Menopause, Perimenopause, and Hormone Replacement Therapy

Menopause is not a disease, but a natural phase of life—even if it doesn’t always feel that way. As the ovaries gradually produce less estrogen, this can cause noticeable symptoms. The good news is that there’s a lot that can be done about it, and together we’ll find the approach that’s right for you—from simple measures to hormone therapy. You don’t have to just tough it out.

What Happens During Menopause

Menopause begins with perimenopause—a transitional phase that often starts many years before the last menstrual period (actual menopause). Sleep disturbances, in particular, are among the first signs. Even in this early phase, the symptoms can be distressing, and sometimes hormone therapy is already advisable at this stage. We usually make the diagnosis based on your symptoms and your menstrual cycle—a blood test is rarely necessary.

The decline in estrogen levels is particularly noticeable in four areas:

• Vasomotor: Hot flashes and night sweats—the most typical symptoms. They last an average of about seven and a half years, though for some women they may last longer (SGGG, Expert Letter No. 90).
• Urogenital: Vaginal dryness, burning, and discomfort during urination or sex.
• Osteo (bone): Bone density decreases, and the risk of osteoporosis increases.
• Psychological: Sleep disturbances, mood swings, irritability, and sometimes difficulty finding the right words (“brain fog”).

The severity of these symptoms varies greatly from woman to woman—and treatment is tailored precisely to this.

Don’t forget about birth control

As long as you still have your period occasionally, you can become pregnant—menopause doesn’t provide protection overnight. Important: Hormone replacement therapy is not a form of birth control. If you want to use reliable birth control, we’ll discuss the right method for this stage of your life (more on this → “Birth Control”).

Three Pillars of Treatment

We don’t treat “menopause” itself, but rather your symptoms—and to do so, we rely on three pillars, which we use individually or in combination depending on your situation. Not every woman needs hormones.

Pillar 1 – Alternative and complementary therapies. Much of this begins with factors you can influence yourself: exercise, a balanced diet, and a healthy weight are good for your overall well-being, sleep, and bone health—even if they don’t reliably reduce hot flashes on their own. Herbal remedies such as Cimicifuga (black cohosh) or micronutrients (e.g., vitamin B6) help some women, but the evidence on this is inconsistent (SGGG, Expert Letter No. 51). Among non-pharmacological approaches, cognitive behavioral therapy has the strongest evidence base: it has been shown to alleviate hot flashes and sleep problems (Ye et al. 2022).

Pillar 2 – Non-hormonal pharmacotherapy. If hormones are not desired or not an option, there are effective non-hormonal medications: Certain antidepressants (SSRIs/SNRIs) and gabapentin can significantly reduce hot flashes (SGGG, Expert Letter No. 51); neurokinin antagonists also represent a new class of drugs specifically targeting hot flashes (Wojciechowski et al. 2026). Melatonin can support sleep.

Pillar 3 – Hormone Therapy. The third pillar encompasses systemic hormone therapy (estrogen, combined with a progestin if the uterus is intact) and local vaginal estrogen therapy for symptoms in the genital area. For severe menopausal symptoms, it is the most effective treatment (SGGG, Expert Letter No. 90)—we will discuss this in detail in the next section.

When Hormone Therapy Is Appropriate

Hormone therapy is always prescribed for a specific reason and is tailored to your individual needs. The main indications are severe menopausal symptoms, an increased risk of bone fractures—and, in particular, early-onset menopause (more on this below). Before starting treatment, we’ll take the time to discuss the benefits and risks for your specific situation.

The “optimal window”: Timing is key

Timing is crucial. If hormone therapy begins within the first ten years after menopause or before the age of 60, the overall health benefits outweigh the potential risks (SGGG, Expert Letter No. 90). Contrary to what was previously assumed, there is no rigid time limit—the therapy does not have to be discontinued after five years. Instead, we’ll review together once a year whether it’s still right for you.

How we select the therapy

We prefer to use estrogen delivered through the skin (as a patch or gel)—this puts less strain on the blood vessels compared to oral tablets and does not increase the risk of thrombosis. We use hormones that are identical to those produced by the body. If you still have a uterus, estrogen is always combined with a progestin (micronized progesterone or a hormonal IUD) to protect the uterine lining; after a hysterectomy, estrogen alone is sufficient. We always choose the lowest dose that reliably relieves your symptoms.

