Hormone replacement therapy

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Overview

Hormone replacement therapy (HRT) is a treatment used to relieve symptoms of the menopause. It replaces hormones that are at a lower level as you approach the menopause.

Benefits of HRT

The main benefit of HRT is that it can help relieve most of the menopausal symptoms, such as:

Many of these symptoms pass in a few years, but they can be very unpleasant and taking HRT can offer relief for many women.

It can also help prevent weakening of the bones (osteoporosis), which is more common after the menopause. 

Risks of HRT

Some types of HRT can increase your risk of breast cancer.

The benefits of HRT are generally believed to outweigh the risks. But speak to a GP if you have any concerns about taking HRT.

How to get started on HRT

Speak to your GP if you're interested in starting HRT.

You can normally begin HRT as soon as you start experiencing menopausal symptoms and won't usually need to have any tests first.

Your GP can explain the different types of HRT available and help you choose one that's suitable for you.

You'll usually be started off on a low dose, which can be increased at a later stage. It may take a few weeks to feel the effects of treatment and there may be some side effects at first.

Your GP will normally recommend trying treatment for three months to see if it helps. If it doesn't, they may suggest changing your dose or changing the type of HRT you're taking.

Who can take HRT

Most women can have HRT if they're experiencing symptoms associated with the menopause.

But HRT may not be suitable if you:

  • have a history of breast cancer, ovarian cancer or womb cancer
  • have a history of blood clots
  • have untreated high blood pressure – your blood pressure will need to be controlled before you can start HRT
  • have liver disease
  • are pregnant – it's still possible to get pregnant while on HRT, so you should use contraception until two years after your last period if you're under 50 or for one year after the age of 50

In these circumstances, alternatives to HRT may be recommended instead.

Types of HRT

There are many different types of HRT and finding the right one for you can be tricky.

There are different:

  • HRT hormones – most women take a combination of the hormones oestrogen and progestogen, although women who don't have a womb can take oestrogen on its own
  • ways of taking HRT – including tablets, skin patches, gels and vaginal creams, pessaries or rings
  • HRT treatment regimens – HRT medication may be taken continuously without a break, or in cycles where you take oestrogen continuously and only take progestogen every few weeks

Your GP can give you advice to help you choose which type is best for you. You may need to try more than one type before you find one that works best.

Read more about the different types of HRT.

Stopping HRT

There's no limit on how long you can take HRT, but talk to your GP about the duration of treatment they recommend.

Most women stop taking it once their menopausal symptoms pass, which is usually after a few years.

Women who take HRT for more than 1 year have a higher risk of breast cancer than women who never use HRT. The risk is linked to all types of HRT except vaginal oestrogen.

The increased risk of breast cancer falls after you stop taking HRT, but some increased risk remains for more than 10 years compared to women who have never used HRT.

When you decide to stop, you can choose to do so suddenly or gradually.

Gradually decreasing your HRT dose is usually recommended because it's less likely to cause your symptoms to come back in the short term.

Contact your GP if you have symptoms that persist for several months after you stop HRT, or if you have particularly severe symptoms. You may need to start HRT again.

Risks and side effects of HRT

As with any medication, HRT can cause side effects. But these will usually pass within three months of starting treatment.

Common side effects include:

Alternatives to HRT

If you're unable to take HRT or decide not to, you may want to consider alternative ways of controlling your menopausal symptoms.

Alternatives to HRT include:

  • lifestyle measures – such as exercising regularly, eating a healthy diet, cutting down on coffee, alcohol and spicy foods, and stopping smoking
  • tibolone – a medication that's similar to combined HRT (oestrogen and progestogen), but may not be as effective and is only suitable for women who had their last period more than a year ago
  • antidepressants – some antidepressants can help with hot flushes and night sweats, although they can also cause unpleasant side effects such as agitation and dizziness
  • clonidine – a non-hormonal medicine that may help reduce hot flushes and night sweats in some women, although any benefits are likely to be small

Several remedies (such as bioidentical hormones) are claimed to help with menopausal symptoms, but these aren't recommended because it's not clear how safe and effective they are.

Bioidentical hormones are not the same as body identical hormones. Body identical hormones, or micronised progesterone, can be prescribed to treat menopausal symptoms.

Read more about alternatives to HRT.

Types

Different types of hormone replacement therapy (HRT) are available.

If you're considering HRT, talk to your GP about the options suitable for you, as well as possible alternatives to HRT.

