Hormone Replacement Therapy: What It Is and Who It Helps

Hormone replacement therapy (HRT) is treatment with oestrogen, plus a progestogen if you still have a uterus, to replace the hormones that fall as the menopause transition progresses. It relieves hot flushes, night sweats, broken sleep and vaginal dryness, and it protects bone while you take it.

The word replacement is the whole idea. This is not a hormone boost and not a cure for ageing. It gives back roughly what your ovaries have stopped making, at the lowest dose that controls your symptoms, and the dose is reviewed as you go.

In Polish clinics the treatment appears as HTZ, and increasingly as MTH, menopauzalna terapia hormonalna. Older articles still use hormonalna terapia zastępcza. The three names describe the same treatment; the newer wording moves the emphasis from replacement to treatment of the menopause itself.

What is being replaced, and why does it matter?

As the supply of follicles in the ovaries runs down, oestrogen production falls. That fall, rather than age on its own, drives most of what you feel: the sudden heat and sweating, the waking at three in the morning, the dry vagina, the aching joints. Menopause usually arrives between the ages of 45 and 55, although it can happen earlier.

Oestrogen is not one substance with one job. It acts on the hypothalamus to steady temperature control, on bone to slow loss, and on the vaginal and urinary lining to keep tissue supple. Replacing it treats several of those systems at once, which is why a single prescription can improve symptoms that seem unrelated to each other.

NICE NG23 states that the benefits and risks it describes apply to HRT taken within licensed doses. A higher dose is not a stronger version of the same thing: the safety data simply does not cover it.

Who is hormone replacement therapy for?

NICE NG23 tells clinicians to offer HRT to people with vasomotor symptoms, meaning hot flushes and night sweats. It also lists the symptoms worth talking through before any treatment decision: poor sleep, low mood, joint and muscle pain, reduced sexual desire, and genitourinary symptoms such as dryness and pain during sex.

Genitourinary symptoms have their own answer. Vaginal oestrogen is offered to people who have them, including people already on systemic HRT, and NICE notes that it is absorbed locally, with a minimal amount reaching the bloodstream compared with systemic treatment. It can be used alone or alongside a non-hormonal moisturiser.

Two groups need a different conversation rather than a standard prescription. People with a personal history of breast cancer, or at high risk of it, should receive information on every option and a referral to a clinician with menopause expertise. People with a history of coronary heart disease or stroke should have HRT discussed, and offered if appropriate, by such a specialist.

Early and premature menopause is the third case, and here the guidance is firm. If menopause began before the age of 45, the advice is to take HRT or the combined pill, usually until at least age 51, to protect bone.

Which type of hormone replacement therapy will you be offered?

The uterus decides the first question. If you still have a uterus, combined HRT is offered, because oestrogen alone thickens the womb lining. If you have had a total hysterectomy, oestrogen-only HRT is offered instead. Either way, the instruction is to use the lowest effective dosage, which is the dose that controls your symptoms with the least exposure, not the weakest option on the shelf.

Within combined HRT there are two patterns, and they are chosen by whether you still bleed.

The risk row is the reason the distinction matters. NICE reports that endometrial cancer risk decreases with continuous combined HRT, while sequential combined HRT may slightly increase it, more so with longer use, with fewer progestogen days per cycle, or with a higher oestrogen dose.

Does the route change the risk?

Yes, for some outcomes. A tablet is swallowed and passes through the liver before it circulates. A patch, gel or spray delivers oestrogen through the skin. That difference shows up most clearly in clotting.

NICE states that venous thromboembolism risk is increased with oral HRT and not with transdermal HRT, and advises considering transdermal treatment for anyone at increased risk of a clot, including people with a BMI over 30. Stroke follows a similar pattern: risk is unlikely to increase with combined HRT containing transdermal oestrogen, but does increase with oral oestrogen, more so at higher doses, with use beyond about five years, and with older age when starting.

Route is a conversation, not a rule. Some people absorb a gel poorly. Some find patches irritate the skin. Some will not remember a tablet taken twice a day. The point is that the choice exists and you should be told about it.

