The perimenopause and menopause can have a significant impact on many women. More than 75% of women experience menopausal symptoms which can have a negative impact on their lives both at home, socially and at work. Hormone Replacement Therapy (HRT) is also known as Menopause Hormone Therapy (MHT). We will refer to it as HRT in this article. What is hormone replacement therapy? Are you starting HRT? Is HRT right for you? What type of HRT is best? What are the benefits and risks of HRT? Many women have questions. This article is written by Dr Carys Sonnenberg, British Menopause Society Menopause Specialist, to help guide you.
HRT is the most effective treatment and, compared with placebo, has been consistently shown to improve menopausal symptoms and is associated with a significant improvement in overall quality of life.
HRT is the use of a variety of hormone treatments to relieve the symptoms of perimenopause and menopause. It is also given to replace hormones in women who have a hormone insufficiency, such as in those with Premature Ovarian Insufficiency (POI) which is when menopause happens under the age of 40 years.
The decision whether to take HRT, the dose and the duration of its use should be made on an individualised basis after discussing the benefits and risks to help you make an informed choice about your care. Dr Carys Sonnenberg takes a holistic approach to this at Rowena Health and sees women from all over the UK via video link to help support them in perimenopause and menopause.
HRT can be made of one hormone (oestrogen) or two hormones together (oestrogen and a progestogen). Systemic HRT regimes involve the hormones being absorbed into the bloodstream. Oestrogen can be absorbed through the skin (transdermally) as a gel, patch or spray, taken orally as a tablet, or absorbed from a subdermal implant. Progestogen, if needed, can be given as a 52mg LNG-IUD (expiry 5 years), absorbed transdermally from a combined oestrogen and progestogen patch, or taken orally as a capsule or tablet. There are many different ways of prescribing HRT, and there is no ‘one size fits all’.
Women who go through menopause after the age of 45 years, usually don’t need to take HRT if they are not bothered by their symptoms.
What is bio-identical HRT?
The term ‘bio-identical’ can cause confusion. There are two types of bio-identical HRT. Bio-identical means having the same structure as a substance produced in the body.
Compounded bio-identical HRT
This uses exact duplicates of human hormones, made by specialist pharmacies, but they do not follow the same MHRA regulatory pathway as conventional regulated bio-identical HRT. There is not enough evidence to justify the multiple expensive serum and saliva hormone tests which are recommended to precisely individualise this type of treatment.
All of the HRT we prescribe at Rowena Health is regulated, we do not prescribe compounded bio-identical hormones as there is a lack of evidence about their effectiveness and safety.
Regulated bio-identical HRT
This uses exact duplicates of human hormones which are made in a conventional way by the pharmaceutical industry and are authorised by the regulators such as the MHRA in the UK. This type of HRT can be prescribed by our clinic at Rowena Health, and by your GP on the NHS. This type of HRT is also known as ‘body identical’ HRT. The dose of these hormones can be adjusted to individualise them to you. Examples include oestradiol (oestrogen), in the form of patches, gels and sprays and micronised progesterone (progesterone).
Regulated HRT includes other types of progestogens, which are not bio-identical/body identical, but are widely used, and have different benefit and risk profiles.
When you book an appointment at Rowena Health we consider many things to help guide our choice about the best type of progestogen for you. This includes your past response to hormones (for example in hormonal contraception) your history of premenstrual syndrome and your medical conditions. There is no one size fits all with our recommendations.
Which hormones are used in HRT?
Oestrogen
The hormone oestrogen (usually in the form of oestradiol) forms the main part of HRT. The symptoms of menopause are caused by the ovaries producing less oestrogen as the number of follicles reduces and ovarian function declines. HRT is given to increase the level of oestrogen and relieve the symptoms.
Oestrogen can be taken as an oral tablet, patch, gel or spray and the dose can be individualised to you.
All women who take oestrogen as HRT, and still have a womb (and for some who do not have a womb) need to take a progestogen to provide protection against cancer of the lining of the womb.
