Does hormone replacement therapy (HRT) reduce metabolic risk in peri/menopause?

With the changes that happen in a woman’s body with peri/menopause, the risk of metabolic health conditions like diabetes, cardiovascular disease, and MASLD/MASH (formerly ‘fatty liver disease’) increase. Can hormone replacement therapy (HRT) reduce this metabolic risk?

Weight management: As blogged previously, HRT does not result in weight loss, and should not be used as a weight management strategy. Some studies have suggested that there may be a little less weight gain in women using HRT, but the effect is very small, about 1-2lb (0.5-1kg). We also don’t have convincing evidence that HRT helps to maintain a favorable body composition (more muscle, less fat). Studies are conflicting as to whether or not HRT has an effect on fat distribution [visceral (in and around abdominal organs) vs subcutaneous fat]. The timing of HRT may however be important here, with at least some data suggesting that there may be less central fat deposition in women who received HRT immediately after menopause.

Diabetes: HRT seems to reduce the risk of developing type 2 diabetes in peri/menopausal women by 21-35% (see here and here and here). This analysis suggested that the estimated benefit for women age 50-59 was 11 fewer cases of type 2 diabetes per 1000 women, per 5 years of HRT use. However, HRT is not recommended for the goal of diabetes prevention.

MASLD/MASH (‘fatty liver disease’): The data are not clear on this, with conflicting results (as blogged previously).

Hypertension: HRT may cause a small increase in blood pressure, and does not protect against the development of hypertension.

Obstructive sleep apnea: Existing data are inconclusive.

Cholesterol: Oral estrogen has some benefit to cholesterol (more so than estrogen gel or patch applied to the skin), though some progestrogens can negate this benefit. HRT should not be used to prevent cholesterol problems.

Cardiovascular (CV) disease: This topic is complex and outside of the scope of today’s post. Whether or not HRT increases CV risk varies by age, type of HRT and how the HRT is given. HRT is not recommended for prevention of cardiovascular disease.

BOTTOM LINE: Hormone replacement therapy (HRT) may have beneficial impact to reduce risk of diabetes, but may increase the risk of other metabolic health conditions. While HRT may be a valuable treatment strategy for some women struggling with menopausal symptoms, it should not be used solely for metabolic health reasons. HRT does not result in weight loss, and should not be used as a weight management strategy. An individualized, holistic strategy to optimize metabolic health in peri/menopause, most often including attention to weight management, is important.

Share this blog post using your favorite social media link below!

Follow me on X/twitter! @drsuepedersen