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Estradiol is the primary and most active form of estrogen, the female sex hormone, in the human body. When estrogen levels decrease many women experience vasomotor symptoms (hot flashes), vaginal dryness and pain with intercourse, urinary urgency/incontinence, decreased libido, increased bleeding with menopausal transition, sleep disturbances, mood lability/depression, migraine headaches, decreased bone mass, and joint aches and pains. The most common symptom of menopause is hot flashes, however, approximately 50% of women develop vulvovaginal symptoms (dryness, irritation, itching, soreness, and pain during intercourse) leading to intimacy and relationship issues. These symptoms can create significant emotional and physical distress.
 
Estrogen replacement therapy replaces the low estrogen levels in the body through an exogenous source (oral pills, transdermal, topical/cream, intrauterine devices, subcutaneous implants) to alleviate menopausal symptoms. Although vaginal creams are the standard treatment for women experiencing only genitourinary symptoms, they do not address other systemic symptoms such as hot flashes. Oral estrogen therapy is the standard treatment for menopausal symptoms and is associated with favorable effects on lipid profiles. Patients are typically started on low doses (0.5mg/day) and titrated to relieve symptoms.
 
Progesterone is a natural hormone produced by the corpus luteum in the ovaries, that is responsible for regulating the menstrual cycle and supporting pregnancy. All women with an intact uterus require the addition of a progestin to their systemic estrogen therapy to prevent endometrial hyperplasia, which may be a precursor to endometrial cancer. Women who have undergone hysterectomy should not receive progestins, as there are no other health benefits other than prevention of endometrial hyperplasia/cancer. In most cases, women taking only low-dose vaginal estrogen do not require progestin.
Oral progesterone, which is bio-identical to progesterone produced by the body, is the preferred choice for progestin therapy. Natural progesterone is believed to have fewer side effects, and be safer for cardiovascular and breast health compared to other synthetic progestins (i.e. levonorgestrel). Although oral progesterone can be taken in a cyclic regimen (12 days/month) to mimic the premenopausal menstrual cycle, most women prefer a continuous combined regimen with estrogen (100 mg daily) to avoid monthly withdrawal bleeding. Women who are not able to tolerate oral progestins, or those in whom oral progestins are contraindicated, 
 
Although estrogen and progesterone are the main female sex hormones, testosterone also plays an important role in libido, maintaining muscle mass and bone density, mood and energy levels, and fertility in women. In addition to decreased testosterone production in menopause, oral estrogens increase levels of sex hormone-binding globulin (SHBG), resulting in even lower free testosterone concentrations. Low testosterone levels in women can lead to diminished libido, vaginal dryness, difficulty reaching orgasm, fatigue, mood swings (depression/anxiety), lack of concentration, muscle weakness, and thinning hair. There is growing evidence to support the use of androgen therapy (i.e. testosterone) in women for sexual function, osteoporosis prevention, brain protection, and breast protection.