What To Expect When Starting Hormone Therapy

By: Alexandria Delasantos, RN, BSN • Posted on August 31, 2023

As a women’s health nurse, I hear many concerns from our patients about starting and using menopausal hormone therapy. Hormone therapy (HT) is a treatment that is used to supplement the body with either estrogen alone or estrogen and progesterone in combination. When the ovaries no longer produce adequate amounts of these hormones (as in menopause), HT can be given to supplement the body with adequate levels of estrogen and progesterone. Hormone therapy helps to replenish estrogen, relieving some of the symptoms of menopause and helping to prevent osteoporosis.

When starting menopausal hormone therapy, women can experience many different symptoms as their bodies adjust to the new hormone levels. These symptoms may include breast tenderness, bloating and spotting or bleeding.

Here are the top 8 questions I get about hormone therapy – and my answers.

1. Is Breast Tenderness Normal?

Menopausal hormone therapy can cause some INITIAL breast tenderness because the hormone therapy increases blood flow all over the body. This minor symptom subsides over time. If you have been low in estrogen for some time and then start up even on a low dose of hormone therapy this may occur but in general, it is not cause for concern unless the breast tenderness persists for more than a few weeks.

Physicians and Advanced Practice Practitioners usually recommend wearing a good support bra, decreasing caffeine intake, and using over the counter Aspercreme. If you are taking a fish oil supplement, you may want to stop as this can cause breast tenderness and breast cysts. Make sure you are currently up to date with your mammograms and continue to complete your monthly self-breast exams. If you experience any of the symptoms below, you should report them to your physician.

Breast pain or palpation of lumps
Bruising or breast discoloration
Nipple discharge

2. Does Menopausal Hormone Therapy Cause Blood Clots?

In general we are not concerned about using oral menopausal hormone therapy, if you have NOT experienced deep vein thrombosis (DVT) blood clots, have taken hormonal contraceptives and/or been pregnant, and had a baby. However the most concerning risk of menopausal oral HT is DVT.

If there is a concern, then transdermal hormone therapy like the menopausal estrogen Patch (or combination estrogen/progestin patch) does not increase one’s risk of DVT. For women who are unable to take hormone therapy or are unwilling to take hormone therapy, there are non-hormonal alternatives for hot flashes, bone loss and vaginal thinning/atrophy.

3. Will I Experience Bleeding or Spotting?

Bleeding or spotting is the most common issue that women deal with when they start menopausal hormone therapy (in women with a uterus). Generally, after initiation of hormone therapy there should be no bleeding or spotting after six months (UNLESS you are placed on a cyclic regimen of progesterone for the first 12 days of the month). Spotting or light bleeding prior to six months can occur. It’s important to keep all follow up appointments - in person or virtually - and let the office know if your bleeding worsens or persists.

Skipping medication can cause bleeding to occur. However, if you are over 40 and complain of abnormal vaginal bleeding it can NOT be assumed that skipping your medication is the reason for the bleeding. If bleeding continues it would be advised to stop your hormone therapy until you follow up with a gynecologist for an evaluation of the lining of the uterus.

A tip I like to tell our patients is to set an alarm on their phones, so they remember to take their medication daily and avoid any bleeding.

4. Does Hormone Therapy Cause Cancer?

After 50 years of research, we can’t say it enough menopausal hormone therapy does NOT increase cancer death risk. However, unopposed unregulated hormone therapy including pellets can increase the risk for uterine/endometrial cancer. Estrogen alone in women without a uterus actually REDUCES breast cancer risk, even into one's 70s.

5. Will I Gain Weight on Hormone Therapy?

Women tend to be leaner on hormone therapy (HT) than women who don't take any postmenopausal hormone therapy. People tend to gain weight with age. However, the doses of menopausal HT do NOT cause weight gain and generally are helpful in maintaining normal body weight. But remember you have to eat less and exercise more to maintain weight and you need to get your sleep.

Some progestins can cause transient bloating and a rare woman is intolerant to even natural progesterone. Keep a diary log and consider seeing a functional medicine specialist if weight and bloating symptoms persist.

6. I’m Starting Vaginal DHEA and Worried About the Side Effects

DHEA stands for dehydroepiandrosterone. It is a hormone produced by the adrenal glands in both men and women. Vaginal DHEA has been used to treat vaginal atrophy and boosts estrogen and testosterone inside the vaginal tissues locally. It can also help with arousal and climax.

Depending on how bad the vaginal atrophy is, it may burn for the first few days but will start to subside. Please watch for odor, itchiness and redness as this may indicate a vaginal infection.

Is vaginal DHEA safe for a partner while having oral or vaginal sexual activity?

Yes, vaginal DHEA suppositories are safe for you and your partner. DHEA is odorless and tasteless and will not affect your partner.

7. Why Am I Being Tested For Various Labs?

When taking HT, you may need fasting blood sugar, thyroid, estrogen, FSH levels as well as a one-time screening for hepatitis C (if this has not been done).
Oral estrogen can affect liver, coagulation factors and Triglycerides. Please do not take biotin (B7) for at least 72 hours prior to having labs drawn.

8. When Will I Feel Better?

Some women feel better within a few days to a few weeks after starting on HRT. For others it can take 12 weeks to hit a steady state. It depends on many factors. Be patient. Most women feel remarkably improved. For those that felt poorly and now feel better this helps reinforce that this is the right option for them!

Be Strong, Be Healthy, Be in Charge!

Alexandria Delasantos RN
Lead Nurse, Center for Specialized Women's Health

About Alexandria Delasantos RN, BSN

Alexandria Delasantos is the current Care Coordinator for Specialized Women's Health at the Cleveland Clinic helping women move through menopause with ease and confidence. Alexandria started working in Women’s Health in 2022 in hopes to build longitudinal relationships with patients through their menopausal journey.

Alexandria started her nursing career in Colorectal Surgery at the Cleveland Clinic, then transitioned into management. She received her BSN at Notre Dame College where she was a National Delegate for the National Student Nurses’ Association (NSNA).

women's health, hormone therapy, hormones, ht, breast tenderness, blood clots, bleeding, cancer, weight gain, DHEA, midlife, menopause, perimenopause

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