Estrogen Therapy in Women: Benefits, Risks, and Modern Options

Introduction

For many women, menopause brings a wave of new symptoms—hot flashes, night sweats, sleep problems, mood swings, vaginal dryness, and more. These changes are often driven by a natural decline in estrogen, a hormone that plays a vital role throughout a woman’s life.

Estrogen therapy can be a safe and effective way to relieve these symptoms and support overall health—but there’s a lot of confusion out there about who should use it, how it’s given, and what the real risks are. Let’s clear that up.

What Is Estrogen and Why It Matters

Estrogen isn’t just about reproduction. It affects nearly every system in the body:

Brain: Supports mood, sleep, and cognitive function
Bones: Helps maintain bone density and reduces fracture risk
Heart and blood vessels: Favors healthy cholesterol levels and vascular function
Muscles, skin, and hair: Influences tissue strength, elasticity, and hydration
Reproductive system: Regulates cycles, fertility, and vaginal health

There are three main forms of estrogen in the body:

Estradiol (E2): The primary and most potent form during reproductive years
Estrone (E1): More common after menopause
Estriol (E3): A weaker form often used in vaginal therapies

As menopause approaches, estrogen production from the ovaries drops significantly. This decline is what leads to many of the common menopausal symptoms.

When Estrogen Therapy May Be Recommended

Estrogen therapy isn’t just for hot flashes (though that’s one of the most common reasons). Doctors may recommend it for:

Menopausal symptom relief – Hot flashes, night sweats, insomnia, mood changes, and vaginal dryness
Bone health – Prevention and treatment of osteoporosis in appropriate candidates
Premature menopause or surgical menopause – Women who lose ovarian function early often benefit from replacing estrogen until the typical age of menopause
Urogenital symptoms – Vaginal dryness, discomfort with intimacy, and urinary tract changes

Estrogen Therapy During Peri-menopause: Why Timing Matters

Many women begin to experience menopausal symptoms years before their periods actually stop. This transitional phase is called peri-menopause, and it can last several years.

During this stage, progesterone levels typically decline before estrogen levels do, and here’s why: progesterone is produced by the corpus luteum—the structure that forms after ovulation. As women begin to skip ovulation more frequently in their 40s, corpus luteum activity declines, resulting in less progesterone production even though estrogen production from developing follicles often remains robust.

The result is relative estrogen dominance—not because estrogen is abnormally high, but because progesterone is too low to balance it. This hormonal shift is what drives many of the classic perimenopausal symptoms, including:

Irregular menstrual cycles
Heavier or prolonged bleeding
Breast tenderness
Mood swings and sleep disturbances
Worsening PMS-like symptoms

Why We Don’t Routinely Give Estrogen During Peri-menopause

Because estrogen levels are still present—and can be erratic or even elevated—adding estrogen too early can worsen the hormonal imbalance, potentially leading to heavier bleeding or other side effects.

For many women in early perimenopause, progesterone support alone (such as oral micronized progesterone taken at night) can help stabilize cycles, improve sleep, and ease symptoms without introducing additional estrogen.

Transitioning to Menopause

Once true menopause is reached—defined as 12 consecutive months without a period—estrogen levels fall significantly, and estrogen therapy often becomes appropriate.

Some guidelines also note that women age 55 and older are presumed menopausal even if they continue to have some bleeding, since persistent ovulation beyond that age is extremely rare. At this stage, estrogen therapy can be considered based on symptoms, risk factors, and personal goals.

Forms of Estrogen Therapy

There are several ways to deliver estrogen, and the right one depends on your health history, preferences, and goals.

1. Oral Estrogen

Taken as a pill daily
Easy to use but passes through the liver first, which can increase clotting risk in some women
Because of the increased risks of clotting compared to other forms, it is rarely recommended anymore

2. Transdermal Estrogen (Patches, Gels, Sprays, Creams, Vaginal Troches)

Applied to the skin or absorbed through mucosal tissue, entering the bloodstream directly
Includes patches, topical gels or creams, and vaginal troches
Bypasses the liver, leading to more stable hormone levels, lower clotting risk, and less effect on liver proteins than oral estrogen
Commonly preferred for women with cardiovascular or metabolic risk factors
Absorption is variable, so can be difficult to get blood levels to the optimal range in some people

3. Subcutaneous Pellets

Tiny pellets inserted just under the skin (usually in the upper buttock, but can be placed in the flank or lower abdomen as well) in a simple in-office procedure
Slowly release estrogen over 3–6 months
Also bypasses the liver, so less clotting risk compared to oral
Pros: Very convenient, provides steady hormone levels without daily dosing
Cons: The dose can’t be adjusted once implanted. Regular monitoring is important.

4. Injections

Less common for estrogen, but occasionally used for those who prefer infrequent dosing schedules. I personally have no experience with this form.

