Hormone replacement therapy and herbal alternatives: Ways to achieve hormonal balance during menopause

Menopause is a natural, biological transition—not a disease. Yet it can be challenging for many women: Hot flashes, sleep problems, mood swings, and difficulty concentrating can significantly impact quality of life. So what can you do when your body is undergoing changes? This article provides an overview of medicinal and herbal options for effectively relieving menopausal symptoms.

Hormone replacement therapy means that the body is supplied with the hormones that it no longer produces sufficiently during menopause – especially estrogen , which decreases significantly with the end of the fertile years.

Estrogen fulfils numerous functions in the body : It protects bones from degradation, stabilizes the cardiovascular system, has an anti-inflammatory effect, keeps skin and mucous membranes elastic and influences the central nervous system - for example , sleep, mood and concentration .

If a woman still has an intact uterus , estrogen must always be combined with progesterone . This is because estrogen alone would permanently stimulate the uterine lining (endometrium) to grow, which can increase the risk of uterine cancer (endometrial carcinoma).

Progesterone acts as an antagonist here : It ensures that the mucous membrane is regularly shed or does not grow excessively in the first place – a natural protective mechanism that the body can no longer provide on its own after menopause.

This combination – bioidentical estrogen plus natural progesterone – now forms the basis of modern, safe hormone replacement therapy.

The WHI (Women's Health Initiative) study was a large-scale, long-term US study conducted starting in 1991 and involving over 160,000 women. Its goal was to investigate the effects of various preventive strategies—including diet, exercise, and hormone replacement therapy—on chronic diseases such as heart attack, stroke, breast cancer, and dementia. In the hormone portion of the study, over 27,000 women received either:

• a combination of conjugated equine estrogens (CEE) – i.e. estrogens extracted from the urine of pregnant mares – plus a synthetic progestogen (medroxyprogesterone acetate), or

• a placebo.

A key problem was that these conjugated equine estrogens represent a heterogeneous mixture of different estrogen types , each mare producing them in different amounts. They are not bioidentical, and their dosage is difficult to control – quite unlike the standardized, body-identical hormones used today.

In addition, the drug was taken orally , meaning it had to be metabolized through the gastrointestinal tract and the liver. This leads to the so-called first-pass effect : The liver is directly stimulated by hormone absorption, which, among other things, triggers the coagulation cascade —a factor that can increase the risk of thrombosis and stroke. Today, hormones are preferably administered transdermally (e.g., as a gel or patch) to avoid this effect.

The interim analysis published in 2002 caused a media sensation: Hormone replacement therapy was linked to an increased risk of breast cancer, heart attack, stroke, and dementia . The result: Millions of women discontinued their treatment, and prescription practices collapsed worldwide.

But the study is now rightly criticized. Because:

Recent evaluations of the WHI data and large meta-analyses show that for women who start modern hormone replacement therapy early (within the “window of opportunity”), the benefits clearly outweigh the risks.

These women:

The often-cited risk of breast cancer is not generally increased , but depends on the combination of hormones, the duration of use, and the individual risk profile . Studies show that, for example, obesity or regular alcohol consumption can have a greater impact on the risk of breast cancer than short-term, well-adjusted hormone replacement therapy.

In the meantime, the study results have been re-evaluated in numerous specialist articles – and the recommendations of leading professional societies, such as the German Menopause Society , have been significantly revised .

Hormone replacement therapy is one of several options for treating menopausal symptoms. Whether it's suitable depends on individual factors: the symptoms, age, time since the last menstrual period, personal preferences, and pre-existing medical conditions.

Hormone replacement therapy is often discussed in medical consultations when certain symptoms are prominent – ​​for example:

• Hot flashes and night sweats , which are perceived as stressful

• Sleep disorders that may be caused by hormones

• Vaginal dryness , pain during intercourse or recurring infections

• Mood swings, irritability or lack of motivation

• An increased risk of osteoporosis or previously diagnosed bone loss

• Onset of menopause before the age of 45

The decision for or against HRT should always be made individually and in a well-informed manner – in consultation with a doctor and based on current medical knowledge.

Modern hormone replacement therapy preparations are based on bioidentical hormones , i.e., substances that are chemically identical to the body's own hormones . They are considered particularly well-tolerated and low-risk. They are administered as:

• Gel, spray or patch (transdermal, i.e. via the skin)

• Tablets

• Vaginal creams or suppositories (for local complaints)

Transdermal applications, in particular, are particularly gentle on the liver and blood vessels. Importantly, the therapy is individually tailored —in terms of dosage, form, and duration—and medically supervised.