Hot flashes in the middle of a working day, night sweats, restless sleep, vaginal dryness: menopausal symptoms can make everyday life much harder. Menopause is a natural stage of life, but you do not have to put up with these symptoms. They can be treated, and hormone replacement therapy (HRT) is one of the options.
Many women prefer hormones that are applied to the skin or used vaginally rather than taken as tablets. Interest is also growing in creams that a pharmacy makes up to an individual prescription. But “hormone cream” can mean three different products. Each does a different job, and they have not been studied equally well.
Three products that get called “hormone cream”
Estrogen gel or patch. Estradiol is absorbed through the skin into the bloodstream and acts on the whole body, just as tablets do, which is why this is called systemic treatment. Systemic estrogen is the most effective treatment for hot flashes and night sweats. Estrogen taken through the skin (transdermally) carries a lower risk of blood clots than tablets. Even so, if you have had a blood clot or a stroke, or have heart or blood vessel disease, tell the doctor at your first visit: in that case a gel or patch also needs careful assessment.
Vaginal estrogen. A low-dose cream, vaginal tablets or pessaries are used to treat vaginal dryness, burning, painful sex and urinary symptoms. Very little of the hormone reaches the bloodstream, so these products do not relieve hot flashes.
Cream compounded by a pharmacy on prescription. A pharmacy prepares it to a formula specified by the doctor, and it may contain one hormone or several. The name alone does not tell you whether the cream is meant for the skin or for vaginal use, so check with your doctor or pharmacist. A cream meant for the skin must not be used vaginally, and vice versa.
What “bioidentical hormones” means
Bioidentical hormones have the same molecular structure as the hormones the body makes itself. Estradiol and progesterone are examples. Licensed prescription medicines contain these same hormones, so a bioidentical hormone is not necessarily one compounded in a pharmacy. The word “bioidentical” describes the molecule only. It says nothing about the dose, the quality of the medicine or its safety, and “natural” hormones can cause side effects too.
What we know about pharmacy-compounded creams
Licensed gels and patches have been through studies that established how much hormone is absorbed and what effect it has. For compounded creams such studies usually do not exist. Absorption depends on the cream base, the hormone concentration and how the cream is applied, so two creams with the same amount of hormone on the label can act differently.
A study published in the journal Menopause in 2023 bears this out: women using compounded estradiol creams received less estrogen than women using licensed gels or patches at similar doses. The study compared laboratory results only, not symptoms or long-term safety. Still, it shows why one product cannot simply be swapped for another at the same dose.
The American College of Obstetricians and Gynecologists (ACOG) and the British Menopause Society recommend choosing licensed medicines whenever they are available. Data on the long-term safety of compounded creams are also lacking: it is not known how they affect the risk of breast cancer or endometrial cancer (cancer of the lining of the uterus).
Sometimes the dose of a cream is set according to hormone levels in saliva or repeated hormone tests. There is no evidence that this makes treatment safer or more effective. The doctor adjusts the dose according to how your symptoms change.
If your doctor does recommend a compounded cream, ask why this one was chosen, what the alternatives are and how the treatment will be monitored.
Progesterone cream does not protect the lining of the uterus
If you still have your uterus, a progestogen must be taken alongside systemic estrogen (gel, patch or tablets). Estrogen on its own makes the lining of the uterus thicken, and over time the risk of endometrial cancer rises.
Progesterone from a skin cream is absorbed unevenly, so such a cream does not reliably protect the lining. The same goes for creams that combine estrogen and progesterone. Reliable protection comes from oral micronized progesterone, another progestogen, or a levonorgestrel-releasing intrauterine system, also known as a hormonal IUD (not every hormonal IUD is suitable for this purpose). Your doctor will choose the most suitable option.
If you use only low-dose vaginal estrogen, a progestogen is not usually needed. High-strength estradiol creams (0.01%) are a different matter: more of the hormone is absorbed into the blood, so the European Medicines Agency has ruled that they may be used for a single course of treatment lasting no more than four weeks. Compounded vaginal creams whose absorption has not been studied call for the same caution.
If your uterus has been removed, estrogen alone is usually enough. There are exceptions, for example endometriosis.
Vaginal dryness, burning and pain during sex
As estrogen levels fall, the tissues of the vagina, vulva and urinary tract become thinner and drier. This can cause itching, burning, pain during sex, and a frequent or urgent need to urinate. Infections and skin conditions cause similar symptoms, so a gynecological examination is needed before treatment.
If these are your only symptoms, low-dose vaginal estrogen is usually enough and systemic hormone therapy is not needed. Vaginal moisturizers ease dryness day to day, and lubricants help during sex. Symptoms often return when treatment stops, so vaginal estrogen is frequently used long term, with regular check-ups.
Women who have had breast cancer are advised to try non-hormonal options first. The decision to use vaginal estrogen is made by the gynecologist together with the oncologist.
