What is HRT? Everything you need to know if you’re considering taking it

HRT is a treatment used to help menopause symptoms, as per the NHS.

As the name suggests, it replaces two key hormones – oestrogen and progesterone – which fall to low levels as you approach the menopause.

The two hormones do different jobs. “You take the oestrogen to make you feel better,” says Dr Sarah Hillman, an associate professor at Warwick University. Meanwhile, “the progesterone is there to make sure that the lining of your uterus or womb stays thin.”

She explains: “If you have oestrogen without progesterone and you still have a womb, the lining of your womb will get thicker, and you put yourself at risk of endometrial cancer. So that’s why you need both.

“The only reason you wouldn’t take progesterone is if you’ve had a hysterectomy, so you no longer have a uterus.”  

HRT comes in many forms and there’s no ‘one size fits all’.

First it depends on where you are in your menopause journey, as Hillman explains: “If you are perimenopausal or within 12 months of your very final period, then we would suggest that you take sequential HRT. That means you have progestogens as part of your cycle, but not all of it, so you still have a bleed.

“If it’s 12 months since your final period, then you have a continuous form of HRT [with no break in progestrogens], and continuous means you shouldn’t have a period.”

There are two main ways that oestrogen is typically administered:

• Orally (as a tablet, pill or capsule)
• Transdermally (as a skin patch, gel or spray)

Oral oestrogen

Oestrogen used to commonly be given in tablet form. However, Hillman notes that “if you take oestrogen orally, you have an increased risk of a clot on your leg or your lung called venous thromboembolism (VTE), which is potentially dangerous.”

She adds: “Although you can still have oral oestrogen, if you’ve got risk factors such as being obese or a family history of VTE then the safe way to have oestrogen is transdermally.” 

Transdermal oestrogen

Transdermal oestrogen is delivered through the skin in the form of a patch (which looks a bit like a plaster), a gel or a spray.

Administered this way, the oestrogen bypasses the liver and is absorbed directly into the bloodstream, according the Dr Louise Newson, menopause expert and founder of Newson Health.

“This means there is no risk of blood clots, and side effects are less likely,” she says.

“It’s also easier to alter the dose of oestrogen when it is given as a patch, gel or spray, compared to a tablet. 

Which is the best option?

The answer is simple: whatever suits you best. Newson explains: “You might absolutely love the convenience of having a patch, or you might find wearing a plaster irritates your skin. Other women really like the gel and spray.

“The important thing is speaking to your healthcare professional about your symptoms, lifestyle and preferences to find something that suits you. The big advantage of HRT is that you can try different options until you hit on something that works for you.”

As already outlined, if you still have a uterus and want to take HRT, you need some form of progesterone with your oestrogen to protect against uterine cancer. 

Ways to receive progesterone include:

• Orally (as a tablet, pills or capsule)
• Hormonal IUS (intrauterine system – often the Mirena coil)
• Combined with oestrogen, in a patch, tablet or capsule form

Not all forms will be suitable for all women.

Oral progesterone

Newson says: “The safest type of replacement progesterone is micronised progesterone. This is body-identical, meaning it has the same structure as naturally produced progesterone, meaning fewer side effects.

“In the UK, body-identical progesterone is branded as Utrogestan and comes in a capsule form. Other types of progesterone are synthetic and are associated with small risks of heart disease and blood clots, which are not associated with the body identical progesterone.” 

Hormonal IUS

“An alternative way to receive progestogen is to have the Mirena coil inserted into your uterus,” says Newson.

This option offers a long-term approach, with the coil needing to be replaced after five years.

“For a lot of women, the Mirena coil is a really good option,” Hillman says. “It acts locally so women tend to get less side effects, and it’s really good at controlling bleeding. A lot of women have either a very light period or no period at all.”  

The Mirena coil also works as contraception, in addition to delivering the progestrone element of HRT.

Which is the best option?

As with oestrogen, it’s important to go with something that works for you, Newson advises. “You might prefer taking a tablet, or the fact the Mirena coil stays in place for five years is a better bet for you.” 

While HRT is considered a safe and effective way to manage menopausal symptoms, it’s not suitable for everyone. In particular, a history of certain cancers – particularly breast cancer – or endometriosis can complicate HRT.

That’s why it’s important to speak to a GP or menopause specialist so they can refer you for specialist advice, if needed.

“HRT prescribing can become a little bit more difficult after breast cancer,” Hillman says.

“If you’ve had breast cancer, then it wouldn’t normally be your GP who would decide about HRT. It would have to be a very informed decision with an expert – maybe your oncologist, because you’re increasing your risk of recurrence.”  

HRT might not be suitable if you’ve had other forms of cancer, too, such as ovarian cancer or womb cancer. Your GP or oncologist will be able to give you more information on this.  

Another instance where prescribing HRT gets more complicated is if you’ve had a hysterectomy because of endometriosis.

“If there’s any residual endometriosis, there’s a concern that HRT might cause it to flare it up,” Hillman advises.

“That’s the one time that you would give combined HRT to someone with no uterus (instead of oestrogen only), because you wouldn’t want to flare the endometriosis.” 

HRT is primarily there to make you feel better, according to Hillman.

“It’s particularly good at treating the vasomotor symptoms of menopause (symptoms that occur due to a dilation or constriction of blood vessels) – the hot flushes, night sweats, palpitations. For other symptoms its effects are more variable.”

That said, Newson has found that many women report improvements in symptoms experienced post-menopause, such as low mood, poor sleep and reduced energy – which they may not have even attributed to their hormones.

