HRT: The Straight-Talking Guide

Few areas of women’s health generate quite as much noise as hormone replacement therapy (HRT).
Depending on what you’ve read lately, HRT is either something to fear or the secret to better bones, a sharper brain, a healthier heart, a better sex life and eternal youth.
Neither version is particularly helpful.
HRT isn’t one drug. Different hormones, doses and ways of taking them have different benefits and risks. And whether HRT is right for you depends on your symptoms, your health and what matters to you.
So, let’s make it simpler.

What is HRT – and what can it help with?

HRT replaces hormones that decline around menopause.
The main hormone used is oestrogen. If you still have your uterus and take systemic oestrogen – HRT that works throughout the body – you’ll generally also need a progestogen to protect the lining of the uterus. Women who have had a total hysterectomy are generally offered oestrogen-only HRT.
HRT is an effective treatment for hot flushes and night sweats and can help with other menopause symptoms. It also helps protect against the loss of bone that accelerates around menopause and reduces fragility-fracture risk while it is being taken.
Vaginal dryness, burning, discomfort during sex and some urinary symptoms can be treated with vaginal oestrogen. This is a local treatment with minimal absorption into the bloodstream compared with systemic HRT and can be used on its own or alongside systemic HRT.
There are also things HRT has not been shown to do. It isn’t recommended for the purpose of preventing cardiovascular disease or dementia, and the evidence on how HRT affects dementia risk varies according to factors including the type of HRT and age at which it is started. The evidence also doesn’t justify presenting HRT as an anti-ageing treatment or guaranteed route to weight loss.
That doesn’t make HRT less useful. It just means giving it credit for what it actually does.

What type of HRT might you take?

Oestrogen can be taken as a patch, gel, spray or tablet. Patches, gels and sprays deliver oestrogen through the skin and are known as transdermal HRT.
There isn’t one universally “best” form. Your medical history, preferences and how you respond to a particular preparation all matter.
But the route can make a clinical difference. Oral HRT increases the risk of venous blood clots, while NICE says this risk is not increased with transdermal HRT. For women with an increased risk of blood clots, transdermal oestrogen is generally preferred.
If you have a uterus, the progestogen part of HRT can also be given in different ways. Options include micronised progesterone, other progestogens and, for some women, a hormonal coil.
You may be prescribed sequential HRT, where progestogen is taken for part of each month and a regular bleed is expected, or continuous combined HRT, where oestrogen and progestogen are taken continuously and the aim is eventually to be bleed-free.
And testosterone? It has a role, but perhaps not quite the one social media sometimes gives it. NICE recommends considering testosterone for low sexual desire associated with menopause when HRT alone hasn’t been effective. It isn’t established as a general treatment for energy, mood, brain fog or muscle.

What are the benefits?

For a woman struggling with frequent hot flushes, drenched sheets and broken sleep, symptom relief can be a pretty substantial benefit in itself.
HRT is an effective treatment for menopausal hot flushes and night sweats. Vaginal oestrogen is an effective treatment for genitourinary symptoms, and systemic HRT has important benefits for bone health.
But the potential benefits and risks aren’t identical for every woman. They vary according to factors including age, medical history, whether HRT contains oestrogen alone or oestrogen plus a progestogen, how it is taken and how long it is used.
And that brings us to the bit everyone wants to know.

Right. What about the risks?

“Is HRT safe?” sounds like a simple question, but it isn’t a particularly useful one.
A better question is:
What are the benefits and risks of this type of HRT for this woman?

Breast cancer

Combined HRT – oestrogen plus a progestogen – is associated with an increased risk of breast cancer. The increase becomes greater with longer use and declines after stopping, although some increased risk can persist for years afterwards.
Oestrogen-only HRT has a different risk profile. NICE’s current assessment is that it produces very little or no increase in breast-cancer risk.
That distinction matters. Saying simply that “HRT increases breast-cancer risk” bundles together treatments that don’t have the same evidence.
It also helps to put risk into actual numbers.
For example, NICE estimates that among women aged 50–54, around 12 in every 1,000 women who never use HRT would be expected to develop breast cancer over five years, compared with around 21 in every 1,000 current users of combined HRT who started at 50 and used it for five years.
These are population estimates, not a prediction of any individual woman’s risk. Your starting risk can be higher or lower depending on factors such as age, family history, alcohol intake and body weight.
But numbers like these are much more useful than saying a risk has risen by a certain percentage without telling you what the risk was in the first place.
You may also have heard that micronised progesterone is safer for the breast than other progestogens. Some observational research suggests there may be differences, but NICE currently concludes that there isn’t enough evidence to establish whether breast-cancer risk differs with micronised progesterone or dydrogesterone compared with other progestogens.

