Women's health
Menopausal hormone therapy (HRT)
Hormone replacement therapy — Relieves menopausal symptoms and protects bone — with an individualised benefit–risk discussion.
Education and reference only. This is a plain-language class overview — it deliberately contains no doses. Always check the current Summary of Product Characteristics (SmPC), the BNF and your local formulary before prescribing or administering any medicine.
What it is
HRT replaces the oestrogen (and, where needed, progestogen) that falls at menopause. It is used to relieve menopausal symptoms, to manage early menopause, and to help protect bone, with the approach tailored to each woman.
How it works
Replacing oestrogen settles the symptoms driven by its withdrawal — flushes, sweats, sleep disturbance and genitourinary changes — and helps maintain bone density. Adding a progestogen for women with a uterus prevents oestrogen from over-stimulating and thickening the womb lining, which would otherwise raise the risk of endometrial problems.
In practice
In practice HRT is the most effective treatment for troublesome menopausal symptoms such as hot flushes, night sweats and many genitourinary changes, and the modern approach is individualised: matching the type, dose and route to the woman and her risks rather than applying blanket rules. Two principles guide prescribing. First, a woman with a womb needs a progestogen alongside oestrogen to protect the lining of the uterus; only women without a uterus can use oestrogen alone. Second, the route matters for risk — transdermal oestrogen (patch or gel) carries little or no excess clot risk compared with tablets, making it preferred where clot risk is a concern. The small changes in breast-cancer risk relate mainly to combined, longer-duration use and are discussed openly, alongside the genuine benefits for symptoms, quality of life and bone protection. Vaginal oestrogen for local symptoms is very low-risk and can be used long-term.
Examples
Practical use
How to take it & use it well
- Take or apply your menopausal hormone therapy (HRT) as prescribed - this may be tablets, patches, gels or sprays - and stick to the routine you are given.
- If you still have your womb, you must take a progestogen alongside the oestrogen to protect the womb lining; do not skip this part.
- Patches, gels and sprays put the hormone through the skin and carry a lower clot risk than tablets, which may suit some people better.
- Report any unexpected vaginal bleeding promptly, as it needs to be checked even though it is often harmless.
- Attend reviews so the type, dose and ongoing need for HRT can be reassessed over time.
Common uses
- Menopausal symptoms (flushes, sweats, sleep, mood, genitourinary)
- Early/premature menopause
- Local vaginal symptoms (low-dose vaginal oestrogen)
Monitoring
- Symptom response and a review (commonly within the first year then periodically)
- Blood pressure and any unscheduled bleeding (which needs assessment)
- Individual risk factors (clot, breast) revisited over time
Weighing it up
Advantages & disadvantages
Advantages
- Effectively relieves hot flushes, night sweats, sleep disturbance and other menopausal symptoms.
- Helps with vaginal dryness and discomfort, and can improve mood and quality of life for many.
- Protects bone strength, reducing the risk of osteoporosis-related fractures.
- Skin-based forms allow lower clot risk and steady hormone levels.
- Doses and types can be tailored and adjusted to suit each person.
Disadvantages
- Tablet forms carry a small increased risk of blood clots compared with skin-based forms.
- Some types are linked with a small increased risk of breast cancer, which varies by type and duration.
- Can cause breast tenderness, bloating, headaches or irregular bleeding, especially at first.
- Is not suitable for everyone, including some people with a history of certain cancers or clots.
Key safety principles
What to watch for
- Women with a uterus need a progestogen with oestrogen to protect the womb lining.
- Clot risk relates mainly to oral oestrogen — transdermal routes carry little or no excess risk and are preferred where clot risk matters.
- A small, duration- and type-related change in breast-cancer risk with combined HRT — discuss individually; vaginal oestrogen is very low-risk.
Key interactions
What to avoid or check alongside
- Enzyme-inducing medicines (some epilepsy drugs, rifampicin): can reduce the effect of oral HRT.
- Blood thinners: HRT can affect clotting risk, so your overall risk should be reviewed.
- St John's wort: can lower the effect of oral HRT.
- Thyroid medicine (levothyroxine): oestrogen may change how much you need, so monitoring may be required.
Patient & carer advice
- There are different types and routes — we will tailor it to you
- Report any unexpected vaginal bleeding
- Keep up breast awareness and screening; local vaginal treatment is separate and low-risk
Use with
Related clinical calculators
Dose and risk decisions for this class often depend on renal function, weight or bleeding/stroke risk. These tools help:
Answers
Menopausal hormone therapy (HRT): frequently asked questions
Do I need a progestogen with my HRT?
If you still have your womb, yes. Oestrogen alone can thicken the womb lining and raise the risk of womb cancer, so a progestogen is added to protect it. If you have had a hysterectomy, you usually need oestrogen only.
Are patches and gels safer than tablets?
For blood-clot risk, hormone delivered through the skin as patches, gels or sprays carries a lower risk than tablets, because it bypasses the liver. This can make skin-based HRT preferable for some people.
Should I worry about unexpected bleeding on HRT?
Any unexpected or new vaginal bleeding should be reported to your clinician. It is often harmless, but it needs checking to rule out problems with the womb lining, so do not ignore it.
Does HRT increase breast cancer risk?
Some forms carry a small increased risk that depends on the type of HRT and how long it is used; oestrogen-only HRT carries less risk than combined. Your clinician will weigh the benefits and risks for you individually.
Authoritative sources
Always verify against the source
This overview is for orientation. For doses, interactions, contra-indications and the full monograph, use:
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