Ask The Expert: Hormone Replacement Therapy and Bone Health

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In this article, Dr. Osiecki, a board-certified Internal Medicine physician with Midi Health, shares her expertise on hormone replacement therapy (HRT) for menopause. With over 25 years of experience in women's health and a focus on osteoporosis prevention, she offers a deep dive into the benefits, tailored approaches and informed choices surrounding HRT for managing menopausal symptoms and bone health.

Disclaimer: If you have any medical questions or concerns, please talk to your healthcare provider. The articles on Well Guide contain information from peer-reviewed research, medical societies and governmental agencies; however, these articles are not a substitute for professional medical advice, diagnosis, or treatment.

What is hormone replacement therapy (HRT)?

Hormone replacement therapy is a type of medication used to treat menopausal symptoms brought on by changes in hormone levels. It works by releasing estrogen into the bloodstream or vaginal tissue, and is available in different forms, including pills, patches, vaginal rings, and topical creams and gels. To protect the uterus (in patients who have not had theirs removed), doctors add progesterone or progestin to estrogen, which reduces any risk of uterine cancer. 

Who usually needs HRT?

If you’ve reached menopause, naturally or because of medical treatment, and are experiencing symptoms, HRT could be for you. Hormone replacement therapy has been shown to be the most effective treatment for relieving menopausal hot flashes and night sweats, and offers significant relief from vaginal dryness, and recurrent urinary tract infections. HRT can also help with insomnia, mood changes, and brain fog. 

Always remember that taking HRT is an individual choice. If you prefer not to use hormones, there are plenty of options available for managing menopause symptoms, including non-hormonal prescription meds, supplements, wellness therapies (think acupuncture or cognitive behavior therapy), and healthy lifestyle changes—recommended for everyone, whatever treatment plan they pursue. 

Because HRT can slightly increase the risk of blood clots, your doctor should do a thorough review of your health history before prescribing HRT. If you have a history of stroke or certain types of blood clots, some types of heart or liver problems, cancer that might be stimulated by hormones (including some kinds of breast and uterine cancer), or are currently dealing with unexplained vaginal bleeding, non-hormonal treatments may be best for you. It’s important to partner with a trained clinician who can personalize your treatment. (I am part of a team of clinicians providing this kind of care virtually for Midi Health.)

When do people usually go on HRT – before, during or after menopause?

You can begin HRT at the very first sign of menopause symptoms, even if you’re in perimenopause and still getting your period. And when started within 10 years of a woman’s last period, the benefits of HRT generally outweigh the risks. What are those benefits, besides symptom improvement? Better heart health and stronger bones (much more on that in a minute).

How long you’re on HRT is up to you and your doctor. Some women use HRT to get over the worst of their symptoms, then go off, while others feel so fantastic on HRT that they choose to not stop taking it. 

What role does HRT play in bone health?

Research shows that when women start hormone replacement therapy within 10 years of their last period, not only do they experience significant relief from menopausal symptoms but they also have a lower risk of bone loss (Cagnacci, 2019; Gambacciani, 2014). That’s because estrogen plays a major role in keeping bones healthy and strong. 

In the years right around menopause, estrogen levels drop and women can lose 2-3 percent of their bone mass each year for several years. This decline in bone mass after menopause can lead to osteopenia—a mild decrease in bone density—or osteoporosis, a more severe loss of bone density that dramatically raises the risk of fractures. But being on HRT causes estrogen levels to increase, helping to prevent bone loss and reducing the chance of breaking a bone or developing osteoporosis. In fact, hormone therapy is FDA-approved for women with osteopenia to prevent the progression to osteoporosis.

If I’ve been diagnosed with osteopenia or osteoporosis, will I need HRT?

This should be a shared decision between you and your doctor. Women with osteopenia may choose to use hormone therapy—in addition to other osteopenia treatments—to help prevent the progression to osteoporosis. While HRT is not FDA-approved for the treatment of osteoporosis, if a woman with osteoporosis takes HRT for hot flashes, night sweats, vaginal dryness, or other menopause symptoms, she may get an added bone health benefit. 

Do I need any other treatment for bone health if I am taking HRT? 

Since women loose bone density during menopause, the more you can do for your bones, the better! All women should aim to get 1000-1200 mg of calcium daily, take 800 IU/day of vitamin D, and participate in regular weight-bearing exercise (like walking, dancing, and doing squats and planks). It’s also important to continue to monitor your bone health using bone density scans while taking HRT. Your doctor can help determine if you’re due for a screening. 

Does HRT have any side effects?

Most women who start hormone therapy enjoy relief of menopause symptoms and feel well, but side effects such as nausea, headache, breast tenderness, vaginal bleeding, and changes in mood can occur. Most of these go away quickly as the body adjusts to the added estrogen. If your side effects are severe or long-lasting, talk with your doctor. Changing your HRT dose or switching to a different form (from the pill to a patch, for example) may solve the problem.

What else do you wish people knew about HRT?

Hormone replacement therapy can be a game-changer for women during midlife. Most women who start HRT within 10 years of their last period enjoy a reduction in risk of heart disease and type 2 diabetes and improved bone health—and that’s in addition to getting relief from often miserable menopause symptoms! But like I mentioned, HRT isn’t for everyone. The bottom line is that women deserve the chance to discuss their options with a knowledgeable clinician and personalize their approach to managing menopause symptoms. At Midi, that’s our mission!

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  1. Cagnacci A, Venier M. The Controversial History of Hormone Replacement Therapy. Medicina (Kaunas). 2019;55(9):602. doi:10.3390/medicina55090602
  2. Gambacciani M, Levancini M. Hormone replacement therapy and the prevention of postmenopausal osteoporosis. Prz Menopauzalny. 2014;13(4):213-220. doi:10.5114/pm.2014.44996

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