The first year after the prescription

The first review comes at three months, to judge whether the treatment is working and whether you tolerate it. Reviews continue annually after that, unless something needs checking sooner.

Bleeding has its own timetable, and knowing it prevents a scare. NICE explains that vaginal bleeding is common during the first six months of systemic HRT, and within any three months after a change of dose or preparation. Bleeding outside those windows should be reported promptly.

If symptoms are not improving, or side effects persist, NICE directs referral to a clinician with expertise in menopause rather than years of trial and error. That referral is part of the pathway, not a sign that you failed at treatment.

What the risk conversation actually says

Many people arrive here with one number in mind: the 2002 Women's Health Initiative headline. The current guidance is narrower and more specific, and it is worth knowing what it does and does not claim.

• Life expectancy: overall, combined or oestrogen-only HRT is unlikely to affect it.
• Breast cancer: with combined HRT the risk rises with how long you take it, is higher while taking than after stopping, and declines after stopping but persists for at least 10 years. The increase in the risk of dying from breast cancer is very small.
• Womb lining: risk falls with continuous combined HRT.
• Ovaries: a very slight increase in risk with combined HRT.
• Heart: coronary heart disease risk does not increase with combined HRT, and cardiovascular mortality does not increase with it.
• Bone: fragility fracture risk falls while you take HRT, and the benefit fades after you stop.
• Memory: dementia risk might increase if combined HRT is started at 65 or over.

NHS adds a practical note about age. After about 60 the risks may begin to outweigh the benefits, partly because symptoms usually improve on their own, so starting then is usually with a low dose and a patch or gel rather than a tablet.

How long can you take it, and how do you stop?

There is no fixed limit. The advice is to continue while the benefits outweigh the risks, with an annual review, and to use a lower dose and a transdermal route if you start after 60. Vaginal oestrogen is treated differently: it does not carry the same systemic risks, so it can continue for as long as you need it.

When you decide to stop, NICE says you should be offered a choice between reducing gradually and stopping immediately. Gradual reduction may limit symptoms coming back in the short term. In the longer term, the two approaches make no difference. A taper over three to six months is the usual suggestion.

Symptoms often return when treatment stops, and that is expected rather than a relapse. Restarting remains an option.

A worked example: what the decision looks like at 51

Suppose you are 51, your last period was seven months ago, and you wake three or four times a night soaked. Your blood pressure is normal, your BMI is 27, there is no breast cancer in your family, and you still have your uterus.

The likely shape of the conversation: combined HRT is the type on the table, because you have a uterus. Sequential or continuous combined depends on whether bleeding has settled, and clinicians may start one way and switch later. A patch or gel may come up because it avoids a daily tablet and has the better clotting profile. The three-month review is booked at the start, and the bleeding rules are explained then, not later.

None of that example is a prescription. It shows the structure of the decision: uterus first, symptoms second, risk factors third, route fourth, review date last. Once you can see the structure, the appointment stops feeling like a test you might fail.

What to bring to the appointment

A short, concrete list makes twenty minutes far more useful:

• The date of your last period, or your best estimate if periods became irregular.
• A symptom log covering two to four weeks: how many flushes a day, how many night wakings, what else changed.
• Blood pressure readings, if you have a monitor at home.
• Family history of breast cancer, ovarian cancer and blood clots, with ages where you know them.
• Every current medicine, including supplements and hormonal contraception.
• Whether you have had a hysterectomy, and if so whether the cervix and ovaries were removed.
• The date of your most recent mammogram.

Ask directly which type you are being offered and why, what the plan is if the first dose does not work, and which bleeding you should report. Those three questions cover most of what goes wrong in the first year.

When to see a doctor:

• Vaginal bleeding that starts after the first six months of systemic HRT, or more than three months after a change of dose or product.
• Heavy or persistent bleeding at any point while taking HRT.
• Sudden breathlessness, chest pain or a swollen, painful leg. Possible clot symptoms need urgent assessment.
• A new breast lump, skin change or nipple discharge.
• Symptoms that have not improved after a fair trial of treatment.
• Side effects you cannot live with, at any dose.
• Any new diagnosis, surgery or medicine that might interact with your treatment.