If hot flashes and night sweats around menopause disrupt your life, see a gynecologist to assess hormone therapy; do not just endure them or buy medication yourself, and do not use it to prevent heart disease

Visit a gynecologist or menopause clinic. The doctor will ask about your medical history, check for conditions that make hormones unsuitable, and prescribe them if appropriate. Once treatment starts, attend follow-up appointments as instructed. The difficult part is letting go of the fear that “any exposure to hormones causes cancer”; equally, do not buy them yourself because you hear they can slow aging.

Cochrane combined 24 randomized trials involving 3329 people, comparing oral hormones with placebo. With hormones, the number of hot flashes per week was about 75% lower than with placebo (95% CI 64.3–82.3, the confidence interval). Their severity was also substantially reduced (OR 0.13, 0.07–0.23). Hot flashes also decreased by about 57.7% in the placebo group, so anything claimed to treat hot flashes needs to be compared with placebo. For risks, consider the US WHI randomized trial. It followed 16608 women aged 50 to 79 with a uterus, taking estrogen plus progestogen, for an average of 5.2 years. Coronary heart disease was about 29% higher (HR 1.29, 1.02–1.63). Invasive breast cancer was about 26% higher (HR 1.26, 1.00–1.59). Stroke was about 41% higher (HR 1.41, 1.07–1.85). Pulmonary embolism was about 2.13 times as frequent (HR 2.13, 1.39–3.25). In absolute numbers, there were 7 additional coronary heart disease cases, 8 strokes, 8 pulmonary embolisms, and 8 invasive breast cancers per 10,000 women per year. At the same time, there were 6 fewer colorectal cancers and 5 fewer hip fractures. Among women who had had a hysterectomy and used estrogen alone, breast cancer was instead about 21% lower over 13 years of cumulative follow-up (HR 0.79, 0.65–0.97). Combining the two trials, all-cause mortality was unchanged over 18 years of follow-up (HR 0.99, 0.94–1.03). Broken down by age at treatment initiation, all-cause mortality in the 50 to 59 age group was about 31% lower during the treatment years (HR 0.69, 0.51–0.94). For ages 60 to 69 it was 1.04 (0.87–1.25), and for ages 70 to 79 it was 1.13 (0.94–1.36); neither was statistically significant. At 18 years, the figure for ages 50 to 59 was 0.89 (0.79–1.01), also no longer statistically significant. The 2017 Cochrane review, looking specifically at women aged 50 to 59, found that the only clear increase was blood clots with combined estrogen and progestogen; the absolute risk was less than 1/500. In women over 65 taking combined estrogen and progestogen, dementia increased over 4 years from 9 cases per thousand to 11 to 30 cases per thousand. In 2022, the US Preventive Services Task Force recommended against hormones for preventing chronic diseases (grade D recommendation), concluding that there was no net benefit.

MacLennan AH, Broadbent JL, Lester S, Moore V (2004). Oral oestrogen and combined oestrogen/progestogen therapy versus placebo for hot flushes. Cochrane Database of Systematic Reviews, (4), CD002978. https://doi.org/10.1002/14651858.CD002978.pub2；Writing Group for the Women's Health Initiative Investigators, Rossouw JE, Anderson GL, Prentice RL, 等 (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA, 288(3), 321-333. https://doi.org/10.1001/jama.288.3.321；Manson JE, Chlebowski RT, Stefanick ML, 等 (2013). Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women's Health Initiative randomized trials. JAMA, 310(13), 1353-1368. https://doi.org/10.1001/jama.2013.278040；Manson JE, Aragaki AK, Rossouw JE, 等 (2017). Menopausal hormone therapy and long-term all-cause and cause-specific mortality: the Women's Health Initiative randomized trials. JAMA, 318(10), 927-938. https://doi.org/10.1001/jama.2017.11217；Marjoribanks J, Farquhar C, Roberts H, 等 (2017). Long-term hormone therapy for perimenopausal and postmenopausal women. Cochrane Database of Systematic Reviews, (1), CD004143. https://doi.org/10.1002/14651858.CD004143.pub5；US Preventive Services Task Force, Mangione CM, Barry MJ, 等 (2022). Hormone therapy for the primary prevention of chronic conditions in postmenopausal persons: US Preventive Services Task Force recommendation statement. JAMA, 328(17), 1740-1746. https://doi.org/10.1001/jama.2022.18625

Controversy: the women in WHI were 63 years old on average and used one fixed oral regimen. Most current users start in their early 50s, shortly after menopause, for symptom relief, so they are not entirely like the trial participants. The lower mortality at ages 50 to 59 emerged from an age subgroup analysis and was no longer statistically significant at 18 years, so hormones cannot be said to extend life. Cochrane also explicitly states that the trials were too small to clarify risks in women within 10 years of menopause. The following groups are generally unsuitable: those with a history of breast cancer or blood clots, those at high cardiovascular risk, and those with marked obesity; the doctor must judge the individual case. In people with a uterus, estrogen alone increases endometrial cancer, so progestogen must be used alongside it; only those who have had a hysterectomy can use estrogen alone. Hormones can also reduce fractures, but are generally considered only when other osteoporosis drugs are unsuitable. For osteoporosis, first see Section 1, item 39 (bone density testing) and Section 1, item 40 (use medication when osteoporosis is diagnosed). The benefit is rated “large” on the basis of about 75% fewer hot flashes; the endpoint is symptoms, not all-cause mortality. The main beneficiary of this item is you, and your mother and spouse may also benefit.