Hormone Replacement Therapy has been through a long and complicated rehabilitation. For years, a 2002 study scared millions of women off HRT — and a generation of doctors became reluctant to prescribe it. That study has since been substantially reanalysed, recontextualised, and in many respects overturned.
Here’s where the evidence actually stands, what HRT can and can’t do, and how to have a productive conversation with your GP.
What HRT Actually Does
During perimenopause and menopause, oestrogen (and in some cases progesterone and testosterone) levels fall. This fall drives most of the symptoms associated with menopause: hot flushes, night sweats, mood changes, vaginal dryness, sleep disruption, brain fog, and joint pain, among others.
HRT works by replacing some of the hormones your body is no longer producing in sufficient quantities. The result, for most women who take it, is a significant reduction in symptoms — often within weeks.
The Safety Question
The 2002 Women’s Health Initiative (WHI) study suggested that HRT increased the risk of breast cancer, heart disease, and stroke. This caused widespread panic and a sharp drop in prescriptions.
What’s now understood is that those findings largely applied to older women taking an older, oral form of combined HRT, and that the risks were smaller than initially reported — and in some cases not applicable at all to the kinds of HRT now commonly prescribed.
The current NHS position, reflected in NICE guidelines updated in 2015, is that for most women under 60 who start HRT within 10 years of menopause, the benefits outweigh the risks. The absolute risk increase for breast cancer from HRT is small — comparable to the risk associated with being overweight or drinking two glasses of wine a night.
Types of HRT Available in the UK
- Oestrogen-only HRT — for women who have had a hysterectomy
- Combined HRT (oestrogen + progesterone) — for women with a uterus
- Body-identical HRT — uses hormones chemically identical to those your body produces; increasingly preferred by many specialists
- Testosterone — not currently licensed for women in the UK but can be prescribed off-label; particularly helpful for low libido and energy
HRT comes as patches, gels, sprays, tablets, and implants. Transdermal forms (patches and gels) are associated with lower risk than tablets because they bypass the liver.
Who HRT Is Particularly Helpful For
- Women with significant vasomotor symptoms (hot flushes, night sweats)
- Women experiencing mood changes, anxiety, or depression related to menopause
- Women with early menopause (before 45) — in whom HRT is strongly recommended to protect bone and heart health
- Women experiencing vaginal dryness or urinary symptoms (local oestrogen is highly effective here)
What to Ask Your GP
Not all GPs have up-to-date training in menopause. If you feel you’re not being heard, you’re entitled to ask for a referral to a menopause specialist, or seek one privately. The British Menopause Society (thebms.org.uk) has a directory of accredited specialists.
Useful questions to ask:
- Am I a good candidate for HRT given my personal and family history?
- Which type and delivery method would you recommend for me?
- What are the risks specifically for someone in my situation?
- How long can I stay on it?
- Can we review my symptoms in three months?
If HRT Isn’t Right for You
Some women can’t take HRT (certain hormone-sensitive cancers, for example) or prefer not to. There are evidence-based alternatives worth discussing with your GP: CBT has good evidence for hot flushes; some antidepressants and blood pressure medications can help with vasomotor symptoms; and local oestrogen for vaginal symptoms is considered safe even for women who can’t take systemic HRT.
The Bottom Line
HRT is not the right choice for every woman, but for many it’s highly effective and safer than was once believed. The key is an informed conversation with a GP or specialist who is up to date with the current evidence — and who takes your symptoms seriously.