Hormone Replacement Therapy
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Hormone Replacement Therapy (HRT)
Types, benefits, risks, who HRT is suitable for, and UK prescription options — the definitive Access Doctor guide.
Key fact: HRT is the most effective treatment for menopausal symptoms and is recommended by NICE for women with troublesome symptoms following an individual benefit-risk discussion. For most healthy women under 60 who start HRT within 10 years of menopause, the benefits outweigh the risks. The landscape of evidence — and medical opinion — has shifted significantly since the 2002 WHI study that caused widespread concern; NICE NG23 (2015, updated 2019) provides a more nuanced, individualised approach.
What Is HRT?
Hormone replacement therapy (HRT) replaces the oestrogen — and where required, progestogen — that the body stops producing at menopause. Oestrogen is produced primarily by the ovaries. At menopause, ovarian function declines and oestrogen levels fall significantly, causing the characteristic symptoms of menopause.
HRT restores oestrogen to physiological levels, relieving symptoms and providing longer-term health benefits including protection against osteoporosis and, in some contexts, cardiovascular disease. When oestrogen is given to women who still have a uterus, a progestogen is added to protect the uterine lining (endometrium) from the stimulatory effect of oestrogen alone, which would otherwise increase the risk of endometrial cancer.
HRT has been used since the 1940s and is the most studied drug class in women’s health. Current UK prescribing is guided by NICE guideline NG23 (2015, updated 2019), which moved away from a “one-size-fits-all” risk approach to an individualised benefit-risk discussion.
Menopause and Perimenopause
Understanding the stages of the menopausal transition helps clarify when HRT is appropriate and which type to use.
| Stage | Definition | Hormone Profile | HRT Role |
|---|---|---|---|
| Perimenopause | The transition period leading up to menopause, typically lasting 4–8 years. Cycles become irregular; symptoms may begin. | Fluctuating FSH and oestrogen; progesterone declining | HRT can be started; combined sequential HRT used if still menstruating; important to maintain contraception |
| Menopause | Defined retrospectively as 12 consecutive months without a menstrual period. Average age in the UK: 51 years. | Persistently elevated FSH (>30 IU/L); low oestradiol | HRT most commonly initiated here; continuous combined HRT appropriate if >1 year post-menopause |
| Premature ovarian insufficiency (POI) | Menopause before age 40 — affects approximately 1% of women. | Elevated FSH before age 40; low oestrogen | HRT strongly recommended until at least age 51 to protect cardiovascular and bone health |
| Surgical menopause | Menopause following bilateral oophorectomy (ovary removal). Abrupt onset; symptoms often more severe. | Immediate very low oestrogen; no transition period | HRT particularly important; oestrogen-only if uterus removed; symptoms typically severe without treatment |
Symptoms HRT Treats
HRT is highly effective for the full range of menopausal symptoms. Some symptoms respond within weeks; others may take 3 months to improve fully.
Vasomotor symptoms
Hot flushes and night sweats affect up to 80% of women. HRT reduces frequency and severity by 75% on average — significantly more effective than any alternative treatment including SSRIs or gabapentin.
Genitourinary symptoms
Vaginal dryness, soreness, and recurrent UTIs due to urogenital atrophy. Responds well to both systemic HRT and low-dose local vaginal oestrogen (which can be used alone or alongside systemic HRT).
Sleep disturbance
Insomnia and non-restorative sleep are frequently secondary to night sweats. Treating vasomotor symptoms with HRT typically produces rapid improvement in sleep quality.
Mood changes
Low mood, irritability and anxiety are common in perimenopause and early menopause, often linked to oestrogen fluctuation and sleep disruption. HRT — particularly oestrogen — has a positive effect on mood in menopausal women distinct from antidepressant activity.
Cognitive symptoms
Brain fog, poor concentration and memory difficulties are common complaints. Evidence suggests oestrogen supports cognition during the menopausal transition, though the long-term picture for dementia risk is complex and not fully resolved.
Musculoskeletal symptoms
Joint aches, muscle pain and stiffness are frequently reported at menopause. Oestrogen has anti-inflammatory properties and may contribute to symptom improvement. HRT also substantially reduces fracture risk through its bone-protective effect.
