For most women, hormone replacement therapy (HRT) is a safe and effective option for relieving menopause symptoms, which can be near disabling and can last for years. And yet, there have been mixed messages about the risks of HRT since the early 2000s when the Womenâs Health Initiative (WHI) suddenly stopped research in its tracks due to concerns about safety.
Experts have since come to question these concerns and have found, for the great majority of women, HRT is a net benefit to health.
By the 1990s, HRT was widely known to significantly reduce many symptoms of menopause. Symptoms include hot flashes, night sweats, poor sleep, mood disorders, trouble concentrating, and problems with sex. There was even some evidence that HRT may be linked to lower risks of age-related conditions like heart disease and dementia. By the turn of the millennium, about 40% of postmenopausal women in the U.S. were using HRT.
But in the early 2000s, the Womenâs Health Initiative released results from two large clinical trials meant to assess the preventive health benefits of oral HRT â either estrogen alone (referred to as ET) or estrogen plus progesterone (EPT) â in almost 30,000 postmenopausal women. The results appeared unexpectedly grim.
According to the WHI, women who received HRT had significantly less osteoporosis and colorectal cancer. But they also reported an apparent higher risk of health conditions such as breast cancer and stroke. The authors made the broad conclusion that HRT poses more risks than benefits and shouldnât be used to prevent disease. The research was stopped due to safety concerns. New prescription guidelines stated that doctors should prescribe HRT only as a last resort, and then only in the smallest effective amount for the shortest possible time. Predictably, prescriptions for oral HRT quickly plummeted.Â
In retrospect, many experts think the WHI conclusions were overly general and the results were sensationalized. âIt was a well-conducted study. Itâs just that itâs more nuanced,â says Jennifer Howell, MD, an OB/GYN and menopause specialist at Duke Health in Durham, NC. âThe study was interpreted more broadly than it should have been.â
Large swaths of women needlessly scaled back or stopped their HRT cold turkey. âIt was a roller coaster,â says Susan Reed, MD, an OB/GYN and menopause research specialist at the University of Washington in Seattle. âI had a lot of people coming in very, very worried.âÂ
Estradiol is a form of estrogen commonly prescribed to women during perimenopause and menopause to help relieve symptoms like hot flashes night sweats vaginal dryness, and mood changes. It comes in various forms like pills, patches, gels, and vaginal rings. While estradiol can be very effective at easing menopause symptoms, some women may eventually decide they want to stop taking it. This leads many to wonder Can I stop taking estradiol cold turkey? Or do I need to wean off it gradually?
The short answer is that quitting estradiol “cold turkey” is not recommended. Stopping it abruptly can cause your menopause symptoms to come back worse than ever. Sudden estrogen withdrawal may also increase your risk for health problems like bone loss and heart disease over time. That’s why most experts advise tapering off estradiol slowly under the supervision of your doctor.
Below is a comprehensive overview of how to safely discontinue estradiol therapy, including why going “cold turkey” is inadvisable, the proper way to wean off estradiol, what withdrawal symptoms to expect, who may require extra care when quitting, and lifestyle changes to ease this transition.
Why Quitting Estradiol Cold Turkey Is Not Advised
While estradiol can be enormously helpful for women in perimenopause and menopause, it does come with potential side effects like bloating, breast tenderness, and an increased risk of blood clots and stroke. Some women also prefer to avoid long-term medication if possible So over time, you may decide you want to stop using estradiol.
When that time comes immediately stopping estradiol is strongly discouraged. This “cold turkey” approach leads to a sudden drop in estrogen levels that can provoke worse menopause symptoms than you had originally. Hot flashes, night sweats vaginal dryness, and mood swings often return with a vengeance. The abrupt loss of estradiol may also trigger new symptoms like joint pain, headaches, and heart palpitations.
In addition, quitting estradiol cold turkey raises your risks for:
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Osteoporosis: Estrogen helps maintain bone density. A steep drop can accelerate bone loss and fracture risk.
