More than 75% of women experience symptoms during the perimenopause and menopause that affect their lives at home, socially and at work. Perimenopause is the time leading up to a natural menopause, lasting months to 10 years. Menopause (for women 45 years or older) is the day 12 months after the last natural menstrual period.
Despite symptoms being common, many women feel uncertain about hormone replacement therapy (HRT), what it actually is, whether it is right for them, and what the different options involve.
This article sets out to answer those questions in plain language, drawing on current evidence and the guidance of the British Menopause Society (BMS).
At Rowena Health, we see women from all over the UK, and the same questions come up again and again. We hope this guide helps.
What are the symptoms of perimenopause and menopause: read our article: click here
First let’s remind ourselves what the ovary does
The ovaries have two main roles. They produce eggs, which are essential for fertility, and they produce hormones, primarily oestrogen, progesterone and testosterone, which regulate your menstrual cycle and support many functions throughout your body, including bone strength, heart health, brain function, mood, sleep and the health of the vagina and bladder.
You are born with 1-2 million follicles (eggs), at puberty you have 200-300 thousand follicles and at the time of menopause you have about 1000 follicles left.
During your reproductive years, the ovaries work in a monthly cycle, rising and falling in hormone production to drive ovulation and prepare the womb for pregnancy.
As you move through perimenopause, the egg supply is reducing and the ovaries begin to function less reliably. Cycles become irregular, and hormone levels fluctuate, sometimes wildly, before gradually declining. This instability is what makes perimenopausal symptoms feel so unpredictable.
Eventually the ovaries run out of eggs, periods stop, and oestrogen and progesterone settle at a consistently low level. This is menopause. It is confirmed after 12 months without a period, and in the UK the average age is 51.
It is these hormonal changes — first the fluctuation, then the decline — that drive the symptoms of perimenopause and menopause. Read about these symptoms in our article by clicking here.
What is HRT?
Hormone replacement therapy (HRT), also called Menopause Hormone Therapy (MHT), is the use of hormone treatments to relieve the symptoms of perimenopause and menopause and improve your quality of life.
HRT includes three different types of hormones: oestrogen, progesterone and testosterone.
- The role of oestrogen: helps to relieve the symptoms of menopause.
- The role of progesterone: protects the lining of the uterus (womb) from the thickening effects of oestrogen. Women who have a uterus will need both oestrogen plus progesterone in a balanced dose. Women who have had a hysterectomy don’t usually need to take progesterone and can take oestrogen only. There are some exceptions, for example hysterectomy if you have endometriosis, subtotal hysterectomy or use of HRT after an endometrial ablation. Your doctor will discuss the right treatment for you.
- The role of testosterone: Testosterone replacement can be added to HRT and may improve sexual desire, arousal, and satisfaction in some women. There is no current good quality evidence that it has other benefits.
These hormones are taken in a way to absorb them into the blood stream (this is called systemic HRT).
There is no single right way to take HRT. Menopause care is individualised, and there are many HRT regimes to choose from.
The decision about whether to start HRT, at what dose, and for how long, should be made together with your prescriber, based on your symptoms, medical history, family history, and personal preferences.
What types of HRT are available?
Oestrogen
Oestrogen forms the main part of HRT. The type of oestrogen usually used now is called oestradiol, which is structurally identical to the oestrogen your ovaries produced before menopause, so it is known as a body identical or bioidentical oestrogen. It can be taken in several ways (gel, patch, spray or oral tablet), and the dose can be adjusted to suit you.
Transdermal oestrogen (absorbed through the skin) is the preferred route for most women, as it does not carry the small increased risk of blood clot that is associated with oral oestrogen tablets. Transdermal options are gel, patch and spray. Oestrogen can also be taken as an oral tablet.
The table below summarises the key differences in oestrogen products to help you think about which might suit your lifestyle.