5. Local Vaginal Estrogen

Creams, rings, or tablets placed in the vagina
Excellent for vaginal dryness, discomfort, and urinary symptoms
Delivers very low systemic levels, making it suitable for many women who don’t need or want full-body therapy

Why Route of Administration Matters

How estrogen is delivered affects not only convenience, but also safety and metabolism. Transdermal estrogen (pellets, patches, gels, creams, vaginal troches, sprays) bypasses the liver, leading to lower risks of blood clots and less impact on triglycerides and liver proteins compared to oral estrogen. For this reason, major medical societies often prefer transdermal over oral estrogen, especially for women with cardiovascular or metabolic risk factors.

Several observational studies have also suggested that transdermal estrogen may carry a lower breast cancer risk than oral estrogen, particularly when combined with micronized progesterone rather than synthetic progestins. Data on pellet therapy and breast cancer risk are more limited, but because pellets deliver estradiol systemically without first-pass metabolism, their risk profile is likely more similar to transdermal than to oral estrogen.

Benefits of Estrogen Therapy

For the right patient, estrogen therapy can be life-changing. Proven benefits include:

Relief from hot flashes and night sweats
Improved sleep and mood
Stronger bones and reduced fracture risk
Better vaginal and urinary health
Possible cardiovascular benefits when started near menopause onset (“timing hypothesis”)
Potential cognitive and mood benefits in some women

Risks and Considerations

Like any medical therapy, estrogen isn’t right for everyone. The risks depend on your health history, age, timing, and the form of estrogen used.

Blood clots and stroke: Oral estrogen increases clotting risk more than transdermal forms. Pellets, patches and gels are usually preferred for women at higher risk.
Breast cancer: Long-term combined estrogen-progestogen therapy can slightly increase risk. Estrogen alone in women without a uterus does not appear to increase breast cancer risk and may even reduce it in some studies. Transdermal estrogen appears to have a lower risk than oral.
Gallbladder disease: Oral estrogen can raise this risk.
Pellets: Because they deliver a fixed dose over several months, there’s a greater chance of getting supraphysiologic levels, which can cause side effects such as breast tenderness, fluid retention, or mood changes. Usually not an issue as long as blood levels are monitored regularly.

Your personal and family medical history is central to deciding whether estrogen therapy is appropriate.

Estrogen Alone vs Estrogen + Progesterone

If you’ve had a hysterectomy, estrogen alone is typically sufficient.

However, if your uterus is intact, you also need progestogens to protect the uterine lining. Unopposed estrogen can stimulate the endometrium and significantly increase the risk of endometrial hyperplasia and cancer over time. Adding progesterone is essential—not optional—for safety.

There are two main types of progestogens:

Synthetic progestins (such as medroxyprogesterone acetate)
Micronized progesterone, which is “bioidentical” and chemically identical to the body’s natural progesterone

While both protect the endometrium, some research (including analyses of the Women’s Health Initiative) suggests that certain synthetic progestins may be associated with a higher risk of breast cancer when used long term, whereas micronized progesterone appears to carry a lower risk in observational studies.

Progesterone Scheduling in Perimenopause vs Menopause

Micronized progesterone is often used cyclically during perimenopause—for example, taken at night for the last 12–14 days of the menstrual cycle. This mimics the body’s natural luteal-phase progesterone production, helps regulate irregular cycles, improves sleep, and counterbalances fluctuating estrogen levels without over-suppressing the endometrium when ovulation is still occurring intermittently.

Once a woman reaches menopause (no menstrual cycles for 12 months), progesterone is typically switched to daily continuous dosing. This provides steady endometrial protection when estrogen therapy is introduced and avoids the monthly withdrawal bleeding that can occur with cyclic regimens. Continuous dosing is generally more convenient in menopause and maintains stable hormone levels.

Timing and Personalization Matter

Starting estrogen therapy near the onset of menopause (usually within 10 years) tends to offer the greatest benefits and the lowest risks. Therapy should be individualized:

Dose: Start low and adjust based on symptoms and goals
Route: Choose based on your risk factors and preferences
Duration: Reviewed regularly—some women benefit from shorter use, others from longer-term therapy

Monitoring and Follow-Up

Good follow-up is essential for safety and effectiveness. A typical plan includes:

Baseline evaluation: Medical history, physical exam, mammogram, and any indicated labs
Follow-up visits: Usually within 3–6 months to assess symptom relief and adjust the dose
Pellet users: Labs are typically checked about 3 months after insertion to ensure hormone levels have fallen low enough to safely pellet again. Even though testosterone levels often drop around the 3-month mark, estradiol levels may remain elevated for 6 months or longer in some women. This timing helps guide safe re-pelleting and avoids accumulation or supraphysiologic levels over time.

The Role of Testosterone in Women

While estrogen often takes center stage in discussions about menopause, testosterone also plays a significant role in women’s health. This hormone supports libido, mood, energy, bone density, muscle mass, and even cognitive function.

