Hormone Replacement Therapy in Chicago: A Practical Guide for Midlife Women

Hot flushes that arrive without warning. Sheets soaked at 3am. Snapping at someone you love and not knowing why. If this is familiar, you are moving through perimenopause or menopause, and hormone therapy is the most effective treatment available for it.

This guide covers what HRT is, the types available, who it suits, what the risks actually are at your age, and how long to stay on it.

What HRT is

Hormone therapy replaces some of the estrogen — and, if you have a uterus, the progesterone — that your ovaries have stopped producing.

If you have a uterus you need a progestogen alongside estrogen. This is not optional. Estrogen alone thickens the uterine lining and raises the risk of endometrial hyperplasia and cancer; the progestogen prevents that. If you have had a hysterectomy, estrogen alone is appropriate.

What it treats well

• Hot flushes and night sweats — the best-established benefit; nothing else works as well
• Genitourinary symptoms — vaginal dryness, pain with sex, recurrent UTIs
• Sleep disturbance, where it is driven by night sweats
• Bone loss — HRT is proven to prevent osteoporotic fracture
• Joint aches and mood symptoms for many, though the evidence here is less clean

It is not a treatment for depression, and it is not a weight-loss treatment.

The types, and why route matters

Estrogen:

• Transdermal — patch, gel, or spray. Absorbed through the skin, bypassing the liver, and therefore not associated with the increased clot risk that oral estrogen carries. This is the preferred route for anyone with clot risk factors, migraine, high blood pressure, high triglycerides, or obesity.
• Oral — convenient and effective, but carries a small increased risk of venous thromboembolism.
• Vaginal estrogen — cream, tablet, or ring. Treats genitourinary symptoms only, with minimal systemic absorption. Because so little enters the bloodstream, it can often be used by people who cannot take systemic HRT — including many breast cancer survivors, after discussion with their oncologist. It does not require a progestogen.

Progestogen:

• Micronised progesterone — structurally identical to what your body makes, and associated with a more favourable breast and cardiovascular profile than older synthetic progestins. Often better tolerated.
• Synthetic progestins — effective, sometimes better for bleeding control.
• The levonorgestrel IUD — provides endometrial protection while also managing heavy perimenopausal bleeding and contraception. An efficient choice if you need all three.

Regimen: if you are still having periods, a cyclical regimen produces a monthly bleed. Once you are past menopause, a continuous regimen avoids bleeding altogether.

On "bioidentical" hormones

This term causes real confusion, so it is worth separating.

Regulated bioidentical hormones — estradiol and micronised progesterone — are FDA-approved, available at any pharmacy, and are what most clinicians prescribe. "Bioidentical" simply means structurally identical to human hormones. This is mainstream treatment.

Compounded bioidentical hormone therapy (cBHT) is different: custom-mixed preparations, often pellets or creams, marketed as individually tailored. These are not FDA-approved, and the National Academies of Sciences, Engineering, and Medicine reviewed them and found insufficient evidence of safety or effectiveness, recommending they be restricted to people who genuinely cannot use approved products. Batch-to-batch dose consistency is not assured.

Salivary hormone testing to "customise" a dose is not valid. Levels fluctuate hourly and do not correlate with symptoms or with tissue effect. Dosing is guided by symptoms, not by saliva tests. Any clinic selling saliva testing plus custom pellets is selling something the evidence does not support.

Risks, in proportion

The Women's Health Initiative results in 2002 caused a collapse in HRT use, and much of the fear dates from initial reporting of that trial. The picture is now considerably better understood.

The timing hypothesis is the central point. Benefit-risk depends heavily on age and time since menopause. For healthy people who start under age 60 or within 10 years of menopause, benefits generally outweigh risks. Starting many years after menopause, particularly over 60, shifts that balance.

• Blood clots — increased with oral estrogen; not meaningfully increased with transdermal. This is the single most useful thing to know when choosing a route.
• Breast cancer — combined estrogen-progestogen therapy is associated with a small increased risk that rises with duration of use. In absolute terms it is comparable to the risk associated with drinking a little more alcohol or being less active. Estrogen-alone therapy in people without a uterus has not shown the same increase, and in the WHI showed a reduction.
• Stroke — a small increase with oral; lower with transdermal and with lower doses.
• Cardiovascular disease — starting within the window is not associated with increased coronary risk, and may be protective. Starting late is a different matter.
• Endometrial cancer — prevented by adequate progestogen. This is why the progestogen is not negotiable.

Who should be cautious

Systemic HRT is generally not appropriate with: current or past breast cancer; estrogen-dependent cancer; unexplained vaginal bleeding that has not been investigated; active or past blood clots or clotting disorders; active liver disease; a history of stroke or heart attack. Some of these are absolute, others are a discussion — vaginal estrogen in particular is often still possible.

How long should you stay on it?

There is no arbitrary stopping date. The old advice to stop at five years, or at a particular age, is no longer supported.

Current guidance is to use the dose that controls your symptoms, for as long as the benefits outweigh the risks for you, with that balance reviewed at least annually. Some people stop after two years; some continue into their sixties and beyond with ongoing review. Vaginal estrogen in particular is usually continued indefinitely, because symptoms return when it stops.

Stopping is best done by tapering rather than abruptly, which reduces symptom rebound.

Monitoring

• A baseline visit covering blood pressure, personal and family history, and current cancer screening.
• Review at 3 months — symptom control, side effects, bleeding pattern.
• Annually thereafter — blood pressure, symptoms, mammography and cervical screening on the usual schedule, and a review of whether to continue.
• Report any unexpected bleeding. Bleeding after 6 months of continuous therapy, or a change in an established pattern, needs assessment.

Routine blood hormone monitoring is generally unnecessary; treatment is titrated to symptoms.

Alongside HRT

None of this replaces treatment, but all of it improves how you feel and how HRT works:

• Resistance training twice a week — the highest-value intervention for midlife body composition and bone density.
• Adequate protein, spread across meals.
• Calcium and vitamin D for bone health.
• Reducing alcohol — a hot flush trigger, a sleep disruptor, and a breast cancer risk factor.
• Stopping smoking — it worsens hot flushes, accelerates bone loss, and raises clot risk.
• CBT for hot flushes has real evidence, and is an option if you cannot or prefer not to take hormones.

Non-hormonal prescription options exist too — SSRIs and SNRIs, gabapentin, oxybutynin, and newer neurokinin receptor antagonists such as fezolinetant.

Questions worth bringing to your appointment

1. Given my history, am I a candidate for systemic HRT?
2. Should I be on transdermal rather than oral?
3. Do I need a progestogen, and which one?
4. What should I expect in the first three months?
5. What bleeding is expected, and what should I report?
6. How will we decide whether to continue?
7. If HRT is not right for me, what else is available?

Talk to us

• HRT and weight changes
• Signs you may need HRT
• Menopause management
• Book an appointment online

Medical disclaimer

This article is general health information, not medical advice for any individual, and it is not a recommendation to start or stop treatment. Whether HRT suits you depends on your age, time since menopause, symptoms, and medical history. Unexplained vaginal bleeding — particularly after menopause — must be evaluated before starting hormone therapy.