HRT hormones

HRT replaces the hormones that a woman's body no longer produces because of the menopause.

The two main hormones used in HRT are:

  • oestrogen – types used include estradiol, estrone and estriol
  • progestogen – a man-made version of the hormone progesterone, such as dydrogesterone, medroxyprogesterone, norethisterone and levonorgestrel

HRT involves either taking both of these hormones (combined HRT) or just taking oestrogen (oestrogen-only HRT).

Most women take combined HRT because taking oestrogen on its own can increase your risk of developing womb (endometrial) cancer. Taking progestogen alongside oestrogen minimises this risk.

Oestrogen-only HRT is usually only recommended for women who have had their womb removed during a hysterectomy.

Ways of taking HRT

HRT is available in several preparations that are taken in different ways. Talk to your GP about the pros and cons of each option.

The main forms of HRT are outlined below.

Tablets

Tablets, which are usually taken once a day, are one of the most common ways of taking HRT.

Oestrogen-only and combined HRT tablets are available. For some women this may be the simplest way of having treatment.

However, it's important to be aware that some of the risks of HRT, such as blood clots, are higher with tablets than with other forms of HRT (although the overall risk is still small).

Skin patches

Skin patches are also a common way of taking HRT. You stick them to your skin and replace them every few days. Oestrogen-only and combined HRT patches are available.

Patches may be a better option than tablets if you think you might find it inconvenient to take a tablet every day.

Using patches can also help avoid some side effects of HRT, such as indigestion, and unlike tablets they don't increase your risk of blood clots.

Oestrogen gel

Oestrogen gel is an increasingly popular form of HRT. It's applied to the skin once a day and is absorbed by the body.

Like skin patches, this can be a convenient way of taking HRT while avoiding an increased risk of blood clots.

But if you still have your womb, you'll need to take some form of progestogen separately too, to reduce your risk of womb cancer.

Implants

HRT can be given using small pellet-like implants inserted under your skin (usually in the tummy area) while your skin is numbed with local anaesthetic, although these aren't widely available and aren't used very often.

The implants release oestrogen gradually over time and can stay in place for several months before needing to be replaced.

This may be a convenient option if you don't want to worry about taking your treatment every day or every few days. But if you still have your womb, you'll need to take progestogen separately too.

If you're taking a different form of oestrogen and need to take progestogen alongside it, another implant option is the intrauterine system (IUS). An IUS releases a progestogen hormone into the womb. It can remain in place for a few years and also acts as a contraceptive.

Vaginal oestrogen

Oestrogen is also available in the form of a cream, pessary or ring that is placed inside your vagina.

This can help relieve vaginal dryness, but won't help with other symptoms such as hot flushes.

It doesn't carry the usual risks of HRT and can be used without taking progestogen even if you still have a womb.

Testosterone

Testosterone is available in the form of a gel that you rub in your skin. It is usually only recommended for women whose low sex drive (libido) does not improve after using HRT. It is used to supplement, rather than replace, your current HRT type.

Current testosterone products available in the UK (such as Tostran and Testogel) are currently unlicensed for the treatment of low sex drive. This means the manufacturers of these products have not specified that they can be used in this way. Despite this, there is evidence that testosterone can be effective.

Your GP should be able to provide more information on testosterone products.

HRT treatment regimens

Different treatment courses of HRT are also available, depending on whether you're still in the early stages of the menopause or have had menopausal symptoms for some time.

The two types are cyclical (or sequential) HRT and continuous HRT.

Cyclical HRT

Cyclical HRT, also known as sequential HRT, is often recommended for women taking combined HRT who have menopausal symptoms but still have their periods.

There are two types of cyclical HRT:

  • monthly HRT – you take oestrogen every day, and take progestogen alongside it for the last 14 days of your menstrual cycle
  • three-monthly HRT – you take oestrogen every day, and take progestogen alongside it for around 14 days every three months

Monthly HRT is usually recommended for women having regular periods.

Three-monthly HRT is usually recommended for women experiencing irregular periods. You should have a period every three months.

It's useful to maintain regular periods so you know when your periods naturally stop and when you're likely to progress to the last stage of the menopause.

Continuous combined HRT

Continuous combined HRT is usually recommended for women who are post-menopausal. A woman is usually said to be post-menopausal if she has not had a period for a year.

As the name suggests, continuous HRT involves taking oestrogen and progestogen every day without a break.