As women age, testosterone levels gradually decline, which can contribute to symptoms like low sexual desire, fatigue, decreased motivation, or diminished sense of well-being. These changes can overlap with or even compound the effects of declining estrogen, which is why a comprehensive hormonal evaluation often includes both estrogen and testosterone.

If you want to learn more, check out my two in-depth articles on testosterone therapy:

In my clinical experience, it’s fairly uncommon to find a woman who needs estrogen therapy alone. Both estrogen and testosterone deficiencies often occur together, and for optimal results, they are typically treated simultaneously.

Non-Hormonal Alternatives

For women who can’t or prefer not to use hormones, other options exist:

Lifestyle changes: Regular exercise, stress reduction, maintaining a cool sleeping environment, and good sleep hygiene can help reduce hot flashes and improve overall well-being.
Non-hormonal medications: Certain SSRIs/SNRIs (e.g., paroxetine, venlafaxine), gabapentin, and clonidine have been shown to reduce hot flashes in some women.
Supplements and herbal options: Some women use supplements for symptom relief, including:
- Black cohosh – modest evidence for reducing hot flashes, though effects are variable.
- Phytoestrogens (e.g., soy isoflavones) – plant-based compounds with weak estrogenic effects that may help mild vasomotor symptoms.
- Evening primrose oil – sometimes used for breast tenderness and hot flashes, though research results are mixed.
- Vitamin E – some studies suggest mild improvements in hot flashes at higher doses.
- Maca root, ashwagandha, red clover – commonly used botanicals with anecdotal and some limited clinical evidence for symptom support.

While these approaches are generally safe for many women, results are often modest and vary individually. It’s best to review any supplement use with a knowledgeable healthcare provider to ensure safety and avoid interactions.

Key Takeaways

Estrogen therapy is one of the most effective treatments for menopausal symptoms and can offer additional health benefits.
The form, dose, and timing of therapy matter greatly for both safety and effectiveness.
Transdermal estrogen is often preferred over oral due to lower clotting and metabolic risks, and may carry a lower breast cancer risk.
In perimenopause, estrogen therapy is usually deferred until true menopause is reached. The hormonal imbalance is usually due to low progesterone, not low estrogen. Using estrogen before menopause can cause worsening of symptoms, not a reduction in symptoms.
Micronized progesterone is used cyclically during perimenopause and daily after menopause to match physiological changes and provide endometrial protection.
Progesterone is essential for women with a uterus receiving estrogen, both for endometrial protection and to minimize long-term risks.
Testosterone often plays a complementary role, and testosterone and estradiol are frequently addressed together for optimal results.
Non-hormonal options, including lifestyle, medications, and certain supplements, can help some women manage symptoms effectively.
Decisions should be made in partnership with a knowledgeable provider who understands your full health picture.

Schedule a Hormone Consultation

If you’re experiencing perimenopausal or menopausal symptoms and wondering whether estrogen therapy is right for you, I can help you explore your options safely and effectively.
👉 Schedule a hormone consultation to get started.

References

The North American Menopause Society. The 2022 Hormone Therapy Position Statement of The North American Menopause Society. Menopause. 2022;29(7):767–794.
Manson JE et al. Menopausal Hormone Therapy and Long-term All-Cause and Cause-Specific Mortality. JAMA. 2017;318(10):927–938.
Canonico M et al. Postmenopausal hormone therapy and cardiovascular disease: an updated review and meta-analysis. BMJ. 2008;336:1227.
Fournier A et al. Use of different postmenopausal hormone therapies and risk of histology- and hormone receptor-defined invasive breast cancer. J Clin Oncol. 2008;26(8):1260–1268.
Stute P et al. The impact of micronized progesterone on breast cancer risk: a systematic review. Climacteric. 2018;21(2):111–122.
Rossouw JE et al. 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.
Prior JC. Progesterone for symptomatic perimenopause treatment. Climacteric. 2018;21(4):338–342.
Glaser R et al. Subcutaneous hormone pellet implants for hormone replacement therapy in women: safety and efficacy. Maturitas. 2013;74(4):357–362.
Davison SL et al. Androgen levels in adult females: changes with age, menopause, and oophorectomy. J Clin Endocrinol Metab. 2005;90(7):3847–3853.
Hitchcock CL, Prior JC. Oral micronized progesterone for vasomotor symptoms—a placebo-controlled randomized trial in healthy postmenopausal women. Menopause. 2012;19(8):886–893.
Scarabin PY et al. Differential association of oral and transdermal oestrogen-replacement therapy with venous thromboembolism risk. Lancet. 2003;362:428–432.
de Lignières B. Hormone replacement therapy: the real benefits and risks. Hum Reprod Update. 2002;8(6):513–530.
Tice JA et al. Phytoestrogen supplements for the treatment of hot flashes: the Isoflavone Clover Extract Pilot Study. J Womens Health Gend Based Med. 2003;12(9):923–930.
Nelson HD et al. Nonhormonal therapies for menopausal hot flashes: systematic review and meta-analysis. JAMA. 2006;295(17):2057–2071.

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