What Hormone Therapy Also Offers—and What It Doesn’t

In addition to relieving hot flashes, hormone therapy often improves sleep and mood, and it protects the bones by slowing bone loss and reducing the risk of fractures (more on this below under “Bone Health”). Let’s address a common concern right away: Hormone therapy does not lead to weight gain (SGGG, Expert Letter No. 90). However, it’s important to be clear: Hormone therapy is not a preventive measure against heart attacks or dementia—it is not used for that purpose.

And the risks? An honest assessment

To help you make an informed decision, we’ll address the risks openly. Overall, they are small and depend heavily on the type of therapy and when it’s administered:

• Breast cancer: Combined hormone therapy is associated with a slightly increased risk—on a scale roughly equivalent to drinking about two glasses of alcohol per day, being overweight, or a lack of exercise (SGGG, Expert Letter No. 90). Estrogen alone (after a hysterectomy) does not increase the risk; in large studies, the risk was actually lower.
• Thrombosis and stroke: This risk primarily applies to the oral form. Based on current knowledge, it is not increased with transdermal administration—a key reason why we prefer this form.
• Endometrium: Without progestin protection, estrogen would increase the risk of endometrial hyperplasia—hence the combined approach when the uterus is intact.

Systemic hormone therapy is generally not recommended after a history of breast cancer. And in cases of significantly increased cardiovascular risk, we discuss this in advance with the cardiology department.

Vaginal dryness: Local therapy is often sufficient

Symptoms such as vaginal dryness, burning, or recurrent urinary tract infections can be treated very effectively with local estrogen therapy—applied as a cream or suppository directly to the affected area. It works exactly where it’s needed, is barely absorbed into the body, and is therefore very safe: It’s an option even if systemic hormone therapy isn’t suitable for you.

Libido and Sexuality

Many women experience a decline in sexual desire during menopause—this has hormonal causes, as well as physical and emotional ones. Often, treating vaginal dryness or using systemic hormone therapy is enough to help. If that’s not enough and the distress is significant, testosterone delivered through the skin (transdermally) may be considered in select cases. No specific medication is approved for this purpose in Switzerland, which is why we prescribe it on a case-by-case basis and openly discuss its benefits and limitations with you. Please talk to us—sexuality is, of course, a topic worth discussing.

Bone Health: Keeping Bones Strong

During menopause, the lack of estrogen accelerates bone loss—the risk of osteoporosis and bone fractures increases, often without you even noticing. The good news: There are steps you can take on your own, and we’ll keep an eye on your bone health.

The most important factors are exercise and nutrition. Regular weight-bearing exercise—such as walking, hiking, and strength training—stimulates the bones to become stronger. Make sure you get enough calcium (from dairy products, green vegetables, or calcium-rich mineral water) and vitamin D, which the body produces very little of on its own in the winter; a supplement is often worthwhile here. Not smoking and drinking alcohol in moderation also helps protect your bones.

We’ll decide together whether a bone density test (DXA) is advisable—especially if you’re at increased risk, such as after a bone fracture with no obvious cause, in cases of early menopause, when taking certain medications (e.g., cortisone), or if there’s a family history of osteoporosis. In these cases, health insurance covers the test.

Hormone therapy effectively slows bone loss and is particularly beneficial for protecting bones in cases of early menopause. If osteoporosis has already been diagnosed, there are also targeted medications that strengthen bones—we’ll discuss which option is right for you.

When Menopause Occurs Early

If menopause begins prematurely—before age 40, it is referred to as premature ovarian insufficiency; between ages 40 and 45, it is called early menopause—hormone therapy is particularly important. This is not just about managing symptoms, but about prevention: A early estrogen deficiency increases the long-term risk of bone fractures and cardiovascular disease. For this reason, hormone therapy is recommended at least until the average age of menopause, around 52 (SGGG, Expert Letter No. 90).

Further Reading

The professional association gynécologie suisse (SGGG) offers an information sheet for women on hormone therapy during menopause, which Dr. Michael Singer helped develop.