Five questions to ask before starting HRT

A note before we start

HRT advice should be individualised. This article is general — it can’t replace a proper conversation with a clinician who knows your history. What it can do is help you ask better questions and feel more in control of the decision.

A few things have changed in the last decade. The Women’s Health Initiative study in 2002 caused HRT prescriptions to collapse globally because of breast cancer concerns. Subsequent re-analysis has shown the risks were overstated for many women, and that the benefits — for symptoms, bone health, and quality of life — are often substantial. The pendulum has swung back toward more nuanced prescribing.

1. Do I actually need HRT?

HRT is for symptoms, not for age. Some women glide through menopause with minimal disturbance and don’t need it. Others have transformative symptom relief from a few months of treatment. Most are somewhere in between.

Symptoms HRT genuinely helps

• Hot flushes and night sweats (vasomotor symptoms) — the strongest indication
• Sleep disturbance — particularly when driven by night sweats
• Vaginal dryness, painful sex, recurrent UTIs (often vaginal-only treatment is enough)
• Mood disturbance — if part of a broader menopausal picture, not as stand-alone depression treatment
• Joint aches that started around menopause
• Cognitive symptoms (brain fog) — somewhat; evidence is mixed
• Bone protection — particularly relevant if early menopause or osteoporosis risk

Things HRT is less reliably good for

• Tiredness without other clear menopausal symptoms
• Weight gain
• Anxiety unrelated to vasomotor symptoms
• Memory complaints in isolation

Alternatives worth considering

• Lifestyle interventions (sleep, exercise, alcohol reduction, cognitive behavioural therapy for vasomotor symptoms)
• Non-hormonal medications — several options for specific symptoms
• Vaginal-only oestrogen for genitourinary symptoms (doesn’t carry systemic risks)
• SSRIs/SNRIs for mood and vasomotor symptoms in selected patients

2. What are the genuine risks for me?

Risks depend on age at starting, type of HRT, duration, and personal/family history. A 52-year-old healthy woman starting transdermal HRT is in a very different position from a 67-year-old starting oral combined HRT with a family history of breast cancer.

Breast cancer

Combined HRT (oestrogen plus progesterone) carries a small increased risk of breast cancer with longer use — about an extra case per 1000 women per year of use. The risk is lower with oestrogen alone. To put in context, lifestyle factors like alcohol intake and weight also influence breast cancer risk at similar magnitudes.

Blood clots (VTE)

Oral HRT increases clot risk. Transdermal HRT (patches, gels, sprays) does not appear to. If you have personal or family history of clots, obesity, or other clot risk factors, transdermal is strongly preferred — or HRT may not be advisable.

Stroke

Small increase with oral HRT, particularly in older women. Less with transdermal.

Heart disease

For women starting HRT under 60 (or within 10 years of menopause), there’s no clear increase in heart disease risk — and possibly some protective effect. Starting much later carries a different risk profile.

Endometrial (uterine) cancer

Only a risk if you have a uterus and take oestrogen alone without progesterone. The progesterone is the protective component. If you’ve had a hysterectomy, you don’t need progesterone.

3. Which type of HRT, and why?

HRT isn’t one drug. There are many combinations, formulations, and delivery methods. The choice matters.

Oestrogen delivery

• Transdermal (patch, gel, spray) — generally preferred. Better for clot risk. More flexible dosing.
• Oral — convenient. Higher clot risk. Reasonable for low-risk patients but no longer the first choice for most.
• Vaginal-only — for local symptoms. Minimal systemic absorption. Very safe.

Progesterone

Needed if you have a uterus. Options include:

• Oral micronised progesterone (body-identical) — preferred for most patients
• Levonorgestrel intrauterine system (IUS) — doubles as contraception and provides progesterone protection of the uterine lining
• Various synthetic progestogens — older options

Cyclical vs continuous

• Cyclical HRT — produces a monthly bleed. Used in peri-menopause or first year of post-menopause.
• Continuous combined — no bleed (after initial settling). Used in established post-menopause.

Testosterone

Some women benefit from testosterone added to HRT — particularly for low libido, mood, energy. Used off-licence in the UK for women. Not first-line, but worth knowing about.

4. How long should I take it?

There’s no fixed time limit. The right duration is one where benefits continue to outweigh risks — reviewed annually.

Realistic ranges

• Some women take HRT for 1–3 years to get through severe symptoms, then stop
• Many continue for 5–10 years
• Some continue much longer, particularly if symptoms return on stopping or if bone protection is a goal
• Stopping isn’t always permanent — some women try a break and decide to restart

Annual review

We review HRT at least annually. The conversation covers: are symptoms still being controlled? Are side effects manageable? Has anything changed in your medical history? Are the benefits still worth the small ongoing risks?

5. What if it doesn’t work?

Most women experience clear improvement within 4–8 weeks. Some don’t. Some develop side effects that need addressing. None of this means HRT is wrong — usually it means the formulation or dose needs adjusting.

Common side effects

• Breast tenderness (usually settles after the first few weeks)
• Mood changes — particularly with progesterone in some women
• Bloating
• Spotting or irregular bleeding
• Headaches

These often respond to switching formulation, changing the dose, or switching progesterone type.

When to switch or stop

• Side effects you can’t tolerate even after adjustment
• Symptoms not improved after 3–6 months of optimised treatment
• New health changes (clot, breast lump, stroke risk factors)
• Personal preference to try without

How to make the decision

1. Write down your symptoms — what bothers you, how much, how often
2. Note your personal medical history — particularly blood clots, cancer, cardiovascular disease, migraine
3. Note family history — breast cancer, blood clots, heart disease in close relatives
4. Have a thorough conversation — with a clinician who has time to discuss the trade-offs
5. Make the decision that feels right for you — with full information
6. Plan a review — usually at 3 months for new treatment, then annually

For most healthy women in the early menopausal years with symptoms affecting quality of life, the answer leans toward HRT being worth considering. But it should be a genuine conversation. See our menopause page for more detail.