Hormone replacement therapy (HRT) is a treatment that replaces hormones — primarily oestrogen and progesterone — that decline during the menopause. It is the most effective treatment for menopausal symptoms and is now recommended by NICE and NHS guidelines as a first-line option for most women. After a period of controversy, a major reassessment of the evidence has confirmed that for most women under 60 or within 10 years of menopause, the benefits of HRT significantly outweigh the risks.
Why HRT Is Needed
During the menopause (average age 51 in the UK), the ovaries stop producing oestrogen and progesterone. This hormonal decline causes the wide range of symptoms associated with the menopause and perimenopause, including hot flushes, night sweats, vaginal dryness, sleep disruption, mood changes, and cognitive difficulties. Beyond symptoms, oestrogen loss accelerates bone loss (increasing osteoporosis risk) and increases cardiovascular risk.
Types of HRT
Oestrogen-Only HRT
Used in women who have had a hysterectomy (no uterus). Taking oestrogen alone in women with a uterus increases the risk of womb (endometrial) cancer — so progesterone must always be added.
Combined HRT (Oestrogen + Progestogen)
- Sequential (cyclical) HRT — Oestrogen taken every day; progestogen added for 12–14 days per month. Causes a monthly bleed. Recommended for perimenopausal women or those within 1 year of last period.
- Continuous combined HRT — Both hormones taken every day; no bleed intended. Suitable for postmenopausal women (12+ months since last period). May cause irregular spotting in the first 3–6 months.
Micronised Progesterone (Utrogestan)
Utrogestan is a body-identical progesterone (bioidentical) — chemically identical to the progesterone made by the body. Evidence suggests it carries a lower risk of blood clots and breast cancer than synthetic progestogens (progestins). It is available on the NHS and is the preferred progestogen in current UK prescribing.
Routes of Administration
| Route | Examples | Key Points |
|---|---|---|
| Patches | Evorel, Estradot, FemSeven | Twice-weekly or weekly; lower clot risk than oral; good for migraines |
| Gel | Oestrogel, Sandrena | Daily application to skin; preferred transdermal route; no first-pass liver effect |
| Spray | Lenzetto | Applied to inner forearm daily |
| Oral tablets | Elleste Solo, Premarin | Convenient but passes through liver; slightly higher VTE risk than transdermal |
| Implants | Oestradiol implant | Inserted under skin; lasts 4–8 months; specialist-led |
| Vaginal (local) | Vagifem tablets, Ovestin cream, Estring ring | Local oestrogen for GSM; minimal systemic absorption; safe long-term |
Transdermal oestrogen (patches, gel, spray) does not increase the risk of blood clots (VTE) or stroke, unlike oral oestrogen. NICE and the British Menopause Society recommend transdermal as the preferred route, particularly in women at higher VTE risk.
What HRT Treats
- Hot flushes and night sweats (vasomotor symptoms) — 90% improvement with HRT; the most effective treatment available
- Sleep disturbance — Directly and indirectly (by reducing night sweats)
- Vaginal dryness, soreness, urinary symptoms — Genitourinary syndrome of menopause (GSM); local or systemic oestrogen effective
- Mood changes, low mood, anxiety — HRT can significantly improve mood in the context of menopause
- Brain fog and cognitive symptoms
- Joint aches and pains
- Reduced libido — Testosterone (off-label) can be added for low sexual desire
- Bone protection — HRT prevents osteoporosis and reduces fracture risk; a recognised indication
Benefits of HRT
- Highly effective symptom relief — improves quality of life significantly
- Reduces risk of osteoporotic fractures (hip, vertebral, wrist)
- Reduces risk of type 2 diabetes
- May reduce cardiovascular disease risk when started within 10 years of menopause (“window of opportunity”)
- Reduces risk of bowel cancer
- May reduce all-cause mortality in women who start HRT before age 60
Risks of HRT
Breast Cancer
The most discussed risk. The absolute risk increase is small and depends on the type of HRT and duration:
- Oestrogen-only HRT: little or no increased breast cancer risk for up to 5 years; small risk increase with longer use
- Combined HRT with synthetic progestogen: small increased risk — approximately 1 extra case per 1,000 women per year of use; less than the risk from drinking one glass of wine per day or being overweight
- Combined HRT with micronised progesterone (Utrogestan): the safest combination — studies (including the French E3N cohort) suggest no significant increase in breast cancer risk
- Risk returns to baseline within a few years of stopping HRT
Blood Clots (VTE)
Oral oestrogen increases VTE risk. Transdermal oestrogen (patches, gel, spray) does not increase VTE risk and is recommended for women with risk factors. This is now well-established in the evidence base.