Progestogen
Taking oestrogen-only HRT can increase the risk of endometrial cancer, so adding a progestogen is necessary to reduce this risk for women who have a uterus (and is recommended for some women who do not have a uterus). Progestogens may be added to an oestrogen for some days of the month (sequential combined HRT) or every day (continuous combined HRT).
Progestogen can be taken as a micronised progesterone (bioidentical/body identical) called Utrogestan or Gepretix, in the UK. It is taken orally as a capsule at bedtime, as it can make you feel sleepy. It can be taken with or without food, it is better absorbed with food. On an individual basis this hormone can be taken vaginally, if there are side effects with oral use.
A body similar progestogen called Dydrogesterone is another good choice, particularly for women who experience bleeding whilst using micronised progesterone, or who have side effects with micronised progesterone.
The 52mg LNG IUD (such as a Mirena) is also a great choice, it releases a progestogen into the womb, to prevent the lining from thickening, and it can remain in place for 5 years before it needs to be changed. It is also an effective contraceptive and can help to reduce heavy periods that can happen in the perimenopause.
Other progestogens are available such as norethisterone or medroxyprogesterone acetate and can be taken in combination patches or tablets.
In some patients, an off license use of different progestogens can be considered on an individual patient basis if other progestogens have not been tolerated. These progestogens can be helpful in perimenopause where they provide ovarian suppression and stability in a time when hormones fluctuate wildly and symptoms can be erratic.
Testosterone
This hormone can be added to HRT for women who experience symptoms of low libido, low arousal and poor sexual satisfaction despite adequate replacement of oestrogen in HRT. For some people testosterone added to HRT can help improve this but it is important to have a detailed discussion about all the possible causes of low libido before this hormone is started. Blood test monitoring is currently advised and the use of this hormone can cause side effects. Currently there is no evidence from properly conducted trials to confirm that testosterone has any other benefit than the improvement of libido in about 2/3 of women who use it. We need more evidence about this as some women who use it do find it improves clarity of mind, sleep and energy.
Localised low dose vaginal/vulval oestrogen
This is not HRT, but it can be taken alongside HRT, or taken on it’s own to relieve symptoms of vaginal dryness, pain on intercourse, soreness of the vulva and vagina, recurrent urinary tract infection and urinary frequency benefit from treatment with vaginal oestrogen. These symptoms are known as genitourinary syndrome of the menopause (GSM).
Localised vaginal/vulval oestrogen (also called topical HRT) is a low dose oestrogen treatment, given as a cream, gel, pessary or silicone ring, applied to the vagina and/or vulva, to relieve the symptoms of GSM, which affect up to 80% of women. A DHEA vaginal pessary is an alternative option.
When can HRT be started?
It is best to start taking when you start to experience symptoms of menopause that have a negative impact on your quality of life. For many women this is in the perimenopause, which is the time leading up to menopause. You do not need to wait until your periods have stopped to start taking HRT. HRT can be started when you are older than this, after menopause. Each person needs an individual discussion.
If you have premature ovarian insufficiency (POI) or early menopause?
Patients with POI (menopause under the age of 40) should be started on HRT, to protect their future health, even if they do not have any menopause symptoms, unless they have an absolute contraindication (in which case please discuss with a menopause specialist). HRT should be continued until at least the age of natural menopause (around age 51). The British Menopause Society (BMS) state that in clinical practice, women with early menopause (menopause between age 40-45 years) should be given similar advice.
If you have had a surgical menopause?
HRT is important in managing surgical menopause, especially in women under the age of 45 years (if there are no contraindications). All women having a surgical menopause should have counselling and be provided with information about the hormonal consequences of the surgery and the role of HRT for them. This should take place before the surgery and before they leave the hospital they should have a clear plan for follow-up.
How do I take HRT?
HRT can be taken in two ways. Your prescriber will advise which regime is correct for you and will review this at your annual review.
Oestrogen
This could be absorbed through the skin through a patch which is changed twice a week, or applied as a daily gel, spray or taken as an oral tablet. If you start HRT in your perimenopause, when you are still having periods, oestrogen is best started in the first 5 days of your period, if you can.
