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Hormone replacement therapy (HRT)

Your health expert: Dr Madhavi Vellayan, Consultant Gynaecologist
Content review by Rachael Mayfield-Blake, December 2023
Next review due December 2026

Hormone replacement therapy (HRT) is a treatment to ease the symptoms of the menopause. HRT tops up or replaces the hormone oestrogen and if required progesterone, and sometimes testosterone too.

Uses of hormone replacement therapy (HRT)

Your ovaries make the hormones oestrogen and progesterone during your menstrual cycle. But when you get close to the menopause, your body naturally produces less of these hormones. You may then get menopausal symptoms.

Low oestrogen levels can lead to a number of physical and emotional symptoms including hot flushes, night sweats and mood swings. The benefit of HRT is that it can help to ease many of these symptoms and improve your quality of life. HRT doesn't stop the menopause, but it can improve the symptoms. HRT can also help if you enter the menopause early. This can happen if you need surgery to remove your ovaries or you go through natural menopause early (premature menopause).

HRT reduces your risk of osteoporosis and may help other health problems that can happen after the menopause – for example, cardiovascular disease and stroke.

Your doctor may prescribe HRT alongside self-help measures if symptoms of the menopause interfere with your daily life.

Types of hormone replacement therapy (HRT)

There are different types of HRT. Your GP will talk to you about which one is best for you.

Oestrogen-only HRT

This form of HRT contains just the hormone oestrogen. It helps to relieve symptoms of the menopause and strengthens your bones. Low levels of oestrogen at the menopause can weaken your bones and make you more likely to break a bone if you fall.

Your GP may offer you oestrogen-only HRT if you’ve had a hysterectomy (an operation to remove your womb). Brand names of oestrogen-only HRT include:

  • Estradot
  • Lenzetto
  • Elleste-Solo
  • Evorel
  • FemSeven
  • Progynova
  • Sandrena
  • Oestrogel

Combined HRT

If you haven’t had a hysterectomy, your doctor will advise you to take the hormone progesterone as well as oestrogen to protect you from developing womb cancer.

You can take oestrogen and progesterone separately or combined in one therapy. If your doctor advises you to take them separately, there are options.

  • One option is micronised progesterone tablets that you can take with oestrogen patches, gel, spray or tablets. The progesterone in this formulation comes from plant sources and is identical to the progesterone that your ovaries produce before the menopause. This option is known as a body identical hormone replacement therapy.
  • Another option is an intrauterine device (IUS or coil such as the Mirena coil). You can use this form of progesterone alongside oestrogen patches, gel, spray or tablets. This option may reduce bleeding problems with HRT.

You can also take combined HRT, which contains oestrogen as well as progesterone (in the form of progestogen). One option is Bijuve, a bioidentical hormone replacement therapy. This means it’s chemically and biologically the same as hormones that naturally circulate in your body.

Other brand names of combined HRT include:

  • Femoston
  • Kliovance
  • Evorel
  • Clinorette
  • Elleste-Duet
  • Evorel Sequi
  • Kliofem
  • Novofem
  • Trisequens

You can take combined HRT in different ways.

  • Monthly cyclical HRT. You take oestrogen every day and add progesterone for 10 to 14 days in a month to mimic your menstrual cycle. If you haven’t entered the menopause yet, you’ll usually bleed (like a period) every month.
  • Continuous combined HRT. With this type, you take both oestrogen and progesterone every day. You won’t have any monthly bleeding (although you might have some light bleeding for the first four to six months).
  • Three-monthly cyclical HRT. You take oestrogen every day and add progestogen for 14 days every 13 weeks. You’ll usually bleed every three months.

The best way for you to take HRT will depend on whether you’re postmenopausal or perimenopausal, and what type of HRT you’d prefer. Your doctor will discuss with you what the best method is for you.

Tibolone

Tibolone is another type of hormone replacement therapy; it mimics the effects of oestrogen and progesterone. It also has weak androgenic (male hormone) properties. As a result, in some people, it can improve libido. You take tibolone as a tablet every day. Your doctor will only prescribe tibolone if you haven’t had a period for 12 months. The brand name of tibolone is Livial.

Talk to your GP about which type of HRT is best for you or any other questions about the menopause.

Testosterone

HRT is the first treatment a doctor will prescribe for you if you have a low sex drive (libido) and other (non-hormonal) reasons for this have been explored. If HRT alone hasn’t worked for you, your doctor may prescribe you testosterone.