| Type | How it is applied | Advantages | Things to be aware of |
|---|---|---|---|
| Oestrogen gel Brands are Oestrogel (pump dispenser) and Sandrena (individual sachets) | Apply gel once daily to clean, dry skin on the upper outer arm or inner thigh. Dose is measured in pumps or sachets. | Easy to use. Dose is flexible and easy to adjust. | Allow 5 minutes to dry before getting dressed. Avoid applying moisturiser or sun cream to the area for 2 hours. Avoid skin-to-skin contact with others/pets for 2 hours after application. |
| Oestrogen patches Brands include Evorel, Estradot, Estraderm MX and Femseven Doses vary from 25mcg ot 100mcg | Applied to clean, dry, non-hair-bearing skin below the waist. Changed twice weekly (FemSeven once weekly). | Delivers a steady level of oestrogen, useful for women with migraines. Change once or twice a week (depending on the brand). Can be worn in the shower, bath or during exercise. | May leave adhesive residue (removed with baby oil). Some women develop skin irritation, try a different brand with a different adhesive if this happens, which often resolves this. If a patch falls off replace it with a new one and then return to your usual changing regime. |
| Oestrogen spray Brand Lenzetto | Applied once daily to the inner forearm or inner thigh. Same circular area each time and do not overlap circular areas. | Absorbs quickly (around 2 minutes). Small area of application. | Avoid skin-to-skin contact with others for one hour after application. Apply sun cream to the area at least one hour after the spray. |
| Oestrogen oral tablet (1mg or 2mg) Brands include Elleste Duet, Ellest Solo, Zumenon | Swallowed at the same time daily | Convenient | Passes through the liver, which is associated with a slightly higher risk of blood clot than if oestrogen is taken via the transdermal routes. |
Whatever your route, if you are still having periods when you start HRT, it is best to begin oestrogen in the first five days of your cycle where possible.
How to use an HRT patch: read our article: click here
How to use Lenzetto spray: read our article: click here
how to use Oestrogel and Sandrena: read our article: click here
Progestogen: protecting the womb lining
All women who have a uterus and take oestrogen as part of HRT need to also take a progestogen. This is extremely important — oestrogen alone thickens the lining of the womb and, over time, increases the risk of endometrial cancer. Progestogen keeps the lining thin and healthy, and significantly reduces that risk.
There are several types of progestogen, and the right one for you will depend on your medical history, your previous response to hormones (for example in contraception), whether you have experienced premenstrual syndrome, and how well you tolerate different preparations. There is no one-size-fits-all answer, and at Rowena Health we take all of these factors into account.
Micronised progesterone (available in the UK as Utrogestan or Gepretix) is structurally identical to the progesterone your body produces. It is taken as an oral capsule, ideally at bedtime, as it has a mild sedative effect that can help with sleep. It is better absorbed with food. For some women who experience side effects with the oral capsule, it can be taken vaginally — but do not change how you take it without speaking to your prescriber first. Micronised progesterone may be associated with a lower breast cancer risk than synthetic progestogens, and carries no increased risk of blood clot.
How to use Utrogestan and Gepretix: read our article: click here
Dydrogesterone is a good alternative, particularly for women who experience breakthrough bleeding or side effects with micronised progesterone. A body similar progesterone with similar safety profile to micronised progesterone.
The 52mg LNG-IUD (such as the Mirena) is a hormonal coil inserted into the womb by a clinician. It releases a small amount of progestogen locally, protects the womb lining, and lasts for five years as part of HRT. Many women find this option appealing because, once fitted, there is nothing to remember daily. It also acts as effective contraception and can reduce heavy periods — which are common in perimenopause. Some women experience symptoms similar to premenstrual syndrome when the coil is first inserted; these usually settle.
Other progestogens such as norethisterone, medroxyprogesterone acetate, drospirenone, desogestrel and dienogest can be prescribed in combination patches or oral tablets. Some women find they tolerate these synthetic options better than micronised progesterone.
Progestogens act on different receptors in the body, and you may experience side effects for this reason.
Sequential versus continuous HRT
The way progestogen is taken depends on whether you are still having periods.
Sequential (cyclical) combined HRT is usually recommended if you have had a natural period within the last 12 months. You take oestrogen every day, and progestogen for approximately 14 days of each 28-day cycle — typically two weeks on, two weeks off. The aim is for you to settle into a regular, predictable bleed of three to seven days at the end of the progestogen phase. Some irregular spotting is common in the first three to six months. Any heavy, prolonged or unexpected bleeding should always be reported to your prescriber.
Continuous combined HRT is recommended for women who have not had a period for at least 12 months. Both oestrogen and progestogen are taken every day with the aim of no bleeding at all. Some unscheduled spotting in the first three to six months is normal, but after six months any bleeding should be reported and investigated.
Your prescriber will advise you when the right time is to move from sequential to continuous HRT.
Testosterone
Testosterone is the third hormone that may be considered as part of your care. It can be added where women continue to experience low libido, reduced arousal or poor sexual satisfaction despite adequate oestrogen replacement.
There is currently one licensed product for women in the UK (Androfeme), but because it is not available on the NHS, most prescribers use small doses of testosterone gel intended for men at much lower doses for this purpose. This is known as off-label prescribing and is accepted practice in specialist menopause care.
Blood tests to monitor your testosterone level are recommended on initiation, after three months of use and annually thereafter, to ensure levels remain within the female physiological range.
