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 Women’s 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 Women’s Health Initiative released results from two large clinical trials meant to assess the preventive health benefits of oral HRT – either estrogen alone (referred to as ET) or estrogen plus progesterone (EPT) – 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 shouldn’t 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. “It was a well-conducted study. It’s just that it’s more nuanced,†says Jennifer Howell, MD, an OB/GYN and menopause specialist at Duke Health in Durham, NC. “The study was interpreted more broadly than it should have been.â€
Large swaths of women needlessly scaled back or stopped their HRT cold turkey. “It was a roller coaster,†says Susan Reed, MD, an OB/GYN and menopause research specialist at the University of Washington in Seattle. “I had a lot of people coming in very, very worried.â€Â
Estradiol is a form of estrogen that is commonly prescribed to treat symptoms of menopause. It can be taken as a pill patch, vaginal ring or cream. Many women who take estradiol wonder if they can stop it suddenly or if they need to wean off it slowly. Here is what you need to know about stopping estradiol cold turkey.
What is Estradiol?
Estradiol is the main estrogen hormone produced by the ovaries. It is responsible for developing and maintaining female sex characteristics and for regulating the menstrual cycle.
As women approach menopause, their estrogen levels drop significantly. This decline in estrogen leads to symptoms like hot flashes, night sweats, vaginal dryness, and sleep disturbances. Taking estrogen replacements like estradiol can help relieve these symptoms.
Estradiol is available in different forms
- Oral tablets – taken daily
- Transdermal patches – applied to the skin twice weekly
- Vaginal ring – inserted in the vagina and replaced every 3 months
- Vaginal cream – used daily or twice weekly
The goal of estrogen therapy is to raise estrogen levels back up to relieve menopausal symptoms. Treatment is usually continued for as long as women have symptoms, which on average is about 5 years
Reasons To Stop Estradiol
There are several reasons why a woman might want to stop taking estradiol:
- Menopausal symptoms have lessened or resolved
- Reached maximum recommended treatment duration (around 5 years)
- Experiencing side effects from the medication
- Concern about potential health risks with long-term use
- Breast cancer diagnosis (estrogen can fuel cancer growth)
- Wanting to try managing symptoms without medication
Your doctor should monitor you closely while on estradiol and reevaluate the need for treatment regularly. Some women may be able to stop estradiol once their hot flashes diminish. Others may need to continue for longer to control severe symptoms.
Is It Safe to Stop Estradiol Cold Turkey?
Most doctors recommend tapering estradiol slowly rather than stopping it abruptly. This is to avoid estrogen withdrawal symptoms.
When estradiol is stopped cold turkey, the sudden drop in estrogen can trigger:
- Return of menopausal symptoms like hot flashes and night sweats
- Mood swings, anxiety, irritability
- Trouble sleeping
- Vaginal dryness and discomfort
These symptoms may be more severe than what women experienced prior to starting treatment. The symptoms typically peak within 3-5 days after quitting estradiol and can last for several weeks.
Tapering estradiol allows the body time to adjust to the decreasing amounts of estrogen and can prevent or lessen these withdrawal effects.
How to Safely Stop Estradiol
To discontinue estradiol therapy safely, doctors generally recommend tapering it over a period of 2 to 3 months. There are two main ways to taper estradiol:
1. Gradually reduce the dose
For oral tablets, start by decreasing the dose by half. Take this lower dose for about 2 weeks. Then take half of that dose for 2 more weeks. Continue reducing the dose every 2 weeks until you are no longer taking it.
If using patches, go from changing them twice weekly to once weekly for 2-3 weeks. Then switch to a lower dose patch for 2-3 more weeks before fully stopping.
2. Slowly increase the time between doses
Another method is to slowly extend the time between doses while keeping the dose amount the same. For example, increase the time between doses by 2-3 days each week.
It is important to follow your doctor’s specific recommendations for tapering based on the formulation and dose you are taking. Quitting estradiol cold turkey without medical supervision is not advised.
What to Expect When Stopping Estradiol
Even with slowly tapering estradiol, some women may still experience hormone withdrawal symptoms. However, they are usually less severe compared to abruptly stopping.
Here’s what to expect when coming off estradiol:
- Hot flashes and night sweats returning within 1-2 weeks, peaking in a few weeks, then improving over 2-3 months
- Mood changes like irritability, anxiety, trouble concentrating
- Vaginal dryness and pain with intercourse
- Joint pain or muscle ache
- Trouble sleeping
- Fatigue
Your doctor can provide tips for managing these symptoms, like using fans or layered clothing for hot flashes. For severe symptoms, adding back the lowest dose may help until the symptoms subside. Over time, your body will adjust to the lower estrogen levels.
Other Considerations with Stopping Estradiol
Here are a few other important points about discontinuing estradiol:
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Schedule follow-up visits with your doctor to monitor symptoms and request lab work to check hormone levels if needed.
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Consider starting an over-the-counter vaginal moisturizer or lubricant for vaginal dryness.
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Be aware that bone loss can accelerate once estradiol is stopped, so your doctor may recommend supplements or medications for bone health.
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Some women notice hair thinning when they quit estradiol. This often stabilizes about 6 months after stopping.
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Discuss using lower dose alternatives if symptoms return severely, rather than completely stopping.