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Heart disease: Estrogen has cardiovascular benefits in younger postmenopausal women. Quickly stopping may reduce these heart protections.
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Other long-term health issues: Estrogen aids cognition, memory, skin health, and more. Losing it abruptly could impact numerous body systems.
Basically, your body needs time to readjust its estrogen levels slowly to avoid shock and complications. As hormone specialist Dr. JoAnn Pinkerton explains, “It is important to wean off estrogen therapy gradually rather than stopping it abruptly. Stopping ‘cold turkey’ can cause significant symptoms because the body has become used to having the estrogen stimulation.”
How To Wean Off Estradiol Properly
To safely discontinue estradiol, doctors recommend tapering it down incrementally under medical supervision. This gradual reduction of your dosage gives your body time to reacclimatize to lower estrogen levels. Follow these tips for weaning off correctly:
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Consult your healthcare provider. They will create a customized weaning schedule for you based on factors like your dosage, duration of use, health status, and menopause symptoms. Never attempt to wean off estradiol on your own.
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Expect a slow process. Weaning off estradiol can take anywhere from several months to a year or longer. The lower your starting dose, the quicker you may be able to taper. Higher doses often require very gradual weaning over many months.
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Reduce the dose incrementally. Your doctor will have you decrease your estradiol dosage by small amounts, like 10-25% every 4 to 8 weeks. This steady downward stepping is key to avoiding symptoms.
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Use a tapering aid if needed. If you have severe hot flashes, your doctor may prescribe a different medication while weaning to ease the transition. Antidepressants like venlafaxine (Effexor) help some women manage menopause symptoms as they wean off estradiol.
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Take calcium and vitamin D. These supplements help protect your bones as you lose estrogen’s effects during the weaning process. Weight-bearing exercise is also important.
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Consider lifestyle changes. Eating a balanced diet, exercising regularly, reducing stress, and getting enough sleep can make weaning off estradiol more comfortable. Some women also find relief through acupuncture, hypnosis, or cognitive behavioral therapy.
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Be patient. Listen to your body and adjust the weaning schedule if needed. You may plateau at a certain dose for a while before being ready to taper further. Allow your body time to adapt at its own pace.
With this gradual approach guided by your healthcare provider, most women are able to wean off estradiol successfully. However, for some, menopause symptoms remain challenging even with a slow taper. In such cases, your doctor may advise restarting estradiol at the lowest effective dose if the benefits still outweigh the risks for you.
What to Expect When Weaning Off Estradiol
Weaning off estradiol impacts each woman differently. But some common symptoms are likely to emerge as your estrogen levels decline during the tapering process. Being prepared for these can help ease worries. Here are some withdrawal effects you may experience:
- Hot flashes that return and intensify
- Night sweats disrupting sleep
- Vaginal dryness and painful intercourse
- Joint pain and stiffness
- Mood changes like irritability, anxiety, or depression
- Fatigue, trouble concentrating, memory lapses
- Heart palpitations or irregular heartbeat
- Headaches and dizziness
- Weight fluctuations
- Hair thinning or loss
Typically, these symptoms peak within 1-3 months after weaning off estradiol but gradually improve over 6-12 months as your body recalibrates. Keep your doctor apprised of any symptoms you have while tapering so they can adjust your treatment plan accordingly.
Special Cases Needing Extra Care When Quitting Estradiol
While most women can taper off estradiol safely under a doctor’s supervision, some special scenarios require extra caution and care. These include:
Women using estradiol for cancer treatment: If you take estradiol to suppress ovarian or breast cancer cell growth, do not stop it without guidance from your oncologist. Quitting may spur rapid cancer progression.
Women who started estradiol many years post-menopause: Your risks for health issues like stroke and heart disease are higher if you begin estradiol therapy far past menopause. Weaning off requires meticulous monitoring.