“Once they start taking HRT they feel so much better,” she says. “So then we know those symptoms were related to their low hormones.”

As well as helping with physical symptoms, using HRT in menopause can also bring long-term health benefits, as Newson explains:  

“HRT helps to protect the bones from weakening due to lack of oestrogen and can reduce the risk of fragility fractures and developing osteoporosis.” 

While some evidence suggests it can be beneficial for the heart, the NHS says research has shown that taking HRT has little or no effect on the risk of getting coronary heart disease.  

“Body-identical HRT may lower blood pressure and reduce the risk of heart failure,” Newson continues. “Additionally, a significant (20%) lower future risk of developing bowel cancer has been shown in women who take HRT, and women who take HRT have a lower future risk of developing type 2 diabetes. This is due to many beneficial effects of oestrogen, including reducing insulin resistance, improving insulin sensitivity in the liver, muscle and fat cells and insulin production in the pancreas.” 

Research is ongoing into the effects HRT can have on various conditions, including dementia – with some potentially encouraging signs. 

“Some studies suggest HRT could potentially reduce the risk of dementia, specifically Alzheimer’s,” Newson says. “Research from the University of Arizona Center for Innovation in Brain Science found that people who took HRT went on to have a 58% lower risk of Alzheimer’s, but other studies have not supported a link, so more research is needed.”

As with many medical conditions, we are still learning more about potential effects. The National Institute for Health and Care Excellence (NICE) has also recommended more research is done in this area.  

The NHS states that “the benefits of taking HRT usually outweigh the risks”, but it’s important to point out that that there are some slightly increased risks for certain medical conditions.  

Oestrogen-only HRT has no, or only a slight change in the risk of breast cancer, but HRT that contains oestrogen and progesterone “does  increase your risk of breast cancer”, Hillman says.

This is currently being reviewed by NICE, to be published in March 2024. NICE points out that while the risk may be higher if you take HRT for longer, it falls again once you stop taking it over a period of time. Again, this is being reviewed by NICE.  

“It also slightly increases your risk of ovarian cancer,” Hillman says, “but that’s a lesser increase because fewer people get ovarian cancer.” 

HRT tablets (but not patches, sprays or gels) may slightly increase your risk of stroke, but it’s also important to remember that the risk of stroke in women under 60 is very low.

Tablets may also slightly increase the risk of developing blood clots, so if you’re at risk of this happening you’ll usually be advised to take the oestrogen component of HRT as a gel, patch or spray.

The risk of developing blood clots is increased if you smoke or are obese. Your GP can discuss this with you in more detail.  

You don’t have to wait until you are menopausal to start taking HRT, according to Newson.

“HRT can be started while you are perimenopausal and, for the majority of women, the benefits outweigh any risks. Research has shown that the earlier a woman starts taking HRT, the better for her future health.”

She offers an additional word of warning.  “The important thing to remember is don’t wait until symptoms become unbearable.

“I see patients who have struggled with symptoms for many months, or even several years, before seeking help. The relief they feel once they have had that help is often enormous and for some can be life changing.”

She advises speaking to your healthcare professional about any symptoms you are having and about your own medical history and preferences to make an informed decision about what is right for you.” 

It’s also important to note that no one is ever “through the menopause”, she says – as the low hormones continue forever.

One symptom that often persists and worsens with time is vaginal dryness, says Newson – or to give it its correct term, genitourinary syndrome of the menopause.

“This is where the tissue lining your vagina thins and becomes drier,” she explains. “You might also experience soreness, itching, irritation and painful sex, vulval changes and urinary-tract symptoms like UTIs.” 

If left untreated, vaginal dryness can be hugely distressing, but it can be successfully managed with the simple addition of vaginal oestrogen. This is a topical or local oestrogen applied directly to the vagina in the form of a pessary, cream or gel, or via a silicone ring you insert inside your vagina.

“Vaginal oestrogen can be safely used long term and alongside HRT,” Newson says.

Lifestyle choices can play an important role in menopause treatment. Some women also opt for other forms of treatment to manage their symptoms, such as cognitive behavioural therapy (CBT) or alternative therapies.

“HRT is a really important treatment option, but not everybody can take it for one reason or another, and not everybody wants to,” says Paula Briggs, chair of the British Menopause Society.

“Lifestyle is so important,” says Briggs. “Sometimes women have unrealistic expectations. They think they’re going to feel incredible [from taking HRT], but just adding hormones is not enough.”

She encourages adopting healthy practices. “It doesn’t need to be anything extreme – just going out for a brisk walk for half an hour a day, combining that with something like Pilates or yoga.”

She adds that eating healthily, minimising alcohol consumption and (if you are a smoker) stopping smoking can all help.

“Obviously some people do have severe menopausal symptoms, but so many women will probably be fine and wouldn’t really notice anything, or they have minimal symptoms that aren’t going to require medication.” 

Cognitive behavioural therapy is a talking therapy. While it can’t treat physical symptoms, it can help you deal with psychological symptoms by building up your coping mechanisms.

You can refer yourself for CBT via NHS talking therapies if you live in England. For those in other parts of the UK, your GP should be able to direct you toward CBT help.

There is some evidence to suggest that St John’s wort and black cohosh might help with hot flushes.

It’s worth noting that the studies into these herbal remedies were small in scale, which makes them harder to rely on. Also, herbal medicines may interact with other medications you’re already taking, so always consult a medical professional before starting something new.