(3), 208–223. https://doi.org/10.1097/PPO.0000000000000591 

1. Lee, D., & Schroeder, E. (2016). Resistance training improves cardiovascular health in postmenopausal women. Menopause, 23(11), 1162-1164. 

1. Kagan, R., Kellogg-Spadt, S., & Parish, S. J. (2019). Practical Treatment Considerations in the Management of Genitourinary Syndrome of Menopause. Drugs & aging, 36(10), 897–908. https://doi.org/10.1007/s40266-019-00700-w 

1. Krause, M., Wheeler, T. L., Richter, H. E., & Snyder, T. E. (2010). Systemic effects of vaginally administered estrogen therapy: a review. Female pelvic medicine & reconstructive surgery, 16(3), 188.