Oestrogen-only HRT is also usually taken continuously.

Side effects

Like any medication, the hormones used in hormone replacement therapy (HRT) can sometimes have side effects.

Any side effects usually improve over time, so it's a good idea to persevere with treatment for at least three months if possible.

Speak to your GP if you experience severe side effects or they continue for longer than three months.

Side effects of oestrogen

The main side effects associated with taking oestrogen include:

  • bloating
  • breast tenderness or swelling
  • swelling in other parts of the body
  • nausea
  • leg cramps
  • headaches
  • indigestion
  • vaginal bleeding

These side effects will often pass in a few weeks, but the following measures may help relieve some of them in the meantime:

  • taking your oestrogen dose with food may help to reduce nausea and indigestion
  • eating a low-fat, high-carbohydrate diet may reduce breast tenderness
  • regular exercise and stretching may help reduce leg cramps

If side effects persist, your GP may recommend switching to a different way of taking oestrogen (for example, changing from a tablet to a patch), changing the specific medication you're taking, or lowering your dose.

Side effects of progestogen

The main side effects associated with taking progestogen include:

As with side effects of oestrogen, these will usually pass in a few weeks,

If they persist, your GP may recommend switching to a different way of taking progestogen, changing the specific medication you're taking, or lowering your dose.

Weight gain and HRT

Many women believe that taking HRT will make them put on weight, but there's no evidence to support this claim.

You may gain some weight during the menopause, but this often happens regardless of whether you take HRT.

Exercising regularly and eating a healthy diet should help you to lose any unwanted weight.

More serious risks

HRT has also been associated with some more serious risks, such as an increased risk of blood clots and certain types of cancer.

Read about the risks of HRT for more information.

Reporting side effects

The Yellow Card Scheme allows you to report suspected side effects from any type of medicine you are taking.

It's run by a medicines safety watchdog called the Medicines and Healthcare products Regulatory Agency (MHRA).

Disadvantages

When deciding whether to have hormone replacement therapy (HRT), it's important to understand the risks.

It's also important to consider HRT as only one of a range of interventions to improve your menopausal and post-menopausal health and wellbeing.

Many studies on HRT have been published over the past 15 years that have highlighted the potential risks. As a result, some women and doctors have been reluctant to use HRT.

But more recent evidence says that the risks of HRT are small and are usually outweighed by the benefits.

Breast cancer

NICE says:

  • taking combined HRT (oestrogen and progestogen) is associated with a small increased risk of breast cancer – some studies have suggested that for every 1,000 women taking combined HRT, there will be around five extra cases of breast cancer (from a normal risk of 22 cases of breast cancer per 1,000 menopausal women to 27)
  • the risk of breast cancer decreases when you stop taking HRT – estimates suggest the level of risk returns to normal after about five years
  • oestrogen-only HRT is associated with little or no change in the risk of breast cancer

Because of the risk of breast cancer, it's especially important to attend all your breast cancer screening appointments if you're taking combined HRT.

Ovarian cancer

Studies looking at whether HRT can increase your risk of ovarian cancer have so far had conflicting results.

It's thought that if there is any increase in cases of ovarian cancer in women taking HRT, the risk is very small.

A recent study found that for every 1,000 women taking HRT for five years, there will be one extra case of ovarian cancer.

Any risk of ovarian cancer is thought to decrease once you stop taking HRT.

Womb cancer

Oestrogen-only HRT can increase the risk of womb cancer (also called endometrial cancer), which is why it's only used in women who don't have a womb (for example, because they've had a hysterectomy).

Taking combined HRT, particularly a course of continuous HRT (where you take both medications without a regular break), largely eliminates this risk.

If you still have a womb and you're taking HRT, it's important to take both medications as advised by your doctor to avoid increasing your risk of womb cancer.

Blood clots

Blood clots can be serious if they become lodged in a blood vessel and block the flow of blood.

The evidence shows that:

  • taking HRT tablets can increase your risk of blood clots
  • there's no increased risk of blood clots from HRT patches or gels

It's thought the risk of developing a blood clot is about two to four times higher than normal for women taking HRT tablets. But as the risk of menopausal women developing blood clots is normally very low, the overall risk from HRT tablets is still small.

It's estimated that for every 1,000 women taking HRT tablets for 7.5 years, less than two will develop a blood clot.

