Hormone replacement therapy explained: types, benefits, risks, and where to get it

If you're in perimenopause or menopause and your symptoms are affecting your daily life, you've probably heard about hormone replacement therapy — or HRT. Maybe your friend swears by it. Maybe you've seen conflicting headlines. Maybe your doctor hasn't brought it up at all.

Let's cut through the noise. Here's what HRT actually is, who it's for, how to think about the risks and benefits, and where you can access it — including a comparison of popular telehealth providers.

What is HRT?

Hormone replacement therapy replaces the estrogen (and sometimes progesterone) that your body produces less of during the menopausal transition. It's the most effective treatment available for hot flashes, night sweats, and vaginal dryness, and it can also help with sleep, mood, and bone density.

HRT has been around for decades, but its reputation took a hit in 2002 when the Women's Health Initiative (WHI) study was widely interpreted as showing that HRT was dangerous. Since then, re-analysis of that data and newer research have given us a much more nuanced picture. For many people, the benefits significantly outweigh the risks — especially when started at the right time.

Types of HRT

• •Estrogen-only therapy (ET): Used for people who have had a hysterectomy. Since there's no uterus to protect, estrogen can be given alone.

• •Combined therapy (EPT): Estrogen plus a progestogen (progesterone or a synthetic progestin). The progestogen protects the uterine lining from the overgrowth that estrogen alone can cause. This is required if you still have your uterus.

• •Bioidentical hormones: These are hormones that are chemically identical to what your body naturally produces. FDA-approved bioidentical options include estradiol patches, gels, and micronized progesterone (Prometrium). The term "bioidentical" is sometimes used in marketing for compounded hormones, which are custom-mixed by specialty pharmacies and are not FDA-regulated in the same way.

• •Synthetic hormones: These include conjugated equine estrogens (Premarin) and synthetic progestins (like medroxyprogesterone). They've been used for decades and have extensive safety data. Many providers now prefer bioidentical options, but synthetic hormones remain a valid choice for some patients.

Delivery methods

How you take HRT matters — both for effectiveness and for risk profile:

• •Transdermal patch: Applied to the skin, changed once or twice weekly. Delivers estrogen steadily and bypasses the liver, which may lower the risk of blood clots compared to oral forms. Examples: Climara, Vivelle-Dot.

• •Topical gel or spray: Applied daily to the skin. Similar benefits to the patch. Examples: EstroGel, Divigel, Evamist.

• •Oral pill: Taken daily. Convenient but passes through the liver first, which may slightly increase the risk of blood clots and may affect cholesterol. Still widely used and effective.

• •Vaginal options: Low-dose vaginal estrogen (cream, ring, or tablet) targets vaginal dryness and urinary symptoms specifically. Very little is absorbed systemically, making it a good option even for people who can't take systemic HRT. Examples: Vagifem, Estring, Premarin cream.

• •Progesterone: Usually taken as an oral capsule (Prometrium) or as part of a combination patch. An IUD (like Mirena) can also provide progestogen protection for the uterus.

The "window of opportunity"

This is one of the most important concepts in modern menopause care. Research suggests that starting HRT within 10 years of menopause onset (or before age 60) provides the best benefit-to-risk ratio. During this window, HRT may not only relieve symptoms but also offer protective benefits for the heart and bones.

Starting HRT after age 60 or more than 10 years past menopause carries higher risks and is generally not recommended for symptom management alone. This is why having the conversation with your provider sooner rather than later matters.

Benefits of HRT

• •Most effective treatment for hot flashes and night sweats
• •Improves vaginal dryness and painful intercourse
• •May improve sleep quality and mood
• •Helps protect against osteoporosis and bone fractures
• •Emerging research suggests potential cognitive and cardiovascular benefits when started in the window of opportunity

Risks to discuss with your provider

• •Small increase in breast cancer risk with combined therapy (estrogen + progestin) used for more than 5 years. Estrogen-only therapy does not appear to increase breast cancer risk.
• •Oral HRT may slightly increase the risk of blood clots and stroke. Transdermal (patch/gel) options appear to have a lower or neutral risk.
• •Not recommended for people with a history of breast cancer, blood clots, liver disease, or unexplained vaginal bleeding.

The key takeaway: the risks are real but often smaller than people think, and they depend heavily on the type of HRT, the delivery method, your age, and your personal health history. This is a conversation to have with a knowledgeable provider.

Who is a candidate for HRT?

You may be a good candidate if you:

• •Are experiencing moderate-to-severe hot flashes, night sweats, or vaginal dryness
• •Are within 10 years of menopause onset or under age 60
• •Don't have contraindications (breast cancer history, active blood clots, severe liver disease)
• •Have discussed your personal risk factors with your provider

Telehealth providers for menopause care

If your current doctor isn't well-versed in menopause care (and many aren't — menopause receives very little attention in medical training), telehealth providers have stepped in to fill the gap. Here's a comparison of some popular options:

• •Winona: Focuses on bioidentical HRT. Pricing starts around $120/month for hormone prescriptions. Direct-to-consumer model with virtual consultations. Offers estradiol, progesterone, testosterone, and DHEA.

• •Midi Health: Menopause-specialist clinicians. Accepts insurance (including many major plans), which can significantly reduce costs. Comprehensive approach beyond just HRT — they address sleep, mood, weight, and more.

• •Evernow: Virtual menopause clinic offering FDA-approved HRT with clinical oversight. Transparent pricing and home delivery.

• •Stella (formerly Versalie): In-network with many insurance plans. Focuses on evidence-based menopause care. Offers HRT and non-hormonal treatment options.

• •Alloy: Direct-to-consumer menopause care. Offers FDA-approved HRT delivered to your door. Straightforward pricing model.

These are not endorsements — each provider has different strengths and limitations. The best choice depends on your insurance, budget, location, and specific needs. We encourage you to research each option and, most importantly, discuss any treatment plan with your healthcare provider.

The bottom line

HRT is not right for everyone, but for many people in the menopausal transition, it can be genuinely transformative. The key is making an informed decision with a provider who understands menopause — and starting the conversation early enough to take advantage of the window of opportunity.

Don't let outdated fears prevent you from exploring an option that could significantly improve your quality of life. Arm yourself with information, find a provider you trust, and make the decision that's right for your body.

*This article is for educational purposes only and does not constitute medical advice. Always consult your healthcare provider before starting any new treatment or supplement.*