Ask your doctor for more information or discuss if this is a treatment option for you.

Taking hormone replacement therapy (HRT)

There are different types of HRT medicine that you take in a number of ways. Your GP will talk to you about your options to help you work out which is best for you.

HRT patches

You stick a self-adhesive patch on your skin below your waist to provide a slow release of hormones. You renew the patch once or twice a week, depending on the product. After removing the patch, you replace it with a fresh one on a different area of your skin each time.

Don’t put the patches on or near your breasts or under the waistband of your clothes. Patches may irritate your skin. If a patch falls off in the bath, put a new one on once your skin has cooled down.

HRT gels

You put HRT gel on a clean, dry area of skin such as on your tummy, shoulder, arms or thighs, every day. Once you have applied it, allow it to dry for five minutes and wash your hands with soap and water. Wait at least an hour before you use any other skin products over the gel or wash that area of skin. And don’t let that area of skin come into contact with anybody else’s skin for at least an hour because oestrogen is absorbed through the skin. This means that if other people touch your skin with the gel on it, they could get a dose of oestrogen themselves.

Don’t apply gels to your breasts or near your face or vulva. Gels are less likely to irritate your skin than patches.

HRT spray

Oestrogen-only HRT is available as a spray, that you spray onto the skin on your forearm or inner thigh. The spray delivers a set dose. Make sure your skin is dry first. To begin with, you’ll usually use a spray once every day. The number of sprays you need can vary – it can be up to three sprays after a while. Your doctor will let you know what’s best for you.

HRT tablets

You can take tablets that contain both oestrogen and progesterone. Or you can take progesterone tablets in combination with oestrogen gels or patches or sprays.

Vaginal oestrogens

Oestrogen replacement also comes in the form of tablets, rings or creams that you put into your vagina. Your doctor may recommend these for you if your symptoms mainly affect your bladder and you need to pee urgently, and more often. Or if you have vaginal dryness that causes soreness or discomfort when you have sex.

Some vaginal creams may damage condoms and diaphragms. This means that if you want to use these contraceptive methods, it’s best to use vaginal tablets or the vaginal ring. You can use vaginal oestrogens in combination with HRT tablets, patches, and gels.

Who can take hormone replacement therapy (HRT)

Most people can use HRT, but your GP may not prescribe it if you have or have ever had:

If you have menopausal symptoms but aren’t sure if you can take HRT, speak to your GP. They’ll check your medical history to see if HRT is right for you and discuss what your options are. HRT should be individual for you and your doctor will balance your personal risks and benefits. There may be other treatment options that are better suited to you. Your GP may refer you to a specialist for further treatment.

Side-effects of hormone replacement therapy (HRT)

HRT side-effects include:

  • tender breasts
  • larger breasts
  • cramp in your legs
  • feeling sick
  • feeling bloated
  • mood swings
  • depression
  • headaches
  • fluid retention – this is when fluid builds up in your ankles or face, which can cause swelling
  • more frequent migraines (if you get them)
  • acne
  • lower back pain or tummy pain
  • indigestion

If you take continuous combined HRT, you may notice a tiny amount of blood, called vaginal spotting, for up to four to six months. While this is normal when you start taking HRT, it’s important to mention it to your GP.

Your GP may recommend that you take HRT for three months at first to see how you get on. Then you’ll have a check-up with your GP every year to see how HRT is working for you, and if it’s worth continuing. You can make an appointment sooner than this if you have any problems. Most side-effects get better but if they don’t improve, your GP may suggest you try a different type of HRT. Your GP may refer you to a menopause specialist for more support.

Always read the patient information leaflet that comes with your medicine.

Risks of hormone replacement therapy (HRT)

HRT is the most effective treatment for the menopause but it has been linked with a higher risk of certain conditions. These are discussed later in this section.

The benefits of HRT often outweigh the risks, particularly if you’re under 60. Any risks associated with HRT are very small, but they can outweigh the benefits for some people. Your GP will discuss any risks that apply to you, so that you have all the information to decide whether or not to take HRT.

Breast cancer

If you take combined HRT, it may slightly increase your risk of developing breast cancer, and this risk increases the longer you take it for. This risk can remain for more than 10 years after you stop HRT. There’s less risk if you take oestrogen-only HRT.