Women with a history of heart problems: Estradiol’s cardio effects can be complex. If you have underlying heart disease, your doctor will monitor you closely throughout the weaning process.
Women using other medications that interact with estradiol: Certain drugs can increase side effects when stopping estradiol. Your tapering schedule must account for these medication interactions.
Women who have had a hysterectomy: You may require additional therapies (like testosterone or progesterone) to counteract estrogen loss during weaning.
Women with severe menopause symptoms: If your symptoms are debilitating despite a slow taper, your doctor may recommend restarting estradiol or trying alternative therapies.
The bottom line is that while most women can successfully wean off estradiol with a slow and steady reduction in dosage, some complex situations require highly customized guidance from healthcare professionals. Don’t hesitate to lean on your doctor’s expertise.
Healthy Lifestyle Changes To Support Weaning Off Estradiol
Making certain lifestyle adjustments can help smooth the process of weaning off estradiol and minimize withdrawal symptoms:
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Eat a nutritious, balanced diet: Eat plenty of fruits, vegetables, whole grains, lean proteins, healthy fats, and calcium-rich foods. Avoid processed foods, excess salt, sugary foods, and refined carbohydrates.
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Exercise regularly: Aim for 30-60 minutes of moderate activity like brisk walking most days to reduce menopause symptoms, strengthen bones, and support heart health.
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Practice stress management: Try yoga, meditation, deep breathing, or mindfulness techniques to counteract mood changes and anxiety during weaning.
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Get enough high-quality sleep: Prioritize 7-9 hours nightly and maintain a consistent sleep routine. This can relieve fatigue, memory issues, and irritability.
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Consider behavioral therapies: Cognitive behavioral therapy, hypnosis, and clinical hypnosis may ease some women through estrogen withdrawal.
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Avoid smoking and limit alcohol: Smoking exacerbates hot flashes and alcohol disrupts sleep. Both undermine your ability to wean off estradiol comfortably.
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Connect with your support system: Share your experience with loved ones. Join a menopause support group to find solidarity.
Implementing healthy lifestyle strategies boosts your chances of successfully discontinuing estradiol therapy. Be patient with yourself throughout the process.
The Takeaway
While estradiol can be very helpful for managing troublesome perimenopause and menopause symptoms, some women
A New Era for HRT
The fear surrounding HRT persisted for years after the WHI studies were published, despite many more studies aiming to clarify the issue, including papers by the WHI itself that separated women by age. None were as highly publicized as the originals. For 2 decades, countless women were under-informed and under-treated for menopause symptoms.
Finally, just in the past year or two, an explosion of media coverage has begun to shift the publicâs opinion to favor hormones again. Some studies suggest estrogen may help prevent Alzheimerâs disease, although more data is needed. Itâs well-established that HRT can significantly improve your risks of osteoporosis, a major health factor for women as they age.Â
Though research is still ongoing, HRT might actually have a protective effect on the heart in some younger women, and while risks to the heart and blood vessels are a key concern in older women, that can sometimes be lessened by using skin patches instead of pills, says Reed. And nothing compares to HRT for relieving menopause symptoms.
But in some ways, the pendulum may have swung too far, says Howell. Many of her patients are getting more and more of their wellness information from social media. Some of them are now under the impression that the WHI trial should be dismissed wholesale and that hormones can be taken at any point without adverse effects.Â
âWhat I see now is more people saying, âNo, that study was debunked! I may be 70, but Iâm ready to go on my estrogen,â â she says. âSome patients get mad at me if I disagree with some influencer that theyâve been following. Itâs so hard to do your job.âÂ
For-profit anti-aging clinics, in particular, have seized the opportunity to market hormonal supplements, including to women who shouldnât be using them, says Howell. âThe predatory wellness industry is kind of telling everybody they should be on hormones â theyâre backing this with half-truths and touting hormones in a very different way from what the actual science is,â she says.Â
People trying to promote their health in ânaturalâ ways end up doing themselves harm by taking unregulated hormonal pills or pellets and spending money out of pocket on unnecessary tests, she says. Some of them end up in Howellâs clinic with bleeding or other problems. âIâve seen cancers, Iâve seen patients with testosterone levels [unintentionally] in the male range, Iâve seen all sorts of things,â she says.
