Hormone replacement therapy in menopause: an updated narrative review of benefits, risks and clinical recommendations

Background. Menopause, resulting from a decline in es­tro­gen production, is associated with vasomotor, urogenital, ske­le­tal, cardiovascular and neurocognitive changes. Hor­mone replacement therapy (HRT) is the most effective op­tion for managing moderate to severe symptoms, but its use requires careful, individualized evaluation of benefits and risks. Methodology. This narrative review synthesizes find­ings from randomized clinical trials, meta-analyses, large-scale observational studies and international guide­lines published between 2000 and 2024, focusing on the efficacy, safety, patient-centered strategies and bio­iden­ti­cal hormone therapy (BHT). Results. Evidence shows that HRT markedly reduces vasomotor symptoms, im­proves genitourinary health, helps maintain bone mi­ne­ral density and, when started before the age of 60 or with­in a decade after menopause, it may provide car­dio­vas­cu­lar advantages. Transdermal estrogen is linked to a reduced risk of venous thromboembolism compared to oral formulations, while low-dose local estrogen effectively treats urogenital atrophy, with minimal systemic exposure. Al­though BHT is well-tolerated in some observational stu­dies, high-quality randomized data remain scarce. Con­clu­sions. Timely and individualized initiation of hor­mone replacement therapy can deliver significant im­prove­ments in symptoms, bone integrity and selected car­dio­vas­cu­lar outcomes. The optimal management should fol­low evi­dence-based recommendations, include periodic reas­ses­sment, and involve shared decision-making with the pa­tient.