Lots of women struggle during perimenopause and menopause and are looking for ways to feel better. While there’s tons of information out there about the benefits of hormone replacement therapy (HRT), it’s important to understand the potential downside too, so you can make the right decision about what’s best for you.
If you do a quick search on HRT, you’ll find sources describing a reduction in insulin resistance, better vaginal health, sharper cognition, and a decrease in overall menopause symptoms. But if you take a closer look at most of these studies, you’ll notice those benefits are primarily when HRT is introduced early (within 10 years of menopause onset), in low doses, and over a short term (less than 5 years).
Every medication has potential side effects (even prenatal vitamins!) and that’s true for HRT too. That doesn’t mean you shouldn’t take it, but it does mean that the more informed you are, the better decision you’ll make about whether it’s right for you. There are increased cancer and cardiovascular risks that accompany HRT, even with short-term use. A large 2025 study found that even when taken within the 5 year time range, HRT increases the risk of breast, endometrial, and ovarian cancers, and the risk remains elevated 5 to 10 years after concluding therapy. Studies also show an increased risk of strokes and clotting, especially with oral administration. While there are “safer” ways to do HRT, such as transdermal (patch or gel), micronized preparations, bio-identicals, and lower doses, research continues to demonstrate increased cancer and stroke rates associated with HRT.
While the debate about HRT and cardiovascular health and cancer risk rages on, the gut microbiome remains a significant but underexplored area. Gut bacteria have a profound impact on long-term health, premature aging, and disease risk. Therefore anything that negatively impacts the gut microbiome can also negatively impact your health and disease risk. In addition, there’s something called the estrobolome, which is the portion of the gut microbiome responsible for metabolizing and recycling estrogen, and which impacts estrogen levels throughout the body.
A review study from 2022 showed that oral estrogen alters gut microbiome markers associated with metabolic health and inflammation. In addition, those with lower bacterial diversity in their estrobolome have a higher risk of health complications when taking HRT. Studies also show that HRT may reduce the abundance of beneficial gut bacteria, as well as lead to GI symptoms like bloating, nausea, constipation or diarrhea.
Bottom line: while HRT has become much safer in recent years (better absorbed synthetic formulas, transdermal delivery through the skin instead of the gut and liver), the scientific evidence regarding health risks and microbiome disturbances is still a concern. Hopefully, ongoing research on timing, delivery methods, and complications will help to make HRT more accessible to women who need it.
Given the potential downside of HRT, are there more holistic modalities to manage menopause symptoms effectively and safely? Yes there are! A landmark PCRM (Physicians Committee for Responsible Medicine) study, published in 2021 in the journal Menopause, showed that a plant-based diet is actually superior to HRT for treating menopausal symptoms. 60% of participants were free of hot flashes within the 12-week period and overall, hot flashes decreased by 79%. The great news is that you don’t need to be 100% plant-based to experience these benefits. Focusing on eating a plant-based dinner, and limiting animal protein to one meal a day, or every other day can make a huge difference in vasomotor symptoms like hot flashes.
What else can you do to improve menopausal symptoms naturally? Here are some gut-friendly ideas:
- Hot flashes & night sweats: Limit triggers like caffeine, alcohol, and spicy foods. Explore breathing exercises, yoga, and meditation that have been shown to reduce frequency and intensity of menopausal symptoms. As with andropause, regular exercise also reduces hot flashes and night sweats.
- Sleep: Consistency is key! Try to go to sleep and wake up at around the same time each day, and limit screens, alcohol, and caffeine in the evening. Here’s a reminder of the beneficial sleep habits we’ve previously discussed on the blog.
- Mood swings & anxiety: Move/exercise daily, limit alcohol, join a support group, surround yourself with supportive friends and family, consider adopting a meditation/yoga/mindfulness practice. I know you’ve heard all this before, but the reason we keep saying it is because it works!
- Weight gain: Increase your fiber consumption and reduce intake of processed foods, especially ultra-processed foods (UPFs). Fasting, or time-restricted eating – going 12 to 16 hours without food over a 24-hour period – has been proven to combat weight gain in menopause. Strength training 3 times per week and a regular walking or low impact cardio routine has also been clinically shown to help combat menopausal weight gain.
- Bone & heart health – The three big ones here are smoking cessation, limiting or avoiding alcohol consumption, and engaging in regular (3X per week) weight-bearing exercise.
A final thought: instead of trying to get back to your “old self”, think about evolving into your “new self”. Managing menopause symptoms naturally allows us to evolve into our post menopause selves while minimizing damage to our gut microbiome, improving our overall health, and decelerating aging. Win, win, win!