Stroke
Oral HRT carries a small increased stroke risk. Transdermal oestrogen at standard doses does not appear to increase stroke risk.
Womb Cancer (Endometrial Cancer)
Oestrogen taken without progestogen increases endometrial cancer risk in women with a uterus. Always taking adequate progestogen (or having a Mirena IUS, which delivers levonorgestrel locally) eliminates this risk.
Who Should Not Take HRT
HRT is not suitable for women with:
- Oestrogen-receptor-positive breast cancer (current or past) — specialist review required; many guidelines now allow local vaginal oestrogen
- Undiagnosed vaginal bleeding
- Untreated endometrial cancer
- Active blood clot (VTE) — transdermal may be considered after risk assessment
- Severe active liver disease
- Pregnancy
Testosterone for Women
Testosterone can be added to HRT for women with low libido (hypoactive sexual desire disorder, HSDD) that has not improved with oestrogen alone. It is used off-label in the UK as no female-specific testosterone product is licensed (men’s products are used at a fraction of the male dose). NICE guidance (2015, updated 2019) recommends considering testosterone for menopausal women with low sexual desire if HRT alone is not effective. Blood levels should be monitored to stay within normal female ranges.
Premature Ovarian Insufficiency (POI)
Women with POI (menopause before age 40) have higher risks of osteoporosis, cardiovascular disease, and cognitive decline from prolonged oestrogen deficiency. HRT is strongly recommended for women with POI and should be continued at least until the average age of natural menopause (51). These women should receive higher doses of oestrogen than standard HRT.
How Long Can You Take HRT?
There is no fixed maximum duration. The decision to continue is individual, based on ongoing symptom benefit versus risks. NICE guidance (2015) and the British Menopause Society support continuing HRT as long as symptoms persist and after annual review of benefits and risks. Many women take HRT for 10 or more years. There is no age at which it must automatically be stopped.
Getting HRT on the NHS
- See your GP — discuss your symptoms; HRT is available on NHS prescription
- From April 2023, a prepayment certificate for HRT (£31.25/year) covers all HRT prescriptions at a fixed annual cost — reducing the cost barrier significantly
- If your GP is unsure, ask for a referral to a menopause specialist or NHS menopause clinic
- The British Menopause Society lists accredited specialists at thebms.org.uk
Support and Resources
- British Menopause Society — thebms.org.uk — Professional guidance and specialist finder
- Menopause Matters — menopausematters.co.uk — Information for women
- Daisy Network — daisynetwork.org — Support for premature ovarian insufficiency
- NHS Menopause information — nhs.uk/conditions/menopause
- Henpicked: Menopause in the Workplace — henpicked.net
This page is for educational purposes. Discuss your individual circumstances with your GP or a menopause specialist before starting or stopping HRT.
Related Health Guides on YourHealthXpert
Explore these related NHS-aligned health guides:
- Menopause Guide — HRT is the primary treatment for menopausal symptoms; understand the full picture of perimenopause and menopause NHS management.
- Osteoporosis Guide — HRT is one of the most effective ways to prevent postmenopausal osteoporosis; learn about the NICE evidence and NHS prescribing.
- Breast Cancer Guide — HRT’s relationship with breast cancer risk is nuanced; understand what the latest NICE evidence says and what to discuss with your GP.
- Heart Attack Guide — Oestrogen has cardioprotective effects; learn how HRT timing affects cardiovascular risk and the NHS guidance on heart-healthy prescribing.
- Cervical Screening Guide — HRT can affect vaginal and cervical cell changes; understand what to tell your smear test nurse and what this means for results.
- Anxiety & Depression Guide — Hormonal changes in perimenopause significantly impact mental health; learn how HRT can help and when additional NHS support is needed.