It’s important to be aware of how your breasts normally look and feel, and to get any changes, lumps or bumps checked by your GP straightaway.

Ovarian cancer

If you take combined HRT or oestrogen-only HRT over a long time, it’s linked to a small increase in the risk of ovarian cancer. This disappears within a few years of stopping HRT.

Endometrial cancer

Oestrogen-only HRT is linked to an increased risk of endometrial cancer (cancer of the lining of the womb). Because of this, your doctor will offer you progesterone too as combined HRT. They’ll only offer you oestrogen-only HRT if you don’t have a womb (you’ve had a hysterectomy).

Blood clots

If you take HRT tablets, it can increase your risk of developing blood clots in your legs (deep vein thrombosis, DVT). Very occasionally, part or all of a blood clot can break away and move to your lungs. DVT is a serious condition and it’s important to see your GP if you think you may have it.

The risk of blood clots is higher if you take HRT tablets (by mouth) and have risk factors for forming clots – for example, obesity. The risk is also higher with HRT tablets if you’re over 60. The risk is lower if you use oestrogen patches, gel, sprays and some types of progesterone replacement, such as micronised progesterone.

Stroke and heart disease

The risks and benefits of HRT on stroke and heart disease are summarised as follows.

  • Oestrogen-only HRT (tablets more than patches or gels) can slightly increase your risk of stroke. But the risk of stroke in women under 60 is very low.
  • Oestrogen-only HRT doesn’t affect your risk of heart disease – it may even reduce it.
  • Combined HRT (oestrogen and progestogen) may slightly increase your risk of heart disease or not affect it at all. This depends on your age and if you have other conditions that may increase your risk – for example, high blood pressure, high cholesterol or are a smoker. If you have these risk factors, you may still be able to take HRT but you’ll need to take steps to manage these conditions first. If you start HRT before 60, it may reduce your risk of cardiovascular disease.

If you’re worried about the risks of HRT or notice any unusual symptoms when you take it, speak to your GP.

Stopping hormone replacement therapy (HRT)

You may wish to stop taking HRT once your menopause symptoms settle, but there’s often no limit on how long you can take it for.

You may find that some of your symptoms come back after you stop taking HRT, particularly if you stop suddenly rather than gradually. So, your GP may advise you to reduce your HRT dose gradually over three to six months, rather than stop it completely. If hot flushes and night sweats, for example, return and are severe, your GP may suggest that you go back on HRT.

Your GP may ask you to stop taking HRT straightaway if you have any severe side-effects, such as a blood clot in your leg.

Your GP will speak to you about the pros and cons of stopping HRT and how best to do it.

Contraception and the menopause

In the years leading up to the menopause, you may notice that you don’t get regular periods anymore. This is called the perimenopause. Once you reach the menopause itself, your ovaries stop releasing eggs and your periods stop completely. But you can still get pregnant during the perimenopause and even for a time after your periods stop. You can get pregnant up to a year after your last period if you’re over 50, and two years if you’re under 50.

HRT isn’t a form of contraception unless you use the Mirena coil to provide the progesterone component of your HRT. Speak to your GP for advice about contraception while you’re going through the menopause.

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You get menopause symptoms such as hot flushes and night sweats when your body reduces production of oestrogen. HRT tops up or replaces low levels of the hormone oestrogen. This can help to ease some of the symptoms of the menopause and improve your quality of life.

For more information, see our section on uses of taking hormone replacement therapy (HRT).

It’s common to put weight on as you approach the menopause but there’s no evidence that HRT itself causes this. If you do gain weight, it’s more likely to be due to the menopause itself. If you’re going through the menopause, it’s important to eat a eat a healthy diet and exercise regularly and lose any excess weight slowly and steadily.

HRT has been linked to a higher risk of some health conditions such as breast cancer and blood clots, but these risks are very small. They can outweigh the benefits for some people depending on their personal circumstances. Your GP can help you to decide if HRT is right for you.

For more information, see our section on risks of hormone replacement therapy (HRT).

There isn’t a particular age when it’s best to start HRT although it’s not usually prescribed for the first time to people over 60 due to the risks. The time to consider taking HRT is when the symptoms of the menopause are affecting your quality of life, despite making changes to your lifestyle.

For more information, see our sections on uses of taking hormone replacement therapy (HRT) and risks of hormone replacement therapy (HRT).

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