It’s a common belief among women that during their middle-age years, perimenopause and menopause symptoms like hot flashes, night sweats, mood changes and vaginal dryness are inevitable. A rite of passage, even.

Dr. Brooke Chalk, an obstetrician/gynecologist at Wilmington’s Novant Health Coastal OB/GYN & Midwifery, wants women to know that they’re not. Hormone replacement therapy (HRT) may reduce and even eliminate these unpleasant changes, significantly adding to women’s quality of life as they age.

There’s no predictor for whether a woman will experience symptoms when she approaches menopause. Chalk said for some, the only indicator that they’ve gone through menopause is the absence of a menstrual period. For others, menopause upheaves their lives. Hormone replacement therapy is a commonly prescribed medical treatment that works by restoring the hormones estrogen and progesterone to their previous levels, alleviating uncomfortable and disruptive menopause symptoms. Chalk is passionate about telling women that they don’t have to suffer.

Brooke Chalk
Dr. Brooke Chalk

“I think for decades, a lot of women have just felt like that's a normal part of aging,” she said. “Women sort of think, ‘Well, I have to deal with this.’”

Chalk said many women don’t know there is a treatment option, while others are nervous about what the risks of taking hormone replacement therapy might be. “Sometimes, it's almost difficult to help them understand that it's probably OK for them to use this,” Chalk said.

When and how is HRT prescribed?

As with any medication, physicians take each woman’s personal health history into account before deciding which form of HRT is appropriate. Typically, HRT is prescribed to be absorbed by the body systemically, through the bloodstream, with an oral tablet, a topical gel or cream, or a transdermal patch. Some commonly prescribed brand names include Estrace, Menest, Premarin and Femtrace.

While a blood test may be used to measure hormone levels in the bloodstream, typically hormone replacement therapy can be prescribed based on age and symptoms alone.

What are the side effects of HRT?

Mild side effects are common for the first one to two months while taking HRT, as the body adjusts to changing hormone levels. These may include bloating, breast tenderness, headache and indigestion. Other side effects that were previously reported, such as heart disease, were found to be the result of an improperly conducted and reported study.

Most of the misconceptions and fear surrounding hormone replacement therapy come from one national study, the Women’s Health Initiative (WHI), which began in 1991 and was terminated in 2002. The study was ended early when results showed an increased risk of heart disease in the group of women taking HRT. In recent years, these results have been more critically analyzed, and researchers have found it is evident that the risks of hormone replacement therapy were overstated based on the WHI study.

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“That study design was flawed and not generalizable to most women,” Chalk said. “Those patients were older and unhealthy (further along in menopause, obese, many were smokers). After that study, we basically said, ‘Nobody should be on hormone replacement therapy.’ Like most things in life and medicine, one size does not fit all. There are some people who probably really should be on something and a few people who really shouldn't, and then there's a gray area for the average woman to decide for herself.”

For the many women who fall into that gray area, the signs of menopause are the best indicator that it’s time to ask about treatment options. Here are five signs that it may be time to ask your doctor about beginning hormone replacement therapy.

1. You’re experiencing night sweats and/or hot flashes.

Night sweats are one of menopause’s trademark symptoms, with an estimated 75 percent of women experiencing them. Waking up drenched is a miserable experience, and one that can have health consequences.

“If you're waking up at night, or you can't sleep at night, your life is significantly impacted by a lack of sleep,” Chalk said. “If that is a chronic condition, that starts to impact not just your functioning, but your health.”

Women may also be impacted by hot flashes during the day, which can diminish their confidence. “Someone with severe hot flashes, they may be too embarrassed to speak in front of people, or go for a promotion,” Chalk said.

Chalk emphasized that while hot flashes and night sweats are a typical symptom of menopause, they shouldn’t be dismissed as normal. “This might really change your quality of life,” she said.

2. You’ve noticed a change in your mood, such as an onset of anxiety or depression

Hormones are brain messengers, and when their levels fluctuate, they can cause changes in feelings, moods and emotions, too.

“There's a lot of evidence that mood disorders, like anxiety and sometimes even depression, can manifest as we approach menopause and in early menopause,” Chalk said. Sometimes, when nothing else has changed, women still find themselves asking, why am I feeling this way? “Well, it's not because you're crazy,” Chalk said. “It's because your body is totally different than it was six months ago.”

When mood changes occur without an inciting incident, fluctuating levels of estrogen and progesterone may be to blame. Throw in other symptoms like sleep disturbances, and it’s like fuel on a fire. Hormone replacement therapy works to increase these hormone levels, and oftentimes feelings of anxiety improve as a result.

3. You’re around 40 years old

The average age of menopause in the United States is 51. But symptoms can start years or even decades before that. Chalk said often women in their 40s notice their menstrual periods becoming heavier and/or irregular as a result of changes in estrogen levels.

“If you're looking at a textbook, the definition of menopause is no period for a year. But what we know is menopause is really a transition,” Chalk said. She encourages women have an open discussion with their gynecologist about what to expect as estrogen and progesterone decline. Being proactive can allow you to have a plan in place before symptoms become severe.

“If you're seeing your OB-GYN once a year, you're probably going to start having signs before it’s time to see me again,” Chalk said.

4. You have vaginal dryness and/or pain with intercourse.

“This is one of those things that a lot of people just think, ‘Oh, well, this is my life now,’ or ‘I have to deal with this.’ Or it may seem unimportant,” Chalk said. “I would disagree with all of that. I think that a healthy sex life can be a huge part of a fulfilling relationship, whether you're 30 years old and newly married, or 65 years old.”

Painful sex is common, and nothing to be embarrassed about. Estrogen is again to blame here, as the hormone that helps maintain the vagina’s elasticity and lubrication. Low levels cause a condition called vaginal atrophy, characterized by dryness and inflammation of the vaginal walls.

Hormone replacement therapy can help to reinvigorate these tissues. While HRT is commonly prescribed to be absorbed by the body systemically, for those whose primary concern is vaginal dryness and discomfort, vaginal estrogen may be a good option.

“This is replacing that estrogen right there where you need it,” Chalk said. “That alone can be really effective.”

Medications like Vagifem are known as local estrogen therapy. Local estrogen therapy results in lower doses of estrogen than systemic treatments. The delivery form, a vaginal ring, tablet or cream, may change the dose amount and frequency, so your gynecologist can help you determine which delivery method is best for you.

5. You want to help protect yourself against osteoporosis, or conditions of cognitive decline, like Alzheimer’s disease

Hormone replacement therapy is typically not prescribed as a first-line treatment for osteoporosis or Alzheimer’s disease. However, evidence suggests that it helps protect against these conditions, making it a complementary therapy to help prevent them.

Estrogen is key for bone health. It regulates bone metabolism by promoting the activity of osteoblasts, the cells that make new bone. When estrogen levels drop, it can also cause a drop in bone density. This makes postmenopausal women at risk of osteoporosis, a disease that diminishes bone density, causing risk of fractures during simple movements like bending or even coughing. While there are no symptoms of osteoporosis, a bone density test can reveal what your risk is.

Research also shows that hormone replacement therapy has protective benefits against dementia and Alzheimer’s disease. A study published in Alzheimer’s & Dementia: Translational Research & Clinical Interventions found that women who underwent hormone replacement therapy for six years or greater were 79% less likely to develop Alzheimer’s disease and 77% less likely to develop any neurodegenerative disease.

“We don't start hormone replacement therapy because of these things, but they are benefits that you can get,” Chalk said. Openly questioning your risk for these conditions, along with discussing the other symptoms you are experiencing, can help you and your gynecologist determine if HRT is a good option for you.