There is no single answer that applies to everyone when it comes to whether menopausal hormone therapy is truly necessary. Even with the same menopause, one person may be unable to sleep because of hot flashes, another may have almost no symptoms, and yet another may need to care for bone and vascular health together because of early menopause. For this reason, hormone therapy is not a binary of "necessary or not," but an area decided individually by weighing benefits against risks on a scale. In the clinic, this very decision-making process is what patients are most curious about, so today we will walk through, step by step, who decides on treatment and by what criteria.
Hormone therapy is not a matter of "whether it is needed" but of "benefit versus risk"
The core of menopausal hormone therapy is not whether it is effective, but whether that effect is greater than the risk one must accept. Modern menopause medicine does not uniformly recommend hormone therapy for all menopausal women. Instead, it advises weighing the pros and cons by considering the severity of symptoms, age, timing of menopause, comorbidities, and personal values together.
In its 2022 hormone therapy position statement, the North American Menopause Society stated that treatment should be a shared decision-making process in which the physician and patient review benefits and risks together, and that it should be reassessed periodically. The UK's NICE likewise emphasized an individualized approach and shared decision-making in its 2024 revision of the menopause guideline. In other words, the correct starting point is not "you are menopausal, so let us start hormone therapy," but "given your symptoms and risk factors, there are these benefits and these cautions—how would you like to proceed?"
Hormone therapy is neither a treatment that everyone must receive nor one that everyone must avoid. It is closer to a tailored treatment in which you decide, in light of your symptoms and health status, whether the benefits outweigh the risks.
In the same vein, the answer to when hormone therapy is needed inevitably differs from person to person.
Three representative situations in which treatment is considered
The situations in which the benefits of hormone therapy appear relatively clearly can be summarized into three. They are also the core axes of menopause care that were noted in the original article.
The first is vasomotor symptoms. Hot flashes, in which the face suddenly feels hot and sweaty, and night sweats are representative, and hormone therapy is reported to be currently the most effective treatment for these symptoms. The second is genitourinary atrophy symptoms. The third is the prevention and treatment of osteoporosis, which helps slow the bone loss accelerated by menopause. In particular, in cases of early menopause, hormone deficiency continues for a long time until the natural age of menopause, so treatment is actively considered to protect the bones and blood vessels.
The following table briefly summarizes what to expect in each of the three situations.
| Situation considered | Main symptoms | What is expected from treatment |
|---|---|---|
| Vasomotor symptoms | Hot flashes, night sweats, sleep disturbance | Reduced frequency and intensity of symptoms |
| Genitourinary atrophy | Vaginal dryness, painful intercourse, itching | Mucosal recovery and reduced discomfort |
| Bone health | Bone loss, osteoporosis, fracture risk | Slowed bone loss and reduced fracture risk |
You can review the detailed symptom patterns together in the menopausal symptoms summary.
Objectively gauging the severity of symptoms — the Kupperman index
To decide whether to treat, you first need to objectively gauge how severe your symptoms are. In the clinic, we refer to the Kupperman index. It is a tool that scores various symptoms such as hot flashes, sweating, insomnia, depression, and joint pain to express the overall burden of menopausal symptoms numerically.
This index does have limitations, however. As the Korean Society of Menopause materials also point out, the Kupperman index does not sufficiently reflect the discomfort and pain of genitourinary symptoms. So even when there are symptoms such as vaginal dryness or painful intercourse that are not well captured in the score but greatly lower quality of life, hormone therapy is considered.
In clinical experience, the process of listening together to how that number translates into discomfort in daily life is more important than the score itself.
Many people are curious from the moment symptoms begin, and understanding the symptoms, causes, and mechanisms of bodily changes in menopause first makes it much easier to assess your own condition. If you are unsure about the severity of your symptoms and whether treatment is suitable, feel free to ask about menopausal symptoms and the direction of treatment.
Genitourinary atrophy, an easily missed decision criterion
Genitourinary atrophy symptoms are one of the important reasons for considering menopausal hormone therapy. The mucosa of the vagina and urethra is highly sensitive to female hormones, so as hormones decrease after menopause, symptoms due to atrophy gradually appear.
Vaginal dryness is representative, and as the elasticity of the vagina declines and lubrication decreases, painful intercourse is induced. Atrophic vaginitis, which causes itching and stinging in the vagina, may also be accompanied by mild bleeding. Such symptoms tend not to improve on their own over time and rather to progress gradually, so consulting early is helpful.