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Let your doctor know if withdrawal symptoms do not start to improve after 2-3 months. An evaluation may be needed to look for other possible causes.
The Bottom Line
While some women may be able to stop estradiol abruptly, most doctors recommend tapering it off slowly over 2-3 months to avoid severe withdrawal symptoms. This gives your body more time to adjust to lower estrogen levels. Expect menopausal symptoms to return temporarily as the estradiol leaves your system. Stay in close contact with your healthcare provider to ensure you safely transition off estradiol therapy. With patience and proper monitoring, you can successfully discontinue estradiol treatment when the time comes.
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 didn’t 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. “When you look at it based on age of initiation, actually, those bad things are only happening to the older women in the study,†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 Women’s Health Initiative. ET – which is used only for women who have had a hysterectomy – 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 – which is more common and is used in women who still have a uterus – 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 – only two percentage points higher. “We need to use absolute risk differences when we interpret our findings for our patients,†Reed says. “Period, end of story.â€
WHI authors themselves noted in the study that the 26% increase in breast cancer rates “almost reached†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
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 public’s opinion to favor hormones again. Some studies suggest estrogen may help prevent Alzheimer’s disease, although more data is needed. It’s 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
“What I see now is more people saying, ‘No, that study was debunked! I may be 70, but I’m ready to go on my estrogen,’ †she says. “Some patients get mad at me if I disagree with some influencer that they’ve been following. It’s so hard to do your job.â€Â
For-profit anti-aging clinics, in particular, have seized the opportunity to market hormonal supplements, including to women who shouldn’t be using them, says Howell. “The predatory wellness industry is kind of telling everybody they should be on hormones – they’re backing this with half-truths and touting hormones in a very different way from what the actual science is,†she says.Â
People trying to promote their health in “natural†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 Howell’s clinic with bleeding or other problems. “I’ve seen cancers, I’ve seen patients with testosterone levels [unintentionally] in the male range, I’ve seen all sorts of things,†she says.
“We’ve been fighting this for at least 5 to 10 years,†says Reed. “Menopause became a business, and people are making money off of people with symptoms.â€
It’s important to remember that while the message about estrogen continues to evolve, it’s 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. It’s also not yet clear whether the risks are different for women of different races, as there’s 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 it’s 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.
Doctor REFUSES HRT | “Risks Are Too High at Your AGE”
FAQ
What happens if you suddenly stop taking estradiol?
NEW YORK (Reuters Health) -Though long-term hormone replacement therapy has serious health risks, going off the medication may lead to a return of menopausal symptoms and increased risk for high blood pressure, according to a new study.
Do you have to wean off estradiol?
There is definitely a “Protocol” for weaning down/off of estradiol and/or progesterone HT. Do not stop it all at once under any circumstances; slowly taper down!
How long does estradiol take to leave your system?
| Clinical data | |
|---|---|
| Elimination half-life | Oral: 13–20 hours Sublingual: 8–18 hours Transdermal (gel): 37 hours IM (as EV Tooltip estradiol valerate): 4–5 days IM (as EC Tooltip estradiol cypionate): 8–10 days IV Tooltip Intravenous injection (as E2 ): 0.5–2 hours |
| Excretion | Urine: 54% Feces: 6% |
Will I lose weight if I stop taking estradiol?
Research indicates that stopping HRT is unlikely to result in weight loss. Weight fluctuations may occur due to factors like ageing or menopause, but they are not necessarily linked to HRT usage.
Can you stop estrogen cold turkey?
You can’t really say you quit cold turkey. Estradiol isn’t a drug that causes dependence and the proper way to stop it is to just stop it. I stopped it and had no after effects. Since its estrogen that usually causes breast tenderness, I have no idea why stopping it would do that.
Is it dangerous to quit vaping nicotine cold turkey?
Quitting vaping nicotine ‘cold turkey’ is not dangerous, but it can be very unpleasant. This is because nicotine alters the way your brain functions such that your body feels dependent on it. Some of the unpleasant side effects of quitting abruptly are tremors, headaches, and nausea. These side effects can make it very hard to quit and often cause people to relapse. Fortunately, these unpleasant side effects can be partially or completely avoided by gradually cutting down your use instead of quitting abruptly. Your primary care physician can help you design a plan to quit vaping nicotine.
What happens if you stop HRT cold turkey?
If you stop HRT cold turkey (suddenly) rather than tapering off the dose, you may be more likely to experience symptoms of estrogen withdrawal. These can include: Are there risks to stopping HRT? The most likely risk is that your menopausal symptoms return.
Is cold turkey a weaning off medication?
Any medication you are quit taking with no weaning off period is called Cold Turkey, whether it be additive or not. But you don’t need to wean off of it so stopping it is just stopping it. Is Gabapentin used for hot flashes and night sweats? Still looking for answers? Try searching for what you seek or ask your own question.
How do I stop taking HRT?
If people choose to stop HRT, experts usually recommend coming off the medication slowly. People can do this by gradually reducing the estrogen dosage every few days over several weeks. It may be best to taper off HRT over 3–6 months. If people want to stop taking HRT, it is best to talk with a doctor about how to do it safely.
Is it safe to take estrogen if you’re on HRT?
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.