Progestogen
This can be taken:
Cyclically – sequential combined HRT
This is usually given if you have had a natural period in the preceding 12 months of starting HRT.
Progesterone is taken for part of the month only, to mimic the luteal phase of your own menstrual cycle hormones and to try and avoid irregular bleeding on HRT.
Usually you take progesterone daily for 14 days in a row and then you do not take it for 14 days, and then repeat this 28 day cycle.
We will advise you when to start taking it in your cycle, usually you start it on day 15 of your menstrual cycle, but this can be difficult if your own cycle is irregular. The aim of this type of HRT is for you to settle into a monthly bleed.
Continually every day -continuous combined HRT .
The aim of this type of HRT is for you not to bleed and this way of taking HRT is usually given to people who start HRT in menopause, after not having had a period for more than a year.
Once you have been on sequential combined HRT we will advise you about the right time to change to continuous combined HRT so you no longer bleed.
Is HRT contraceptive?
HRT is not a contraceptive, unless you use a 52mg LNG-IUD like a Mirena.
When will I feel better if I start HRT?
Some women notice a difference in their symptoms within a few days, but most women see a slow and steady improvement in their symptoms over weeks and months.
You may notice physical symptoms get better first, for example, at the correct dose of estrogen, hot flushes and night sweats are often much better after 6 weeks.
Psychological symptoms, such as low mood, anxiety and your brain fog can take a few more months to improve.
It is important to take HRT for at least 3-6 months before deciding whether it is the right dose and is right for you.
Side effects of HRT?
Each hormone in HRT affects the body differently and some women do experience side effects from use of HRT.
Keeping a symptom diary helps us work out what symptoms you are having and when you are having them.
We may need to make an adjustment to your HRT, to give you the balance of hormones that are right for you.
This can take time to settle when you start HRT, particularly if you start in perimenopause, as your own hormones are fluctuating.
Any side effects that have not settled down by 3 months please let us know at your follow-up appointment, especially if you only notice them in the two weeks of taking progesterone.
If you are using patches, they can leave sticky marks from the glue which can be removed with baby oil and a cotton pad or dry flannel. If your skin becomes red from the patch, stick the next patch onto a different area of skin. If your skin irritation persists, please let us know, as there are often other brands to try, that may not cause the same irritation.
Side effects of oestrogen can be:
- Bloating
- Leg cramps
- Swelling
- Breast tenderness or swelling and nipple sensitivity, make sure you have a well fitting bra
- Feeling sick
- Headaches or migraine attacks
- Vaginal bleeding as estrogen thickens the womb lining, it is common to get some bleeding or spotting when you start taking HRT which should settle at 3-6 months. Please talk to us if you are still having this problem at 3 months. If you are having heavy prolonged bleeding with clots, or you are bleeding after sex please see your GP.
- Indigestion
We can manage this by adjusting the dose of oestrogen or changing the regime.
Side effects of progesterone HRT can be:
- Breast tenderness
- Swelling and bloating
- Mood swings and feelings of low mood
- Vaginal bleeding
- Abdominal pain
- Acne
Progesterone all women who use oestrogen replacement HRT and who have a womb (uterus) require the addition of a progestogen to protect the lining of the womb from the thickening effect of estrogen. If you are taking progesterone, you may notice a dip or change in your mood initially. It is important to take progesterone or a progestogen if you take oestrogen, we can work with you to change the type of progestogen you take or how you take it if you are having side effects, but you must take this, if you have a womb.
Side effects of Testosterone can be:
- Local hair growth to the application site
- Acne and greasy skin
- Increased hair growth
- Weight gain and appetite change
- Male pattern baldness
- Enlargement of the clitoris
- Deepening of the voice
Testosterone is usually given as a gel and is applied once daily to the outer thigh or lower abdomen. To reduce the small risk of localised hair growth at the site of application it is best to rotate the site you apply it.
