HRT Explained: Types, Benefits, Risks and What to Ask

Hormone replacement therapy replaces the estrogen the ovaries stop producing. It is the most effective treatment available for hot flashes and night sweats, and it is also used for the vaginal and urinary changes of menopause and to protect bone density. Whether it suits you depends on your symptoms, your age, how long it has been since your final period, and your medical history.

This guide explains the choices so you can follow the conversation with your clinician. It contains no doses and makes no recommendation about your own treatment.

What HRT is, and what it treats

HRT has two main components, and sometimes a third.

• Estrogen is the part that treats the symptoms. In the UK it is spelled oestrogen; it is the same hormone.
• A progestogen is added if you still have a womb, to protect the womb lining. The NHS puts it plainly: if you still have your womb you need both, because taking both helps protect against the risk of womb cancer. This is not an optional extra.
• Testosterone is sometimes added separately, mainly for persistently low sex drive. The NHS notes it may be available on prescription from a menopause specialist.

The NHS lists the symptoms HRT is effective for as hot flashes, night sweats, sleep problems caused by menopause, anxiety and low mood caused by menopause, and vaginal dryness. It also states that HRT helps prevent osteoporosis by raising estrogen levels, and can help muscles stay strong.

It is not prescribed to prevent heart disease or dementia, and it is not a standalone treatment for clinical depression. If you are still working out whether what you are experiencing is menopause at all, start with what menopause is.

Estrogen-only or combined HRT

Which one you are offered depends on a single question: do you still have a womb?

Combined HRT is then given in one of two patterns, and the NHS ties each to where you are in the transition.

A hormone-releasing intrauterine system can supply the progestogen part of a combined regimen while also acting as contraception. The NHS notes it can stay in place for up to five years.

How HRT is taken

The route matters more than people expect, because it changes the risk profile rather than just the convenience.

NICE recommends considering transdermal rather than oral HRT for people at increased risk of venous thromboembolism, including those with a BMI over 30. If you have clot risk factors, this is worth raising by name.

Vaginal estrogen sits apart from the rest. It is local rather than systemic, it does not generally require a progestogen alongside it, and it can usually be used at the same time as systemic HRT when vaginal and urinary symptoms are not fully controlled.

Body-identical, bioidentical and compounded

These terms get used loosely and the difference matters. Regulated body-identical preparations — micronised progesterone and estradiol — are structurally identical to human hormones, licensed, quality-controlled and available on prescription. Professional bodies generally regard these as the preferred options.

Compounded bioidentical hormones are custom-mixed by private clinics or pharmacies, often sold alongside saliva or blood testing and a personalised blend. Major menopause societies do not recommend them: they are not regulated in the same way, purity and dose consistency are not assured, and protection of the womb lining cannot be relied on. If a clinic offers a bespoke compounded regimen, ask whether the products are licensed.

What HRT helps with

The Menopause Society's 2022 hormone therapy position statement describes hormone therapy as the most effective treatment for hot flashes and night sweats, and supports considering it for people within ten years of their final period who have no reason to avoid it.

• Hot flashes and night sweats, where the effect is largest and best established.
• Sleep disruption, where it is being driven by night sweats.
• Mood symptoms arising during the transition, particularly alongside other menopausal symptoms.
• Vaginal and urinary symptoms, especially with vaginal estrogen.
• Bone density. The NHS states HRT helps prevent osteoporosis, and notes it can help muscles stay strong.

Expect the conversation with your clinician to cover what is bothering you most, your medical and family history, which route suits your risk profile, and what improvement would look like. It usually takes some weeks to judge the effect.

The risks, by type and route

This is where outdated headlines do the most damage, in both directions. The figures below are absolute numbers from NHS guidance — ask for absolute numbers at your appointment too, because a relative increase can sound alarming while describing a very small change.

Two things shape how those numbers apply to you. Timing: guidance distinguishes starting near menopause — generally under 60 or within ten years of your final period — from starting many years later, where the balance is less favourable. And baseline risk: five extra cases per thousand means something different depending on where your own risk already sits, which is why this is a conversation rather than a table.

Early menopause is framed differently again, and the section below explains why.

Common side effects

Side effects are common in the first weeks and are not the same thing as risks. The NHS lists them separately for each hormone, and says they will often go away after a few weeks.

If they do not settle, the NHS notes a GP may adjust the dose, change the type of HRT, or change how you take it — for example moving from tablets to patches. Contact a GP if side effects are severe, or if they carry on beyond three months.