If your periods have not stopped yet
Treatment can start during perimenopause, while you are still having periods. At this stage a progestogen is usually taken on set days of the cycle, followed by a period-like bleed. After menopause, a regimen in which both hormones are taken every day without a break is more common.
HRT does not protect against pregnancy. For as long as pregnancy is possible, you need to keep using contraception. Discuss with your doctor when it can be stopped: an improvement in symptoms does not mean contraception is no longer needed.
Do I need hormone tests before treatment?
Women over 45 with typical symptoms do not usually need hormone tests: the doctor goes by the symptoms and changes in the menstrual cycle. An FSH (follicle-stimulating hormone) test can be useful between the ages of 40 and 45, and when symptoms appear before 40. In that case premature ovarian insufficiency has to be ruled out. If it is diagnosed, HRT is usually recommended at least until the age when menopause would occur naturally.
If you use hormonal contraception, tell your doctor, because it affects the test results. Tiredness, insomnia and palpitations can have other causes too, so the doctor may order further tests.
Who is HRT suitable for?
For many healthy women troubled by menopausal symptoms, the benefits of treatment outweigh the risks if it is started before the age of 60 or within ten years of menopause.
Your doctor must know if you have had breast or endometrial cancer, a blood clot or a stroke, or if you have heart or liver disease or unexplained bleeding. In these cases systemic hormone therapy is often unsuitable, or the decision is made in consultation with another specialist. Mention migraine, high blood pressure and smoking as well.
Combined estrogen and progestogen therapy increases the risk of breast cancer, and the risk grows the longer the therapy is used. Your doctor can explain how large that risk is at your age and in your situation.
There is no fixed point at which treatment has to stop, neither after five years nor at 65. The first follow-up visit is usually after three months, then at least once a year. At each visit you and your doctor decide together whether to continue.
How to use a gel or cream on the skin
Apply the prescribed amount to the area of skin you were told to use, let it dry and then wash your hands. The package leaflet says how long after application you should avoid washing and skin contact with other people. This matters because the hormones can transfer to a partner’s or child’s skin. Such cases have also been reported with compounded creams.
Do not use a cream prescribed for someone else, and do not change the dose on the basis of advice found online. If your doctor switches you to a different product, ask how to use the new one, even if the name or the amount of hormone is similar.
Bleeding during treatment
On a cyclical regimen, bleeding after the progestogen course is expected. Light spotting in the first months of treatment is also common; sometimes the doctor changes the regimen because of it.
Contact your doctor if the bleeding:
- is heavy or prolonged;
- comes back after a spell without bleeding;
- starts more than six months after beginning treatment, or more than three months after a change of product or dose.
You should also see a doctor about any bleeding after menopause if you are not taking hormones. If you have very heavy bleeding with fainting, sudden shortness of breath, chest pain or signs of a stroke, call 113 immediately.
How to prepare for your appointment
Before the visit, write down which symptoms bother you most and when they started. Bring the results of earlier tests and a list of all the medicines you take. If you already use a compounded cream, the prescription or a photo of the label showing the ingredients and concentration will be useful.
Questions worth asking the gynecologist:
- Do I need systemic hormone therapy, a vaginal product, or both?
- Is a licensed estradiol gel or patch suitable for me?
- How will the lining of my uterus be protected?
- How do I use the medicine correctly, and what should I do if I miss a dose?
- When should I come back for a check-up?
- Do I still need contraception?
You do not need to know which hormones you need or at what dose. The doctor will work that out with you at the consultation.
Frequently asked questions
Does HRT cause weight gain?
No. Around menopause, weight is affected by age and lifestyle. Hormone therapy does not cause weight gain, but it is not a weight-loss treatment either.
Do hormones improve sleep and mood?
If night sweats are disturbing your sleep, hormone therapy can improve it. Mood swings linked to menopause may ease as well. Long-lasting depression or insomnia needs to be assessed separately.
Does every woman need testosterone cream?
No. Testosterone is considered for postmenopausal women with markedly low sexual desire, once other possible causes have been assessed. It is not used to boost energy or to lose weight. Possible side effects are acne and increased hair growth, and long-term safety data are limited.
What if I cannot or do not want to take hormones?
There are other options: cognitive behavioral therapy adapted for menopausal symptoms, and non-hormonal medicines prescribed by a doctor. Moisturizers and lubricants relieve vaginal dryness.
Gynecologist consultation at Republikas laukuma klīnika
If hot flashes, night sweats or vaginal dryness are getting in the way of your daily life, book a gynecologist consultation at Republikas laukuma klīnika. The doctor will listen to your concerns, assess your health and choose the most suitable treatment together with you: an estrogen gel or patch, a vaginal product or a non-hormonal option. If you use or are considering a compounded cream, bring the prescription with you and the doctor will explain whether it is right for you.