âWeâve been fighting this for at least 5 to 10 years,â says Reed. âMenopause became a business, and people are making money off of people with symptoms.â
Itâs important to remember that while the message about estrogen continues to evolve, itâs only one piece of the puzzle. Along with the timing, risks and benefits also vary depending on your weight, your bone health, whether you have diabetes, and more. Itâs also not yet clear whether the risks are different for women of different races, as thereâs a lack of data on HRT in non-White women.
Ultimately, deciding whether to start HRT, and how long to continue it, is highly specific to each person. As you reach menopause, the best way forward depends on your age, how long itâs been since your last period, your risks of disease, your heart health, and how severely your menopause symptoms are affecting your quality of life. Talk with your doctor about what the most up-to-date research says, and if you have doubts, see a specialist who can give you the best advice possible.
A Reassessment of HRT and the WHI trials
The WHI studies included women within a fairly wide age range of 50 to 79. Most of these women were postmenopausal, something the authors didnât take care to emphasize. Furthermore, none of the women in the study had menopause symptoms.Â
Applying the same conclusion across the board was a mistake, Howell says. The risks depend heavily on timing. âWhen you look at it based on age of initiation, actually, those bad things are only happening to the older women in the study,â she explains. For younger women in good health, HRT is still the first-line treatment for menopause symptoms.Â
Several experts say concerns about increased breast cancer risk may have been overemphasized by the Womenâs Health Initiative. ET â which is used only for women who have had a hysterectomy â had no negative effect on breast cancer risk. In fact, follow-up studies show estrogen can actually protect those women from breast cancer.Â
EPT â which is more common and is used in women who still have a uterus â did appear to increase breast cancer risk by 26% in the WHI studies. That may sound like a lot, says Reed, but it equates to an increase of less than 1 in 1,000 women per year. Put another way, for a 50-year-old overweight person, she explains, the baseline risk of breast cancer is about 6%. Taking EPT for 5 years puts that risk at about 8% over 20 years â only two percentage points higher. âWe need to use absolute risk differences when we interpret our findings for our patients,â Reed says. âPeriod, end of story.â
WHI authors themselves noted in the study that the 26% increase in breast cancer rates âalmost reachedâ statistical significance, but not quite. This means the apparent increase could still be due to chance. Certain common lifestyle habits are known to increase breast cancer risk about the same amount or more, including smoking, alcohol use, and a poor diet.Â
In addition, the risk appears only to develop after about 5-10 years of EPT, then appears to go up slowly with each year of treatment. Further studies have shown that the risk is lower for younger women. More research is needed to find out if HRT is the cause of this increased risk and if it holds true for all women.
There are some real concerns for some women on HRT, says Howell. As a woman gets older and further past menopause, it might be dangerous to reintroduce estrogen after many years without it. In women with arterial plaque buildup, estrogen may cause clotting that, in an already narrowed blood vessel, could lead to a stroke, heart attack, or dementia. Women with breast cancer, heart disease, or who are at a higher risk of getting heart disease may also need to be more cautious with HRT. Talk with your doctor to learn more about your individual risks.Â
But overall, the research is clear that HRT is safe for most women who start it within about 10 years of their last menstrual period, Howell says. For those women, there are actually more benefits than risks, especially in the first 5 years of treatment. A careful analysis of the WHI and other data shows that estrogen actually protects women under 60 from heart disease and osteoporosis, she says.Â
I Stopped Taking HRT (Hormone Replacement)… Here’s What Happened!
FAQ
What happens if you suddenly stop taking estradiol?
Do you have to wean off estradiol?
What are the symptoms of estrogen withdrawal?
Can I stop estrogen pills cold turkey?