Hormone replacement therapy explained
HRT has had a strange journey. For decades it was the default treatment for menopausal symptoms. Then one large study in 2002 produced scary headlines and millions of women came off it overnight. A generation of younger women were told never to start. Now the picture has clarified, the original study has been reinterpreted and UK guidance has moved firmly back toward prescribing HRT for women who want it. Here is what HRT actually is, what it does and how to think about whether it suits you.
The basics
HRT replaces the hormones your ovaries are no longer reliably producing. The aim is to ease menopausal symptoms and support longer term health.
What you are replacing
Mostly oestrogen. This is the hormone whose decline drives most menopausal symptoms. Women who still have a uterus also need progesterone alongside oestrogen because unopposed oestrogen can thicken the womb lining and raise the risk of cancer. Some women also benefit from testosterone, particularly for libido and energy, though testosterone HRT is less commonly prescribed in the UK.
How you take it
Oestrogen can be taken as patches, gels or sprays through the skin or as tablets by mouth. The skin routes are generally preferred now because they carry less risk of blood clots than tablets. Progesterone is usually taken as a tablet or as part of an intrauterine device (the Mirena coil). The combinations and dose options have expanded significantly in recent years.
When you start
Most women start HRT during perimenopause when symptoms begin to affect life or in the first years after menopause. Starting earlier in this window has the best risk benefit profile. UK guidance has moved toward earlier prescribing for women who need it. There is no minimum amount of suffering required before HRT is appropriate.
How long you take it
There is no fixed maximum duration. The previous idea that HRT should only be used for 5 years has been retired. Many women stay on HRT for 10 years or longer. The decision to continue or stop is based on individual symptoms, risks and preferences rather than the calendar. Speak to your GP about reviewing your HRT periodically.
The actual effects
HRT addresses the symptoms caused by declining oestrogen. The effect is often striking for women with significant symptoms.
Hot flushes and night sweats
These are the symptoms HRT works on most reliably. Most women see significant improvement within weeks. Night sweats often go first, which improves sleep substantially. The cascade effect of better sleep then improves energy, mood and almost everything else. For women whose lives have been wrecked by flushes and sweats, HRT can be transformative.
Mood and brain symptoms
HRT helps with the mood symptoms and brain fog of perimenopause for many women. The effect varies. Some women find their mood transforms within weeks. Others find more modest improvement. For some HRT is not the answer for mood and other treatments are better. Speaking honestly with your GP about whether HRT is helping helps adjust treatment.
Vaginal and urinary symptoms
Vaginal dryness, painful sex and frequent urinary infections are common after menopause and often persist for years if untreated. HRT helps. Local vaginal oestrogen (creams, tablets or rings used directly in the vagina) is also available and has very low systemic absorption, making it suitable even for women who cannot take systemic HRT for other reasons.
Bones and long term health
HRT slows the bone loss that accelerates after menopause and significantly reduces the risk of osteoporotic fractures. The cardiovascular picture is more complicated. Starting HRT in early menopause may have cardiovascular benefits. Starting much later may not. The bone benefits are well established and substantial.
What you actually need to know
HRT is not risk free but the risks are smaller than the 2002 panic suggested for most women. Here is the honest picture.
Breast cancer
Combined HRT (oestrogen plus progesterone) does produce a small increase in breast cancer risk after several years of use. The increase is similar to that produced by drinking 2 units of alcohol a day or being moderately overweight. Oestrogen only HRT (for women who have had a hysterectomy) has minimal effect on breast cancer risk. The risk reduces back to normal within a few years of stopping HRT.
Blood clots
Tablet HRT slightly increases the risk of blood clots. Patches and gels (which deliver oestrogen through the skin) do not have this effect. This is one reason the skin routes are preferred for most women now. Women with known clot risk factors are usually steered toward skin based HRT rather than tablets.
Stroke and heart disease
The relationship is complicated. HRT started in the early menopausal years probably has neutral or slightly protective cardiovascular effects. HRT started much later, particularly in women already approaching their seventies, has been associated with worse outcomes. Most women start HRT in their forties or fifties where the cardiovascular picture is not concerning.
The headline benefits versus risks
For most women in early menopause with significant symptoms, the benefits of HRT outweigh the risks. The decision involves individual factors including personal medical history, family history, current health and personal preferences. UK guidance acknowledges this clearly. Speak to your GP for individual advice.
How to make HRT work for you
HRT is not a one size fits all prescription. Getting the right combination, dose and route matters. A few practical points help.
Skin patches and gels are usually preferred
For most women starting HRT in 2026 the recommendation is oestrogen through the skin (patches, gels or sprays) rather than tablets. This avoids the blood clot risk and works just as well for symptoms. Tablets are still appropriate for some women but the skin route is generally first choice.
Body identical hormones
Modern HRT uses oestrogen and progesterone molecules identical to those your body produces. This is different from the older synthetic versions used in the 2002 study. The body identical hormones probably have a different risk profile than the older synthetic ones, though large definitive trials are still ongoing. The pharmacist may use different brand names but the molecules are the same.
Adjustments take time
Finding the right HRT for you may take a few adjustments. Doses can be increased if symptoms persist. Routes can be changed if side effects are a problem. The body takes 6 to 12 weeks to fully settle on a new regimen. Persistence usually pays off. If your first HRT regimen does not feel right, go back to your GP for review rather than giving up.
Reviewing periodically
HRT should be reviewed at least annually. The review covers whether symptoms remain controlled, whether side effects are present, whether the dose still suits and whether continuing makes sense. Women who started in their early fifties may eventually choose to stop, gradually reduce or continue depending on circumstances. Speak to your GP for review.
HRT sits in the female health library alongside guides on menopause, perimenopause and the hormonal changes of midlife. For the full female health catalogue see our Female Health hub.
Back to the Female Health Hub
This guide sits inside our female health library covering hormones, cycles, fertility, menopause and the conditions women face across the lifespan. Head back to the hub for the full catalogue.
More on female health
For the menopause context our Menopause: A Complete Guide covers the life stage HRT addresses. Perimenopause: A Complete Guide covers the transition where many women start HRT. And What Causes Hot Flushes and Night Sweats covers the symptoms HRT helps most reliably.
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