OBJECTIVE: To comprehensively evaluate the efficacy and safety of hormone replacement therapy (HRT) in managing menopausal syndrome through a meta-analysis. METHODS: A systematic search was conducted across Pubmed, Embase, and Cochrane Library databases utilizing keywords such as "menopause", "hormone replacement therapy", and "menopausal syndrome" from their inception until July 2024. Randomized controlled trials (RCTs) related to HRT's role in treating menopausal symptoms were included. Two researchers independently reviewed literature, extracted data, and assessed study quality. Meta-analysis was performed using RevMan 5.3 software, incorporating calculations of standardized mean difference (SMD) and odds ratio (OR), using either fixed-effects or random-effects models. RESULTS: A total of 24 studies, involving 5089 patients, were included in the analysis. Among these, 3062 patients received HRT as the HRT group, while 2027 patients without HRT comprised the control group. The pooled results: (1) In subgroups with estradiol-containing drugs, the change in Kupperman menopause index (KMI) in the HRT group was significantly smaller than that in the control group [SMD=-1.21 (-1.43, -0.98), CONCLUSION: HRT can enhance the quality of life and vaginal health in women experiencing menopausal symptoms, elevate estrogen levels, and improve bone density, while demonstrating a favorable safety profile with no significant increase in adverse events or dyslipidemia risk. Further investigations involving multi-center, large-scale studies with long-term follow-up are warranted to substantiate this conclusion.