Blood clots, stroke and heart disease

Route matters here.
Oral HRT increases the risk of venous thromboembolism – blood clots in the veins – whereas NICE says the risk is not increased with transdermal HRT.
Stroke risk also varies with route, dose and age. NICE considers stroke risk unlikely to increase with transdermal oestrogen, while oral oestrogen is associated with increased stroke risk, particularly with increasing dose and age at initiation.
That doesn’t mean transdermal HRT prevents strokes. It means oral and transdermal oestrogen have different risk profiles.
For coronary heart disease, NICE describes the evidence as showing little or no increase in risk with combined HRT and no increase, or a reduced risk, with oestrogen-only HRT. But HRT isn’t recommended specifically for preventing cardiovascular disease.

The lining of the uterus

Systemic oestrogen taken without adequate progestogen increases the risk of endometrial cancer in women who have a uterus.
That’s why the progestogen part of HRT isn’t an optional extra. Its job is to protect the endometrium – the lining of the uterus – from the effects of oestrogen.
And the big-picture number? NICE concludes that overall HRT is unlikely to affect life expectancy. It shouldn’t be presented as either a life-extending miracle or something that generally shortens women’s lives.

So what was all the fuss about HRT?

Much of the fear surrounding HRT can be traced back to 2002, when the first major results from the US Women’s Health Initiative (WHI) hormone trial were published.
The combined-HRT arm studied oral conjugated equine oestrogens plus medroxyprogesterone acetate in postmenopausal women aged 50 to 79. It was stopped early when researchers concluded that the overall balance of risks and benefits didn’t support using that treatment to prevent chronic disease.
The headlines that followed changed attitudes towards HRT for years.
There are now two equally unhelpful ways of telling that story:
“WHI proved HRT is dangerous.”
and
“WHI was wrong and has been debunked.”
Neither is accurate.
WHI remains hugely important. But it studied specific hormone preparations – oral conjugated equine oestrogens and medroxyprogesterone acetate – rather than every form of HRT used today.
That matters because, as we’ve already seen, risks can vary according to the hormones used and how they’re taken.
Longer-term follow-up of the WHI trials has also provided much more information, including different breast-cancer outcomes between women taking combined HRT and those taking oestrogen alone.
The useful lesson isn’t to ignore WHI. It’s to understand that HRT isn’t one treatment with one set of risks.
Side effects, bleeding and finding the right dose
Starting HRT isn’t always a magical moment when everything immediately clicks into place.
Some women experience breast tenderness, headaches, nausea, bloating, mood changes or bleeding when starting or changing treatment. Changing the dose, route or progestogen can sometimes improve side effects.
Bleeding is particularly confusing.
Current NICE guidance says vaginal bleeding is common during the first six months after starting systemic HRT, or for three months after changing the dose or preparation. Bleeding beyond those windows should be discussed promptly with a healthcare professional rather than simply assumed to be caused by HRT.
That doesn’t mean unexpected bleeding automatically means something serious. It means it deserves appropriate assessment.
NICE recommends using the lowest dose that effectively controls symptoms. That’s the lowest effective dose – not the lowest dose you can grit your teeth and tolerate while continuing to have symptoms.

Who needs a more individual conversation?

Some medical histories make HRT decisions more complicated rather than automatically impossible.
Women with a history of breast cancer, blood clots or a medical condition that increases their tendency to clot, cardiovascular disease or stroke, unexplained vaginal bleeding, significant liver disease or certain gynaecological conditions may need individual assessment or specialist advice.
Previous breast cancer is a good example of why blanket rules aren’t always helpful. Systemic HRT isn’t routinely offered after breast cancer, although NICE allows it in exceptional circumstances after discussion of the risks when menopausal symptoms are severe.
Vaginal oestrogen is a separate question because systemic absorption is minimal compared with systemic HRT, although specialist advice may still be appropriate for some women, particularly those taking aromatase inhibitors – a type of hormone treatment used for some breast cancers.
If menopause happens before 40, the advice is different. HRT is generally recommended for women with premature ovarian insufficiency until at least the usual age of natural menopause, unless there is a medical reason not to take it.

Thinking about HRT? Start here

You don’t need to arrive at your GP appointment knowing which patch, progesterone or dose you want.
It helps to know what you’re trying to improve.
Think about your symptoms, how much they’re affecting everyday life, your periods and bleeding, contraception if relevant, your medical and family history, and any medication you’re taking.
For otherwise healthy women aged 45 or over with typical menopause symptoms, hormone blood tests generally aren’t needed to diagnose perimenopause or menopause.
If you start HRT, it may take some adjustment to find the formulation and dose that suit you. Treatment should be reviewed to see whether it’s working, whether you’re experiencing side effects and whether the balance of benefits and risks has changed.
And there isn’t a universal birthday or arbitrary number of years at which every woman must stop HRT.
That doesn’t mean HRT becomes risk-free if you take it indefinitely. It means there isn’t one stop date that makes sense for every woman.

The bottom line

HRT can be a highly effective treatment for menopausal symptoms and has important benefits for bone health. It also has risks – and those risks aren’t the same for every woman or every type of HRT.
You don’t need to be “pro-HRT” or “anti-HRT”.
You need good information about the potential benefits, the risks that actually apply to you, and the options available.
HRT isn’t a miracle and it isn’t a menace. It’s a treatment – and the right decision is an individual one.