Types of HRT
The type of HRT prescribed depends primarily on whether a woman still has her uterus.
| Type | Components | Who It’s For | Regimen |
|---|---|---|---|
| Combined sequential HRT | Oestrogen daily + progestogen for 12–14 days per cycle | Women with a uterus who are perimenopausal or within 1 year of last period | Produces a monthly withdrawal bleed; mimics a cycle |
| Combined continuous HRT | Oestrogen daily + progestogen daily | Women with a uterus who are >1 year post-menopause | No withdrawal bleed; may cause irregular spotting initially; preferred long-term option |
| Oestrogen-only HRT | Oestrogen daily; no progestogen | Women who have had a hysterectomy (uterus removed) | Simplest regimen; carries no endometrial risk without a uterus; lower breast cancer risk than combined |
| Local vaginal oestrogen | Low-dose oestrogen (cream, pessary, ring) | Women with genitourinary symptoms only; or as add-on to systemic HRT | Minimal systemic absorption; safe long-term; can be used without progestogen; does not treat hot flushes |
| Testosterone | Testosterone cream or gel (off-label in the UK) | Women with persistent low libido not responding to oestrogen | Applied in small doses to skin; used alongside systemic HRT; requires prescriber assessment |
Delivery Methods Compared
| Method | Examples | Advantages | Considerations |
|---|---|---|---|
| Patches (transdermal) | Evorel, Estradot, Estraderm | Bypasses liver; lower VTE risk than oral; twice-weekly or weekly application; stable oestrogen levels | Skin reactions possible; may not adhere in heat; visible |
| Gels (transdermal) | Oestrogel, Sandrena | Bypasses liver; flexible dosing; no adhesive; lower VTE risk than oral | Daily application; must dry before contact; separate progestogen required |
| Sprays (transdermal) | Lenzetto | Bypasses liver; discreet; quick-drying; lower VTE risk than oral | Separate progestogen required; dose titration by number of sprays |
| Tablets (oral) | Elleste Solo, Premarin | Convenient; familiar; combined products available | First-pass liver metabolism; small increased VTE risk compared to transdermal; less preferred for women with VTE risk factors |
| IUS (progestogen component) | Mirena | Provides both contraception and endometrial protection; very low progestogen dose systemically; 5-year duration | Requires fitting; suitable as progestogen component of combined HRT with transdermal oestrogen |
NICE recommendation on route: Transdermal HRT (patches, gels, sprays) does not carry an increased risk of VTE compared to no treatment, whereas oral HRT is associated with a small increase. NICE recommends considering transdermal delivery for women at higher VTE risk, including those who are overweight or obese.
Benefits of HRT
- Vasomotor symptom relief: Reduces hot flush frequency and severity by ~75%; most effective treatment available
- Bone protection: Prevents postmenopausal bone loss; reduces fracture risk by 25–30% during use; most important in women with early menopause or POI
- Cardiovascular benefit: In women who start HRT before age 60 or within 10 years of menopause, evidence suggests a reduction in cardiovascular events and all-cause mortality (the “timing hypothesis”)
- Genitourinary health: Prevents and reverses urogenital atrophy; reduces recurrent UTIs; improves sexual comfort
- Mood and quality of life: Significant improvement in low mood, brain fog and overall wellbeing reported by most women
- Sleep: Improvement in sleep quality once vasomotor symptoms are controlled
- Collagen and skin: Oestrogen maintains skin thickness and collagen content; may reduce rate of skin ageing
Risks: A Balanced View
The risk profile of HRT depends heavily on type, route, duration and individual patient factors. The 2002 WHI study — which used oral conjugated equine oestrogen plus medroxyprogesterone acetate in older women — substantially overstated risk in the population most likely to benefit from HRT. More recent evidence, incorporated into NICE NG23, gives a more accurate picture.
| Risk | What the Evidence Shows | Modifiable? |
|---|---|---|
| Breast cancer | Combined HRT: small increased risk after ~5 years use — comparable to drinking 1 small glass of wine daily. Oestrogen-only: no significant increase in most studies. Absolute risk for most women under 60 is small. | Use lowest effective dose; use oestrogen-only if hysterectomy |
| Venous thromboembolism (VTE) | Oral HRT: small increased risk. Transdermal HRT: does not significantly increase VTE risk vs non-users. | Use transdermal route, especially in overweight women or those with personal/family VTE history |
| Stroke | Oral HRT: small increase in ischaemic stroke. Transdermal HRT: no significant increase. Risk confined to older women starting HRT late. | Use transdermal route; start before age 60 |
| Endometrial cancer | Oestrogen alone increases risk; adequately opposed oestrogen (combined HRT) does not increase endometrial cancer risk. Oestrogen-only is safe only in women without a uterus. | Always use progestogen if uterus intact |
The NICE position: For most healthy women under 60 with troublesome menopausal symptoms who start HRT within 10 years of menopause, the benefits of HRT outweigh the risks. Women should receive an individual benefit-risk discussion rather than a blanket recommendation for or against HRT.
Who Is HRT Suitable For?