When you need specialist advice first

Some histories do not rule HRT out, but they do mean the decision should not be routine. Raise these explicitly rather than waiting to be asked:

• Current or previous breast cancer, or another hormone-sensitive cancer.
• A previous blood clot in a vein or lung, or a known clotting disorder.
• A previous stroke or heart attack.
• Active liver disease.
• Vaginal bleeding that has not been explained — this needs investigating before HRT is started.
• Migraine with aura, worth naming specifically because the rules for the combined contraceptive pill are not the same as those for HRT, and the two get confused.

HRT after early or surgical menopause

The NHS defines early menopause as periods stopping before 45, and premature menopause as before 40. It can also follow radiotherapy or chemotherapy, certain hormone medicines, or surgery to remove the ovaries.

The reasoning for treatment here is different. The NHS states it is important to replace missing hormones if menopause has started before 45, because of the higher chance of problems with bones and heart, and that the main treatments are the combined contraceptive pill or HRT, usually taken until at least the age of 51. In other words, this is replacing hormones you would ordinarily still have, and the risk framing used for menopause at a typical age does not transfer.

See early menopause for the fuller picture, including diagnosis.

Contraception, monitoring and follow-up

HRT is not contraception. It does not prevent pregnancy, and pregnancy is still possible during perimenopause — see pregnancy during perimenopause for how long contraception is needed. The NHS also notes you cannot take HRT at the same time as the combined pill, though it can be used alongside progestogen-only methods.

On review: the NHS says treatment is usually reviewed every year, and that there is no fixed limit on how long you can take HRT, though it should continue only while the benefits outweigh the risks. If you decide to stop, the NHS notes it is usually recommended to reduce the dose gradually over three to six months; symptoms may return either way, and more noticeably if you stop suddenly.

Report any unscheduled bleeding. The NHS advises telling your GP if irregular bleeding lasts more than six months after starting, if bleeding becomes heavier, or if you bleed after a long gap without periods.

If HRT is not suitable, or you would rather not take it

There are options, and wanting to avoid hormones is a good enough reason to ask about them. Our guide to non-hormonal treatments for menopause looks at the evidence for each in more detail.

• Cognitive behavioural therapy. The NHS notes CBT may be offered for hot flashes and night sweats.
• Clonidine, which the NHS lists for hot flashes and night sweats and notes does not affect hormone levels. It may take two to four weeks to notice an effect, and side effects include dry mouth, drowsiness, depression and constipation.
• Antidepressants — SSRIs and SNRIs — which the NHS describes for mood symptoms where depression or anxiety has been diagnosed. Side effects such as feeling agitated, shaky or anxious usually improve over time.
• Practical measures: layered clothing, a cool bedroom, cutting back on alcohol, stopping smoking, and regular exercise including strength training.

On herbal remedies, the NHS names evening primrose oil, black cohosh, angelica, ginseng, St John's wort and red clover, and is direct about them: these may help with some menopause symptoms but this is not supported by scientific evidence, and there is uncertainty about the right doses and whether any benefit lasts. It warns that they are not tested and regulated in the same way as medicines, that quality, purity and ingredients cannot always be guaranteed, and that some — especially St John's wort — can cause serious side effects taken with other medicines. Tell your clinician what you are taking.

Questions to take to your appointment

Our HRT Question Builder turns your own concerns into a list you can take with you, and the Appointment Builder does the same for the appointment as a whole. If you would rather start from a general list:

1. Given my history, is HRT a reasonable option for me, and which type?
2. Would a patch, gel or spray suit me better than a tablet, given my clot and stroke risk?
3. If I still have my womb, what is protecting the lining, and how?
4. What are my absolute numbers — not percentages — for the risks that apply to me?
5. How long before I know whether it is working, and what should I do if it is not?
6. What bleeding should I expect on this regimen, and what would count as unexpected?
7. Do I still need contraception, and for how long?
8. When will we review this, and what would make us change it?
9. If HRT is not right for me, what else is worth trying?

Preparing beforehand makes a short appointment go further — see your first menopause appointment.

When to get medical help

Book an appointment if menopause symptoms are affecting your sleep, work, relationships or wellbeing, if you are under 45 and think you may be going through menopause, or if you want to discuss treatment.

Get checked promptly for any vaginal bleeding 12 months or more after your last period, bleeding after sex or between periods, very heavy bleeding, or periods stopping before 40. Seek emergency care for chest pain, sudden breathlessness, or signs of a stroke. If low mood includes thoughts of harming yourself, contact emergency services or a crisis line in your country straight away.

Do not start, stop or change a prescription because of something you read here, including on this page. Talk to your prescriber first.