Menopausal hormone therapy (MHT) is an established first-line therapy for moderate to severe vasomotor symptoms and genitourinary syndrome of menopause (GSM), and it helps maintain bone density to prevent osteoporosis. MHT typically consists of estrogen (e.g., 17β-estradiol or conjugated equine estrogens) with addition of a progestogen for women with a uterus. It can be administered orally or transdermally for systemic relief, or via low-dose vaginal estrogen for isolated GSM symptoms. Therapy should be individualized in terms of patient selection, timing, dose, and route: initiating MHT within 10 years of menopause onset or before age 60 optimizes benefits and minimizes risks. MHT effectively alleviates hot flashes (~90% reduction) and urogenital atrophy, prevents bone loss and fractures, and may confer metabolic and mood benefits, thereby improving quality of life. Adverse effects include nausea, bloating, and mood swings; prolonged or late-initiated therapy can increase risks of breast cancer, venous thromboembolism, and stroke. Absolute contraindications include estrogen-dependent malignancies, unexplained vaginal bleeding, and active thromboembolic or cardiovascular disease. Newer alternatives such as tibolone (a synthetic steroid) and estetrol (a novel estrogen) are being explored to expand therapeutic options. Overall, when used judiciously in appropriate candidates, MHT safely improves menopausal symptom control and quality of life.