- Women with troublesome vasomotor symptoms (hot flushes, night sweats) affecting quality of life
- Women with genitourinary symptoms (vaginal dryness, recurrent UTIs, discomfort during sex)
- Women with mood disturbance, sleep problems or cognitive symptoms related to menopause
- Women with premature ovarian insufficiency (POI) — strongly recommended until at least age 51
- Women with surgical menopause following bilateral oophorectomy
- Women at high risk of osteoporosis who cannot tolerate or prefer not to use alternative bone therapies
Who Should Not Take HRT
- Women with a current or recent (within 5 years) diagnosis of oestrogen-receptor-positive breast cancer
- Women with undiagnosed abnormal vaginal bleeding — this requires investigation first
- Women with active or recent VTE (unless using transdermal route under specialist supervision)
- Women with active liver disease
- Women with known or suspected endometrial cancer
- Pregnancy (though HRT is not a contraceptive — women in perimenopause still need contraception)
Contraception reminder: HRT is not a contraceptive. Women in perimenopause can still conceive and require contraception until 2 years after their last period (if under 50) or 1 year after their last period (if over 50). The Mirena IUS, progestogen-only pill, and barrier methods are all compatible with HRT.
Starting HRT: What to Expect
- A full clinical assessment is required before HRT is prescribed, including blood pressure measurement and a thorough medical and family history
- Start at a low dose and titrate up based on symptom response; full effect may take up to 3 months
- An initial review at 3 months is recommended to assess symptom control, side effects and dose adequacy
- Annual reviews are recommended for women on long-term HRT to reassess risk-benefit balance
- There is no fixed duration limit for HRT in NICE guidance — duration should be guided by symptom need and individual risk factors
- Stopping HRT should be done gradually (dose step-down) rather than abruptly to minimise rebound symptoms
Get HRT Prescribed Online
Access Doctor provides prescription HRT — including patches, gels and tablets — following a confidential online clinical assessment with our GPhC-registered pharmacist independent prescribers. Blood pressure measurement and full medical history review included. No GP appointment required.
Get HRT Online →When to Seek Help
- You have menopausal symptoms significantly affecting your quality of life, sleep, work or relationships
- You experience symptoms of menopause before age 40 — this is premature ovarian insufficiency and requires urgent assessment
- You are experiencing unscheduled vaginal bleeding on combined continuous HRT after the first 3–6 months
- You develop breast changes, unexplained weight loss or other new symptoms while on HRT
- Your symptoms are not controlled despite dose adjustments
Seek urgent medical attention if you develop sudden severe chest pain, shortness of breath, severe headache, sudden visual changes, or severe unilateral leg swelling while on HRT — these may indicate a blood clot (VTE) or stroke. Call 999 immediately.
Related Guides
Frequently Asked Questions
What is HRT and who is it for?
HRT replaces the oestrogen the body stops producing at menopause. It is primarily used to relieve menopausal symptoms including hot flushes, night sweats, vaginal dryness, mood changes and sleep disturbance. NICE recommends HRT for women with troublesome menopausal symptoms after individual benefit-risk discussion.
What are the different types of HRT?
Combined HRT (oestrogen plus progestogen) is used by women with a uterus. Oestrogen-only HRT is for women who have had a hysterectomy. HRT is available as patches, gels, sprays, tablets, or via a Mirena IUS as the progestogen component. Transdermal routes (patches, gels, sprays) are often preferred as they avoid first-pass liver metabolism and carry a lower VTE risk than oral tablets.
Does HRT cause breast cancer?
Combined HRT carries a small increased risk of breast cancer after around 5 years of use — comparable to drinking one small glass of wine daily. Oestrogen-only HRT carries little to no increased risk. For most women under 60 starting HRT within 10 years of menopause, NICE considers the benefits to outweigh the risks. Individual assessment is essential.
Is HRT safe for blood clots (VTE)?
Oral HRT carries a small increased VTE risk. Transdermal HRT (patches, gels, sprays) does not significantly increase VTE risk and is preferred for women with risk factors including obesity or previous VTE. A clinical assessment of individual risk is essential before prescribing.
How quickly does HRT work?
Most women notice improvement in hot flushes and night sweats within 4 weeks, with maximum benefit at 3 months. Vaginal dryness may take longer to improve. Mood and sleep often improve once vasomotor symptoms are controlled. Some women need dose adjustment to achieve optimal symptom relief.
Can I get HRT online in the UK?
Yes. Access Doctor provides prescription HRT — including patches, gels and tablets — following a confidential online consultation with our GPhC-registered pharmacist independent prescribers. A full clinical assessment including blood pressure review and medical history is carried out before any prescription is issued.
References
- National Institute for Health and Care Excellence (NICE). Menopause: diagnosis and management. NICE guideline NG23. Updated 2019. nice.org.uk/guidance/ng23
- British Menopause Society. BMS tools for clinicians: HRT — benefits and risks. 2022. thebms.org.uk
- NHS. Hormone replacement therapy (HRT). NHS.uk, 2023. nhs.uk/medicines/hormone-replacement-therapy-hrt
- Collaborative Group on Hormonal Factors in Breast Cancer. Type and timing of menopausal hormone therapy and breast cancer risk. Lancet. 2019;394(10204):1159–1168.
Medical disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional for diagnosis and treatment. In a medical emergency, call 999.
