HRT and Menopause: Everything Patients Need to Know
What Is Menopause?
Menopause is a natural biological process marking the end of menstrual cycles. It's diagnosed after 12 consecutive months without a period. In the UK, the average age of menopause is 51 years, though it can happen earlier (premature ovarian insufficiency, or POI, affects women before age 40).
Perimenopause is the transition period leading up to menopause, which can last for several years. During perimenopause, hormone levels fluctuate unpredictably, and this is often when symptoms are at their most disruptive.Common Symptoms of Menopause
Vasomotor symptoms:- Hot flushes (experienced by up to 80% of women)
- Night sweats
- Sleep disturbance
- Mood changes, irritability, anxiety, low mood
- Brain fog and difficulty concentrating
- Low motivation
- Vaginal dryness and discomfort (genitourinary syndrome of menopause — GSM)
- Painful sex
- Urinary urgency or increased UTIs
- Joint aches and pains
- Skin changes (thinning, dryness)
- Hair thinning
- Osteoporosis (reduced bone density)
- Increased cardiovascular disease risk
- Urogenital atrophy
What Is Hormone Replacement Therapy (HRT)?
HRT replaces the hormones that decline during menopause — primarily oestrogen and, for women who still have a uterus, progesterone (to protect the lining of the womb).
HRT is widely recognised as the most effective treatment for menopausal symptoms. The 2023 NICE guideline (NG23) on menopause strongly supports HRT as the first-line treatment for bothersome menopausal symptoms, and emphasises that the benefits typically outweigh the risks for most healthy women under 60 or within 10 years of menopause.
Types of HRT
1. Combined HRT (Oestrogen + Progestogen)
For women who have a uterus (womb). The progestogen protects the womb lining from the effects of unopposed oestrogen. Continuous combined HRT:- Oestrogen and progestogen taken every day, no break
- No periods (suitable for women who are post-menopausal or ≥1 year since last period)
- Examples: Evorel Conti patches; Femoston Conti tablets; Kliofem
- Oestrogen daily + progestogen added for 10–14 days per month
- Results in a monthly bleed (period-like)
- Generally used in perimenopause or within first year post-menopause
- Examples: Evorel Sequi patches; Femoston; Elleste Duet
2. Oestrogen-Only HRT
For women who have had a hysterectomy (no uterus). No progestogen needed.- Examples: Oestrogel pump gel; Estradot patches; Zumenon tablets; Sandrena gel
3. Local (Vaginal) Oestrogen
For genitourinary symptoms (vaginal dryness, urinary symptoms) only. Very low systemic absorption — safe for almost all women, including those with contraindications to systemic HRT.- Examples: Vagifem / Vagirux pessaries; Ovestin cream; Estring ring; Imvaggis pessary
4. Testosterone (for Women)
Low-dose testosterone is increasingly recognised for loss of libido, brain fog, and fatigue in menopause. It is currently off-label in the UK (no licensed product for women), but is advocated by the British Menopause Society (BMS).- Used as a gel applied to the skin (Testogel — off-label dose for women: 2.5–5mg daily)
Routes of Administration
| Route | Examples | Notes |
|---|---|---|
| Transdermal patch | Evorel, Estradot | Applied 1–2x weekly; lower blood clot risk than oral |
| Gel | Oestrogel, Sandrena | Applied daily; very stable levels; lower clot risk |
| Tablets | Femoston, Elleste | Most studied; slightly higher clot risk than transdermal |
| Sprays | Lenzetto | Applied to wrist daily |
Benefits of HRT
Symptom Relief
- Hot flushes: 75–95% reduction with HRT
- Night sweats: significant improvement
- Mood / anxiety: substantial improvement
- Vaginal dryness: improvement with local or systemic oestrogen
- Sleep quality: improved
- Libido: improved, especially with testosterone
Long-Term Health Benefits
- Bone protection: HRT maintains bone density, reducing fracture risk
- Cardiovascular benefit: started within 10 years of menopause or before age 60, associated with lower cardiovascular disease risk
- Reduced all-cause mortality in this same window
- May reduce risk of type 2 diabetes and colon cancer
Understanding the Risks
Breast Cancer
The breast cancer risk associated with HRT has been the subject of significant debate — and recent re-analysis of data has substantially revised older estimates downward.
Key facts:- Oestrogen-only HRT (in women without a uterus): no increased risk, and possibly a reduced risk of breast cancer
- Combined HRT (with progestogen): small increased risk — equivalent to drinking 1 glass of wine daily, or obesity
- The absolute increased risk is small: approximately 1 additional breast cancer case per 1,000 women over 5 years of use with combined HRT
- Body-identical progesterone (micronised progesterone, e.g., Utrogestan) appears to carry a lower breast cancer risk than synthetic progestogens
Blood Clots (VTE)
- Oral HRT tablets: small increased risk
- Transdermal HRT (patches, gels): no increased risk
Stroke
- Oral oestrogen: small increased risk
- Transdermal oestrogen: no significant increased risk
When to Seek Medical Advice Urgently
Contact your prescriber or GP immediately if you notice:- Unusual leg swelling or pain (possible DVT)
- Chest pain or breathlessness (possible PE)
- Sudden severe headache
- Yellow skin or eyes (jaundice)
Who Can Take HRT?
Most women can take HRT. However, it may not be suitable for women with:
- Active or recent oestrogen-sensitive breast cancer
- Untreated endometrial cancer
- Recent arterial thromboembolic event (e.g., heart attack, stroke) — with specialist input
- Undiagnosed vaginal bleeding
For women with complex histories (e.g., past breast cancer, unprovoked VTE), specialist menopause clinics can often still help find safe options — most are not absolute contraindications.
Getting Started with HRT
A typical HRT consultation will include:
1. Review of your symptoms and their impact on quality of life
2. Full medical and family history
3. Blood pressure measurement
4. Discussion of HRT options and your preferences
5. Discussion of risks based on your individual profile
6. A prescription and clear plan for monitoring
At GetClinic, our prescribers specialise in women's health and follow current NICE and British Menopause Society guidance.
Frequently Asked Questions
How long can I take HRT? There is no arbitrary time limit. NICE advises that the decision to continue HRT should involve an annual review, weighing individual benefits against risks. Many women choose to continue well into their 60s. Can I start HRT years after my menopause? Yes, though the cardiovascular benefits are most pronounced when started within 10 years of menopause or before age 60. The benefits for symptoms and bone health persist. Will I have periods on HRT? On sequential HRT, yes — a regular withdrawal bleed. On continuous combined HRT, most women have no bleeds (some light spotting in the first few months). Does HRT cause weight gain? Menopause itself causes changes in fat distribution (more abdominal weight). HRT does not cause weight gain and may help by redistributing fat more favourably when oestrogen is replaced.Medical Disclaimer: This article provides general health information only and does not constitute medical advice. Please consult a qualified healthcare professional for personalised guidance.