There is a reason this part is important among the decision criteria. Even for someone for whom systemic hormone therapy feels burdensome, if the symptoms are confined to the genitourinary area, a more localized method such as local estrogen can be reviewed as an option. The detailed usage and cautions are summarized in the safe use of local estrogen, and you can also refer to self-diagnosis and care for menopausal vaginal dryness. Depending on the location and extent of the symptoms, the approach of menopausal hormone care also varies.
Bone health and other benefits, and early menopause
The prevention and treatment of osteoporosis is another clear axis for considering hormone therapy. It is reported that providing hormone therapy to menopausal women can reduce bone loss and decrease fractures due to osteoporosis.
As mentioned in the original article, hormone therapy has been reported in some studies to be associated with ancillary benefits such as a reduced risk of colorectal cancer and improved skin elasticity. However, these additional effects are not the main purpose of treatment. The NICE 2024 guideline recommends hormone therapy for the purpose of symptom relief but states that it should not be used for the purpose of preventing cardiovascular disease or dementia. In other words, the approach of "receiving hormone therapy for prevention" is not recommended.
By contrast, early menopause is a different matter. When hormones are deficient at an early age, the effects on bones and blood vessels accumulate over a long period, so hormone therapy is generally actively considered until the natural age of menopause. If you are curious about managing bone health, we recommend reading the diagnosis and prevention of osteoporosis together.
The timing of initiation determines benefit and risk
Even with the same hormone therapy, the balance of pros and cons changes depending on when it is started. The North American Menopause Society's 2022 position statement recommends stratifying risk by age and time elapsed since menopause.
In general, in healthy symptomatic women who are under 60 and within 10 years of menopause, the benefits are reported to outweigh the risks in many cases. Conversely, when starting for the first time more than 10 years after menopause or at age 60 or older, it is explained that the absolute risks of coronary artery disease, stroke, and venous thromboembolism increase, making the balance of pros and cons less favorable.
The method of administration also governs risk. It is reported that transdermal preparations absorbed through the skin and low doses may help reduce the risk of venous thrombosis and stroke more than oral medications. So even for the same patient, individualization is needed to find the most suitable method by combining age, timing, and route of administration. For this reason, how long hormone therapy should be continued is also decided differently for each person.
Cases that require caution or should be avoided
Hormone therapy has clear benefits, but there are also cases that should be approached cautiously or avoided. This is why risk factors must be checked thoroughly in the decision-making process.
In general, in cases with a history of hormone-dependent malignancies such as breast cancer, venous thromboembolism or active thrombotic disease, or cardiovascular disease such as coronary artery disease or stroke, it is recommended that systemic hormone therapy be avoided or decided on very cautiously. Both the American College of Obstetricians and Gynecologists and the Korean Society of Menopause's 2025 guidelines emphasize that, after checking for such contraindications, treatment should be started at the lowest effective dose in symptomatic women without contraindications and reassessed periodically.
Below is a brief summary of the items checked before a decision.
- A personal or family history of hormone-dependent cancers such as breast cancer
- A history of venous thrombosis, pulmonary embolism, or deep vein thrombosis
- A history of cardiovascular disease such as coronary artery disease or stroke
- Vaginal bleeding of unknown cause
- Comorbidities such as liver disease and medications being taken
Of course, having a contraindication does not mean every path is blocked. Other options such as non-hormonal treatment or local treatment can be reviewed together. If you have wondered whether it is safe because you are worried about side effects of hormone therapy, this very checking process is the procedure for securing safety.
In the end, the decision is made together, and revisited regularly
The decision about menopausal hormone therapy does not end with a single moment. Beyond weighing the benefits and risks when first starting, the decision must be re-examined periodically throughout the course of treatment, reflecting changes in symptoms and new risk factors.
That is why the process of deciding together with an obstetrician-gynecologist who can provide a thorough history and tailored consultation is most important. The essence of hormone therapy is finding together, by synthesizing your symptoms, age, timing of menopause, and comorbidities, "which choice has the greater benefit for me right now." If you are hesitant about whether to undergo treatment, we recommend a consultation in which you weigh the benefits and risks together with a specialist rather than judging alone.
Written by: Lee Dong-hee Director · Obstetrics and Gynecology Specialist · View medical staff profile
First published November 5, 2023 · Last reviewed May 30, 2026
References: The North American Menopause Society 2022 Hormone Therapy Position Statement (2022), NICE Menopause Guideline NG23 (2024), Korean Society of Menopause Clinical Practice Guidelines for Menopausal Hormone Therapy (2025), American College of Obstetricians and Gynecologists Hormone Therapy for Menopause (2023)
This article is intended to provide general health information and does not replace individual diagnosis or treatment. If you have symptoms, please consult through a medical visit.