Perimenopause

Hormone replacement therapy (HRT) in the menopause: benefits and risks

Hormone replacement therapy (HRT) replaces the oestrogen and progesterone whose levels fall around the menopause and, according to the NHS, is effective for most symptoms – hot flushes, night sweats, sleep problems, anxiety and vaginal dryness. For women under 60 with symptoms who are not at high risk of breast cancer or blood clots, the NHS states that the benefits are likely to outweigh the risks. The decision is made together with a doctor, who assesses the type, dose and form.

What is hormone replacement therapy (HRT) and how does it work?

According to the NHS, hormone replacement therapy (HRT) is a treatment for the symptoms of the menopause. It replaces oestrogen and progesterone – the hormones whose levels fall as the menopause approaches. Most women take a combination of oestrogen and progestogen, while those who have had their womb removed (hysterectomy) can usually take oestrogen only.

The NHS describes different forms – tablets, patches and gel – and different hormones and dosing schedules. Which option is right for you is decided by your doctor, taking into account your symptoms, your health history and your preferences.

Which symptoms does HRT help with?

The NHS states that HRT is effective for most symptoms of the perimenopause and menopause. Relief is usually felt within days or weeks. The symptoms it helps with include:

• hot flushes and night sweats
• sleep problems
• mood changes, anxiety and low mood
• vaginal dryness

In addition, HRT helps to prevent bone thinning (osteoporosis) by raising oestrogen levels. According to the NHS, this is especially important if your periods stopped before the age of 45. HRT can also help keep your muscles strong, but the NHS stresses that exercise is just as important for this.

What are the risks of hormone replacement therapy?

The NHS is clear: serious side effects usually carry a very low risk, and the level depends on the type of HRT, how long you take it and your personal health risks.

• Breast cancer: HRT slightly increases the risk. For combined HRT, the NHS gives around 5 extra cases per 1,000 women who take it for 5 years. The risk rises with duration and age and falls after stopping. With oestrogen-only HRT the increase is small or absent. Women with a history of breast cancer are usually advised not to take HRT. Regular mammograms are especially important.
• Blood clots: tablets increase the risk, although it remains very low. Patches, sprays and gels do not increase it, so if you are predisposed, these are usually recommended.
• Stroke: tablets slightly increase the risk; patches, gels and sprays – do not. The risk remains very low, especially under the age of 60.

According to the NHS, HRT has little or no effect on coronary heart disease, does not increase the risk of type 2 diabetes (some studies even suggest a slight reduction), and whether it affects the risk of dementia is not known.

Who is HRT not suitable for?

According to the NHS, HRT is usually suitable for any woman with menopause symptoms, but there are conditions where it may not be recommended or may require a specific form:

• a history of breast, ovarian or womb cancer
• a history of blood clots – in this case patches or gel can be used instead of tablets
• untreated high blood pressure – it needs to be controlled before you start
• liver disease
• pregnancy – the NHS reminds you that HRT is not contraception and that protection is needed for up to 2 years after your last period if you are under 50, or 1 year if you are over 50

In these cases the doctor may suggest alternatives. Vaginal oestrogen, according to the NHS, does not increase the risk of breast cancer or blood clots and, because of the low dose, is considered safe for long-term use.

How do you start and what should you expect?

The NHS recommends starting treatment with a low dose, which is increased if needed. Symptoms should improve within days or weeks. A review is usually scheduled 3 months after starting or after changing the type of HRT, and if all is well – once a year. If your symptoms do not improve or you have side effects, the doctor may change the dose or form, or refer you to a menopause specialist.

Side effects do not affect everyone; when they do occur, they are usually mild and pass within 3 months. According to the NHS, treatment usually lasts 2 to 5 years, sometimes longer.

Before your appointment, write down the changes in your cycle and all the medicines and herbal supplements you take. Useful questions: how will HRT help me, when will I feel an improvement, what are the benefits and risks for me, are there other options, how long should I take it and how do I choose the type.

When should you see a doctor?

According to the NHS, see a doctor (non-urgently) if:

• you are over 45, have menopause symptoms and are considering HRT
• you are under 45 and have menopause symptoms – this may be an early or premature menopause
• you are already taking HRT but your symptoms are not improving or you have side effects
• you have a history of breast, ovarian or womb cancer, blood clots, high blood pressure or liver disease and want to discuss your options

The NHS sums it up: if you are under 60, have symptoms and are not at high risk of breast cancer or blood clots, the benefits are likely to outweigh the risks – but the decision is personal and is made together with a doctor.

Frequently asked questions

Sources

• NHS – About hormone replacement therapy (HRT) – last reviewed by the NHS: 7 February 2023
• NHS – Benefits and risks of hormone replacement therapy (HRT) – last reviewed by the NHS: 8 February 2023

Informational article retold in our own words from the sources listed. It does not replace a consultation with a doctor; in an emergency call 112. If you spot an inaccuracy, write to [email protected].

More on this topic