The gel is applied once daily to the outer thigh or lower abdomen, rotating the site each day to minimise the small risk of local hair growth.
Some women taking testosterone report wider benefits beyond libido, including improvements in energy, concentration, mood and sleep, but robust trial evidence for these additional effects is still emerging. A thorough discussion about the possible causes of low libido and a review of oestrogen levels should always happen before testosterone is started.
Side effects can include local hair growth at the application site, acne and greasy skin and, at higher doses, other signs of androgen excess. These are usually avoidable with careful dosing and monitoring.
It is important to let your prescriber know if you are a competitive athlete.
Local vaginal oestrogen: a separate consideration
Up to 80% of women experience symptoms of genitourinary syndrome of the menopause (GSM) — a term that includes vaginal dryness, soreness, discomfort during sex, recurrent urinary tract infections, urinary urgency and frequency. Unlike hot flushes, which often improve with time, these symptoms tend to be progressive and can significantly affect quality of life and intimate relationships.
Local vaginal oestrogen delivers a low dose of oestrogen directly to the tissues of the vagina and vulva, with minimal absorption into the bloodstream. Because the absorption is so low, women using vaginal oestrogen alone do not need to take a progestogen alongside it. It can be used indefinitely — it is a long-term treatment, not a short course — and works well alongside good vulval care, non-hormonal vaginal moisturisers and lubricants.
It can be taken alongside HRT if these symptoms are not controlled with the systemic HRT hormones above, or it can be used on it’s own.
The table below compares the available forms to help you decide which might suit you.
| Type | How it is used | Advantages | Things to be aware of |
|---|---|---|---|
| Tablet / pessary Vagifem, Vagirux GinaTM is available to buy from the pharmacy | Inserted into the vagina using an applicator, usually at night. Used daily for 2-4 weeks then twice weekly ongoing. | Clean and easy to use. Gina can be bought without prescription from the pharmacy for women over 50 years who have not had a period for 12 or more months. | Vagifem has a single-use blue plastic applicator. Vagirux requires reloading the tablet into the white reusable applicator. |
| Waxy bullet pessary Imvaggis | Inserted into the vagina using the fingers. Used daily for 3 weeks then twice weekly ongoing. | No applicator. The waxy texture has a lubricating effect that can help with dryness. | Can produce a slight waxy discharge. Can damage latex condoms |
| Cream Estriol 0.1% (0.5mls per dose) Estriol 0.01% (5mls per dose) Ovesse is available to buy from the pharmacy | Inserted into the vagina daily for 2-4 weeks then twice weekly. Can also be applied to the vulva with a finger | Soothing and can be applied with the applicator or a finger | Can be a bit messy The 0.1% cream does not affect a condom The 0.01% contains peanut oil so avoid if you or your partner has a peanut allergy and it can damage latex condoms |
| Gel Blissel | Inserted into the vagina daily for 3 weeks then twice weekly. | Rapidly absorbed and soothing | Mild itching or irritation when first using it usually settles. |
| Vaginal ring Estring | A soft silicone ring inserted into the vagina by you or a health professional. Stays in place and releases oestrogen continuously for 90 days. | You don’t need to remember to apply a regular cream or pessary | Does not usually interfere with sex, but you can remove it beforehand and reinsert afterwards |
| DHEA pessary Intrarosa | Inserted into the vagina once daily. | Does not contain oestrogen directly — prasterone (DHEA) is converted to oestrogen and testosterone within vaginal cells. | Can damage latex condoms |
Other options include an oral tablet called Ospemifene.
If symptoms are not improving after two to four months, it is important to have an examination to rule out other causes for symptoms, such as lichen sclerosus. The dose of your low dose oestrogen product could be adjusted or you could try another product.
Women who have had a hormone-receptor-positive breast cancer are usually advised not to take systemic HRT, but vaginal oestrogen is increasingly considered safe in this group due to its minimal systemic absorption. Women using an aromatase inhibitor who develop GSM symptoms should speak to a menopause specialist.
The benefits of HRT
The evidence for HRT is substantial and covers several areas.
Symptom relief. HRT is the most effective treatment for hot flushes, night sweats, sleep disturbance, low mood, anxiety, brain fog, joint pain and fatigue. Physical symptoms such as hot flushes and night sweats often begin to improve within six weeks at the right dose. Psychological symptoms — mood, concentration, anxiety — may take a few months longer. It is important to give HRT at least three to six months before deciding whether it is working for you.
Bone health. HRT maintains bone mineral density and reduces the risk of osteoporotic fractures.
Cardiovascular protection. Evidence suggests that HRT started within ten years of the menopause, or before the age of 60, is associated with a reduced risk of cardiovascular disease.