Heart disease and strokes

The evidence shows that:

  • HRT doesn't significantly increase the risk of cardiovascular disease (including heart disease and strokes) when started before 60 years of age
  • oestrogen-only HRT is associated with no, or reduced, risk of heart disease
  • combined HRT is associated with little or no increase in the risk of heart disease
  • taking oestrogen tablets is associated with a small increase in the risk of stroke, although the normal risk of women under 60 having a stroke is very low, so the overall risk is small

Speak to your GP if you're taking HRT or are considering taking it and are worried about the risk of stroke or heart disease.

Alternatives

If you're unable to take hormone replacement therapy (HRT) or decide not to, you may want to consider alternative ways of controlling your menopausal symptoms.

These lifestyle changes can also be helpful alongside HRT.

DO:

  • regular exercise – regular physical activity can reduce hot flushes and improve sleep
  • have a healthy diet – a balanced diet can help make sure you do not put on weight and can keep your bones healthy
  • wear loose clothes and sleep in a cool, well-ventilated room if you get hot flushes and night sweats – this can help you to stay cool
  • cut down on caffeine, alcohol and spicy food – they have all been known to trigger hot flushes
  • quit smoking – giving up can help reduce hot flushes
  • try a vaginal lubricant or moisturiser if you have vaginal dryness – several different types are available to buy from shops and pharmacies

Hormone replacement therapy (HRT) is the most common treatment for menopause symptoms, but it's not suitable for everyone. If you've had breast cancer, for example, you'll usually be advised not to take it.

If you cannot take HRT or do not want to, you may still be able to take other medicines that can help your menopause symptoms.

Ask a GP for advice.

Antidepressants

Antidepressants can help with mood symptoms if you've been diagnosed with depression or anxiety.

There are 2 types of antidepressants – selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs).

Your doctor will discuss the possible benefits and risks with you.

Side effects of SSRIs and SNRIs can include feeling agitated, shaky or anxious, feeling sick, feeling dizzy and a reduced sex drive.

Any side effects will usually improve over time, but see a GP if they do not.

Clonidine

Clonidine is a prescription medicine that can help reduce hot flushes and night sweats caused by menopause. You take it as tablets 2 times a day.

It does not affect hormone levels, so unlike HRT it does not increase the risk of breast cancer.

Clonidine can also cause side effects such as dry mouth, drowsiness, depression and constipation.

It may take 2 to 4 weeks to notice the effects of clonidine. Speak to a GP if your symptoms do not improve or you have problems with side effects.

Complementary therapies

Health shops sell a variety of products to treat menopause symptoms. But they're not tested and regulated in the same way as medicines such as hormone replacement therapy (HRT), so it's not known how safe and effective they are.

It's a good idea to ask a GP or pharmacist for advice if you're thinking about using a complementary therapy.

Herbal remedies that are sometimes taken for menopause symptoms include:

  • evening primrose oil
  • black cohosh
  • angelica
  • ginseng
  • St John's wort
  • red clover

Herbal remedies such as red clover contain plant hormones that can act in a similar way to oestrogen, while black cohosh is believed to balance oestrogen and progestogen levels. These may help with some menopause symptoms but this is not supported by scientific evidence.

Even when there is some supporting evidence, there's uncertainty about the right doses to use and whether the health benefits last.

Some of these remedies (especially St John's wort) may also cause serious side effects if they're taken with other medicines.

These products are often marketed as "natural", but this does not necessarily mean they're safe. The quality, purity and ingredients cannot always be guaranteed, and they may cause unpleasant side effects.

Bioidentical or "natural" hormones

Bioidentical hormones are made from plant sources and are described as being similar or identical to human hormones.

Some people claim that these hormones are a "natural" and safer alternative to standard HRT medicines.

However, bioidentical hormones are not recommended because:

  • they're not regulated and it's not clear how safe they are – there's no good evidence to suggest they're safer than standard HRT
  • it's not known how effective they are in reducing menopause symptoms
  • the balance of hormones used in bioidentical preparations is usually based on the hormone levels in your saliva, but there's no evidence that these levels are related to your symptoms

Body identical hormones are different. Because they have been regulated, tested and thoroughly researched, they can be prescribed to treat menopause symptoms.

Many standard HRT hormones are made from natural sources, but unlike bioidentical hormones, they're closely regulated and have been well researched to make sure they're as effective and safe as possible.



The information on this page has been adapted by NHS Wales from original content supplied by NHS UK NHS website nhs.uk
Last Updated: 05/10/2023 12:49:01