Currently blood tests are required to monitor testosterone levels. If you have a blood test take care not to touch the gel with your hand or to apply it to the arm the blood will be drawn from for at least a week (can be up to 4 weeks before the test) as this may contaminate the result and cause a falsely high level.
HRT is not suiting you?
If you are struggling with HRT side effects, and things aren’t settling down in a few weeks, please let us know. We can help and may change your HRT dose, or the type of hormones you take, or change the way you take your hormones.
Bleeding on HRT?
When you start HRT you should be advised what may happen to your bleeding pattern.
Please seek medical advice if you are experiencing bleeding you are not expecting when you take HRT. It may be that the dose or regime of your HRT needs to be changed or it may be that you need some further investigations to find the cause for the bleeding. Please do not ignore it.
If you are having unscheduled or unexpected bleeding on HRT please read this Women’s Health Concern fact sheet.
What is good about taking HRT?
HRT has been shown to be the most effective treatment to relieve the symptoms of menopause and to improve quality of life.
Maintenance of bone mineral density and reduced risk osteoporotic fractures. Remember to look at the Royal osteoporosis website for advice about calcium in the diet, vitamin D and exercise for bones.
There is evidence that HRT started within 10 years of the menopause, or below the age of 60 is associated with a reduced risk of cardiovascular (heart and blood vessel) disease.
Reduced risk colorectal cancer and reduced risk Type 2 diabetes mellitus.
What are the risks of taking HRT?
As with any medication there are risks and benefits. With HRT they are generally regarded as low, and depend upon the type of hormones that you take and upon your own medical conditions and health profile.
Studies show that taking combined HRT, that is an oestrogen plus progesterone, there may be a small increased risk of breast cancer. The risk may vary with the type of progestogen used and with the length of time HRT is taken for. There may not be an increased risk if you take oestrogen only HRT, but if you have a womb, it is vital that you take progesterone as well in order to reduce the risk of endometrial cancer.
The links below give you more information in pictorial form.
- NICE guidance HRT and the likelihood of some medical conditions
- Understanding breast cancer the risks
- Wellspring HRT risks and benefits
Oral oestrogen tablets have been associated with an increase with blood clot and stroke. Using oestrogen through the skin transdermally, as a gel patch or spray does not carry this same risk.
Limited evidence suggests that HRT may be associated with a risk of ovarian cancer, about 1 extra case per 1000 women.
Risk from lifestyle and HRT
Lifestyle and being overweight play a significant role in the chance of developing breast cancer – in some cases they play a
much greater role than that of HRT.
It is estimated that 23 women in every 1000 will develop breast cancer over a period of 5 years between the ages of 50-59 (background risk).
- If you take the contraceptive pill or combined HRT that figure rises by 4 cases/1000 to 27/1000 women
- If you drink more than 2 units of alcohol a day it rises by 5 cases/1000 to 28/1000.
- If you smoke there are an extra 3 cases taking it to 26/1000.
- If you have a BMI of more than 30 the risk more than doubles with an extra 24 cases/1000 women or 47/1000.
- If you exercise 30 min daily for 5 days a week, it drops by 7 cases down to 16/1000.
HRT after cancer
Many women who have had cancer can use HRT but there are some in whom it is not recommended. Please make an appointment to discuss this. There are other options for you which are non hormonal to help relieve your symptoms and improve your quality of life.
It is recommended that women who have had a hormone receptive breast cancer do not take systemic HRT and choose non-hormonal options. Vaginal oestrogen is increasingly being considered safe as there is little to no systemic absorption after
the initial loading dose. If you are using an aromatase inhibitor then please speak to a menopause specialist if you have symptoms of genitourinary syndrome of the menopause about the use of vaginal oestrogen.
Tips for remembering your HRT
Find a way that works for you to remember to regularly take your HRT. It needs to be applied it at the same time every day, usually when getting up and dressed or when going to bed. You should avoid the application of moisturiser or sun cream to the area within one hour of application of your gel or spray. If you split your dose of gel or spray into a morning and evening application, leave about 12 hours between doses, if you can.