Quality of life. The improvements that come with effective symptom control — better sleep, more stable mood, greater energy, improved sexual health — have a meaningful impact on daily life, relationships and work.
The risks of HRT
As with any treatment, HRT has risks as well as benefits. The risks are generally low and depend on the type of hormones used, how long they are taken, and your individual health profile.
Breast cancer
This is the risk that concerns most women.
Around one in seven women in the UK will develop breast cancer during their lifetime. This background risk is influenced by many factors: age, family history, weight, alcohol intake, smoking and exercise levels. Studies show that taking combined HRT (oestrogen plus a progestogen) for more than five years may carry a small increased risk of breast cancer. The risk may vary with the type of progestogen — micronised progesterone and dydrogesterone appear to carry a lower risk than synthetic progestogens. The risk also increases with longer duration of use.
To give some perspective, consider these figures per 1,000 women aged 50–59 over five years. The background rate — the number of women in this age group who would develop breast cancer without any of the factors below — is approximately 23 in every 1,000.
| Factor | Approximate change in breast cancer cases per 1,000 women |
|---|---|
| Combined HRT or the contraceptive pill | +4 (27 per 1,000) |
| Drinking more than 2 units of alcohol daily | +5 (28 per 1,000) |
| Smoking | +3 (26 per 1,000) |
| BMI over 30 | +24 (47 per 1,000) |
| 30 minutes of exercise 5 days a week | −7 (16 per 1,000) |
Importantly, HRT does not increase the risk of dying from breast cancer. For most women with menopausal symptoms and a low baseline risk, the benefits of HRT for up to five years will outweigh the potential risks. Healthy lifestyle choices matter enormously — as the figures above illustrate.
Blood clots and stroke
Oral oestrogen tablets carry a small increased risk of blood clot (venous thromboembolism) and stroke. Transdermal oestrogen — gel, patch or spray — does not carry this same risk because it bypasses the liver. For this reason, transdermal oestrogen is generally preferred, particularly in women with any additional risk factors for clotting.
Ovarian cancer
Limited evidence suggests that HRT may be associated with a very small increased risk of ovarian cancer — approximately one additional case per 1,000 women.
Other risks
Your individual medical history, family history and current medications will influence whether HRT is right for you and which type is safest. Women with a history of hormone-receptor-positive breast cancer are generally advised not to take systemic HRT, though there are non-hormonal alternatives that can help with symptoms.
What if you don’t think your HRT is working?
If you feel that your HRT is not working, it is important not to give up without speaking to your prescriber first. There are several common reasons why HRT may not seem to be helping.
It may simply be a matter of time — HRT often needs three to six months to reach its full effect, and stopping too soon means you may not have given it a fair chance. The dose may need adjusting, as the starting dose is not always the right dose for you. If you are using a gel or spray, absorption through the skin can vary between women, and switching to a patch or changing the application technique can sometimes make a significant difference. The type of hormone or the way you are taking it may also need reviewing.
It is also worth reflecting on lifestyle factors. High levels of stress, poor sleep, low physical activity, alcohol and an unhealthy diet can all undermine how well you feel, even on HRT. HRT works best alongside a healthy lifestyle, and if these factors are significant, addressing them may make a real difference to how you respond.
It is also worth considering whether there is another explanation for your symptoms. Some conditions — such as thyroid problems, anaemia or low mood — can cause symptoms that overlap with menopause, and these will not improve with HRT alone. If symptoms persist despite good HRT optimisation, your prescriber may recommend further investigation.
It may be that low dose localised vaginal oestrogen needs to be added to your HRT, if bladder, vaginal and vulval symptoms are not relieved on systemic HRT.
It could be that instead of your HRT not working, you are actually experiencing side effects from use of the hormones of HRT. Keep a symptom diary which can help to decide if this could be happening.
With the right adjustments, most women do find a regime that works for them.
Side effects of HRT
Side effects are common when starting HRT, particularly in perimenopause when your own hormones are still fluctuating. Most settle within three months with the right adjustments. Keeping a symptom diary can help your prescriber identify patterns.
Common side effects of oestrogen include breast tenderness, bloating, nausea, headaches, leg cramps and skin sensitivity at the application site (for patches). Some women experience vaginal spotting when first starting, which usually settles by three to six months.
Common side effects of progestogen include breast tenderness, bloating, mood changes and abdominal discomfort. If you notice these mainly during the fortnight when you are taking progestogen, mention this at your review — it may be that a different progestogen, a different dose, or a different route of administration would suit you better.
