When menopause is discussed, a clear message often emerges: hormone replacement therapy is the most effective. Herbal remedies usually fare worse in comparisons. This was also the case in a report by n-tv based on an evaluation by Stiftung Warentest.
The statement that hormone therapies are more effective against symptoms like hot flashes is technically correct. However, what is often lacking in public discourse is a nuanced consideration of the benefits and risks.
This article puts the data into context and shows what the research actually says.
What hormone therapies can achieve
Menopausal hormone therapy (MHT), formerly often referred to as hormone replacement therapy, usually consists of estrogen alone or a combination of estrogen and progestin. It is considered the most effective treatment for vasomotor symptoms such as hot flashes and night sweats.
International guidelines clearly confirm this efficacy. The North American Menopause Society (NAMS) states that hormone therapy is the most effective treatment for vasomotor symptoms (NAMS Position Statement 2022, PubMed: https://pubmed.ncbi.nlm.nih.gov/35797481/ ). ).
The large Women's Health Initiative (WHI) also provided robust data on symptom control, but at the same time made it clear that a differentiated risk assessment is necessary (WHI Follow-up Analyses; PubMed: https://pubmed.ncbi.nlm.nih.gov/12117397/ ). ).
In such assessments, the rating "effective" primarily refers to the degree of symptom reduction. It says nothing about how the overall benefit-risk profile should be evaluated.
Which risks are scientifically described
Thrombosis and stroke
Several large randomized trials and meta-analyses show that oral combined hormone therapies may be associated with an increased risk of venous thromboembolism. The risk of stroke may also increase slightly under certain circumstances.
A comprehensive meta-analysis in The Lancet describes an increased risk of venous thrombosis during oral hormone therapy, particularly with combination preparations (Vinogradova et al., 2019; PubMed: https://pubmed.ncbi.nlm.nih.gov/30910380/ ). ).
The individual risk depends heavily on age, time since menopause, pre-existing conditions, body mass index, and route of application. Transdermal applications appear to be more favorable with regard to thrombosis than oral preparations.
Breast cancer risk
One sensitive issue is the risk of breast cancer. In 2019, the Collaborative Group on Hormonal Factors in Breast Cancer published a large meta-analysis in The Lancet, which showed that combined estrogen-progestin therapies in particular are associated with an increased risk of breast cancer, which increases with the duration of use (PubMed: https://pubmed.ncbi.nlm.nih.gov/31474332/ ). ).
The important thing to put it in perspective: the absolute risk remains relatively low for many women, but increases with longer use.
Ovarian cancer
Observational studies also suggest a slight increase in the risk of ovarian cancer during long-term hormone therapy, although this is significantly less common than in breast cancer (Collaborative Group on Epidemiological Studies of Ovarian Cancer, Lancet 2015; PubMed: https://pubmed.ncbi.nlm.nih.gov/25684585/ ). ).
The timing window
Modern guidelines refer to the so-called "timing hypothesis" approach. If hormone therapy is started in healthy women under 60 years of age or within ten years of menopause, the benefit-risk ratio appears to be more favorable than if it is started later.
This is also pointed out in the position paper of the North American Menopause Society (PubMed: https://pubmed.ncbi.nlm.nih.gov/35797481/ ). ).
Comparison of herbal preparations
Herbal remedies such as isoflavones from soy or red clover, black cohosh (Cimicifuga) or special rhubarb extracts are often used as hormone-free alternatives.
Systematic reviews show that isoflavones can moderately reduce hot flashes, but significantly less so than classic hormone therapy (e.g., Taku et al., 2012; PubMed: https://pubmed.ncbi.nlm.nih.gov/22433977/ ). ).
The data on black cohosh is heterogeneous. Some studies show effects, others do not. Overall, the evidence is less consistent than for hormone therapies.
It is important to put things into perspective: Lower average efficacy does not mean ineffectiveness. At the same time, herbal preparations do not interfere systemically with the hormonal balance in the same way and usually exhibit a different side effect profile in studies.
Why "stronger" doesn't automatically mean "better"
The decision for or against hormone therapy is not a purely pharmacological question, but rather an individual assessment.
The following should be taken into account:
• Severity of symptoms
• Personal risk factors
• Age and time since menopause
• Planned duration of application
• Personal preferences and need for security
International guidelines explicitly emphasize the need for individualized advice and joint decision-making.
Conclusion
Hormone preparations are considered the most effective therapy for pronounced vasomotor symptoms of menopause. At the same time, they are associated with clearly described, albeit individually varying, risks.
Herbal preparations show, on average, lesser effects, but may be an option for women with mild symptoms or contraindications to hormones.
A responsible approach to menopause means presenting the benefits and risks transparently and making individual decisions.
This article serves solely to provide factual information about the current state of research. It does not constitute medical advice or a recommendation to take specific products.