If you are taking Utrogestan, please take it before bed as it can act as a sedative. If you find that difficult and it doesn’t make you too sleepy, then any time of day is ok. The most important thing to do is to take it regularly to protect your womb. If you find that you are forgetting this please talk with us so we can change your preparation to something that is easier to use like putting in a Mirena IUS or having a patch or combined tablet which contains your progesterone.
We advise an annual review when you take HRT, to check your medical history, family history, medication, supplements, BP and weight.
When should HRT be stopped?
HRT can be continued for as long as is needed, there is not a cut off age or maximum length of time for taking it. You should have an annual review with a health professional, with shared decision making, to ensure there is a clear reason for using HRT and that the benefits outweigh the risks and there are no contraindications. This also ensures that the dose is right for you and that you are taking adequate progesterone in dose and duration each month, for you.
The HRT pre-pay certificate
HRT prescriptions are free in Wales, Scotland and Northern Ireland. In England the HRT prescription prepayment certificate (HRT PCC) is a scheme designed to reduce the cost of HRT. It covers all eligible HRT products prescribed for a set cost for a 12-month period.
Lifestyle helps!
Even if you take HRT, it is not a magic pill that will do it all, healthy lifestyle choices like prioritising sleep, having a healthy balanced diet, moving every day aerobic and strength, reducing alcohol, not smoking, keeping a healthy body weight and managing your stress are so important.
HRT works hand in hand with these choices and will help manage any symptoms and protect your future health. You can complement HRT and lifestyle choices by finding social support like time with family and friends, practicing yoga, trying acupuncture and using reflexology.
Summary: 9 Things to Discuss Before Starting HRT
Thinking about HRT? Before you start, make sure you and your prescriber have covered the essentials. Hormone therapy works best and is safest when it’s tailored precisely to you.
- What are your main symptoms?
Identify what is most troublesome. Is it hot flushes, sleep disturbance, anxiety or mood changes, joint or muscle pain, vaginal or bladder symptoms, brain fog, or low libido? This will help guide the choice of treatment and dose. - What is your menstrual pattern?
Are you still bleeding? Is it regular or irregular? The answer determines whether you need a cyclical or continuous HRT regime or whether you need investigations first to see why you are bleeding heavily or irregularly. - What is your medical history?
Do you have high blood pressure, suffer from migraine, have a clotting disorder, thyroid disease, metabolic syndrome, or previous cancer? All influence whether HRT is the right choice for you and determine the safest HRT regime. - What is your family history?
Note any breast, ovarian, or endometrial cancer, early cardiovascular disease, or osteoporosis. - Do you take medication and/or supplements?
Always review your full list including thyroid replacement, SSRIs, antihypertensives, and “natural” supplements for interactions and duplication. - What is the preferred route of oestrogen?
Patch, gel, spray, or tablet: each has different absorption, convenience, and side-effect profiles. Choice depends on your physiology and lifestyle. - What is the right progestogen for you?
If you have a uterus, you must use progesterone or a progestogen to protect the endometrium. Discuss options such as micronised progesterone, a 52mg LNG -IUD (a hormonal intrauterine device like a Mirena) or another type of progestogen. - Lifestyle factors?
Alcohol intake, smoking, diet quality, and physical activity all affect cardiovascular and breast cancer risk and general health. - Review plan.
HRT requires at least an annual review, earlier if you change formulation or develop bleeding, pain, or new health issues. Reviews should include BP, weight, symptom score, and screening reminders.
Tip: HRT is highly effective for managing menopausal symptoms. It is not one-size-fits-all. A personalised approach balancing symptom relief with medical history and risk profile gives the best outcomes.
For an appointment at Rowena Health Menopause Specialist Clinic online if you are in the UK or in person at our Guildford Clinic, please visit the booking page of the website.
Last updated October 2025 Dr Carys Sonnenberg GP and British Menopause Society Menopause Specialist and founder of Rowena Health
This information is general advice only and is not intended to be personal or individual advice. Please consult with a doctor to discuss your individual medical care.