Testosterone side effects are usually dose-dependent and include local hair growth at the application site, acne and greasy skin. These are minimised by rotating the application site and using the prescribed dose accurately.
If side effects are troublesome and have not settled after a few weeks, contact your prescriber. There are many adjustments we can make before concluding that HRT is not for you.
How long can I take HRT?
There is no fixed cut-off age or maximum duration for taking HRT. What matters is an annual review in which you and your prescriber weigh the benefits against the risks in the context of your current health, and confirm that there is a clear clinical reason to continue. At each review your blood pressure and weight should be checked, your symptoms assessed, your medication and supplements reviewed, and reminders given about appropriate health screening.
If you decide to stop systemic HRT, it is often worth continuing local vaginal oestrogen, as GSM symptoms do not improve with time and will return without treatment.
HRT is not contraceptive
HRT does not provide contraception unless you are using a 52mg LNG-IUD such as the Mirena or a progestogen only method of contraception.
You can take a progestogen-only contraceptive alongside HRT if contraception is needed. A barrier method such as a condom also offers protection against sexually transmitted infections. Your prescriber can clarify whether your current HRT regime provides contraceptive cover.
A note on lifestyle
HRT works most effectively alongside healthy lifestyle choices. Prioritising sleep, eating a balanced diet, moving daily (both aerobic exercise and strength training), reducing alcohol, not smoking, maintaining a healthy weight and managing stress are all important. These are not just extras, they affect your risk profile for breast cancer, cardiovascular disease and osteoporosis.
In England, the HRT Prescription Prepayment Certificate (HRT PCC) allows you to pay a single annual fee covering all eligible HRT prescriptions. HRT prescriptions are free in Wales, Scotland and Northern Ireland.
What about bio-identical HRT?
The term “bio-identical” is widely used but can be confusing because it covers two very different things.
Regulated bio-identical (or body-identical) HRT is manufactured by the pharmaceutical industry to MHRA standards, and includes products like oestradiol gels, patches and sprays, and micronised progesterone. These are the hormones prescribed at Rowena Health. They are structurally identical to the hormones your body produces, and they follow a conventional regulatory pathway, which means their safety and efficacy are well established.
Compounded bio-identical HRT is produced by specialist pharmacies to individual prescriptions, often using saliva or serum testing to guide the formulation. While the hormones themselves may also be structurally identical to the body’s own, they are not subject to the same regulatory oversight as licensed medicines. There is insufficient evidence to support the complex and often costly testing protocols associated with this approach, and Rowena Health does not prescribe compounded bio-identical hormones.
Nine things to discuss before starting HRT
If you are thinking about HRT, the following checklist covers the key conversations to have with your prescriber before starting.
1. What are your main symptoms? Identifying what is most troublesome — hot flushes, poor sleep, mood changes, joint pain, vaginal symptoms, brain fog, low libido — guides the choice of treatment and dose.
2. What is your menstrual pattern? Whether you are still bleeding, and whether your periods are regular or irregular, determines whether you need sequential or continuous HRT, or whether any investigations are needed first.
3. What is your medical history? Conditions such as high blood pressure, migraine, a clotting disorder, thyroid disease or previous cancer all influence whether HRT is appropriate and which type is safest for you.
4. What is your family history? Note any history of breast, ovarian or endometrial cancer, early cardiovascular disease, or osteoporosis.
5. What medications and supplements do you take? A full review of everything you take — including thyroid replacement, antidepressants, antihypertensives and herbal supplements — is essential to check for interactions.
6. What is your preferred route of oestrogen? Patch, gel, spray or tablet each have different absorption profiles, practical considerations and side-effect profiles. Your choice should reflect your physiology, lifestyle and preferences.
7. What is the right progestogen for you? If you have a uterus, this is not optional — the discussion is about which type and how best to take it.
8. What are your lifestyle factors? Alcohol intake, smoking, diet, physical activity and weight all affect risk and should be part of the conversation.
9. What is the review plan? HRT requires at least an annual review, and sooner if you change formulation, experience unexpected bleeding, or develop new symptoms.
In summary
HRT is a safe and highly effective treatment for most women with menopausal symptoms. It is not one-size-fits-all — and it should not be. The right type, dose and route of administration will depend on you as an individual: your symptoms, your history, your preferences and your values. When prescribed with care and reviewed regularly, HRT can make a profound difference to how you feel and to your long-term health.
If you have questions about whether HRT is right for you, or would like to discuss your current treatment, you are welcome to book an appointment with Dr Sonnenberg at Rowena Health.
This article is for informational purposes only and does not constitute medical advice. Please consult a qualified healthcare professional before starting or changing any hormone treatment.
© Rowena Health | rowenahealth.co.uk