How long you can take HRT is decided by how well it controls your symptoms and how your risks change with age, not by a fixed clock. NICE guideline NG23 asks your clinician to discuss the likely duration at the start, to check again at 3 months, and to review the balance every year after that. It sets a review schedule, not a stop date.
HRT (hormone replacement therapy) is oestrogen, plus a progestogen if you still have a womb, taken to replace the hormones your ovaries stop making. Polish speakers know the same treatment as HTZ, hormonalna terapia zastępcza. It treats symptoms. It is not a longevity treatment, and NICE is explicit about what it should not be used for.
What does HRT treat?
NICE recommends offering HRT to anyone with vasomotor symptoms: hot flushes and night sweats around menopause. For genitourinary symptoms, meaning vaginal dryness, pain during sex and discomfort when passing urine, it recommends vaginal oestrogen. Vaginal oestrogen can be used alone or alongside systemic HRT, and only a minimal amount of it reaches the bloodstream.
If you have a womb and take systemic oestrogen, you also need a progestogen. Oestrogen alone raises the risk of endometrial cancer in a womb that has not been removed, and the progestogen protects the lining. NICE recommends combined HRT for people with a uterus and oestrogen-only HRT for people who have had a total hysterectomy.
Is HRT worth it?
The honest answer is that it depends on what you are treating. NICE states that, overall, taking either combined or oestrogen-only HRT is unlikely to change life expectancy. That cuts both ways. HRT will not make you live longer, and it will not shorten your life. What it does is reduce symptoms that interfere with sleep, work and relationships.
Breast cancer is the fear that stops most women. NICE does not avoid it. Combined HRT increases breast cancer risk while you take it, and the increase is higher in current users than in past users. It declines after you stop, but persists for at least 10 years after stopping. Oestrogen-only HRT carries very little or no increase in breast cancer risk. With combined HRT there is a very small increase in the risk of dying from breast cancer.
Those statements describe averages. Your own starting risk depends on your age, family history, weight, alcohol intake and other factors. NICE asks for the discussion to be tailored to your age, your circumstances and your risk factors, which is why two women the same age can hear different advice.
If you have a personal history of breast cancer, or a high risk of it, NICE does not leave the decision at that. It asks for information on every management option and a referral to a clinician with expertise in menopause, so that the choice is made with someone who handles these cases regularly.
What HRT does not do
- NICE says do not offer combined or oestrogen-only HRT for primary or secondary prevention of cardiovascular disease.
- NICE says do not offer HRT to prevent dementia. With combined HRT started at 65 or over, dementia risk might increase.
- Fragility fracture risk falls while you take HRT. The benefit is maintained during treatment, decreases once you stop, and may last longer in people who take HRT for longer. There is also limited evidence that HRT may improve muscle mass and strength.
- The risk of developing type 2 diabetes does not increase with HRT, and blood glucose control is generally not affected, whether HRT is taken orally or through the skin.
How long can you take HRT?
NICE asks clinicians to discuss the possible duration of treatment at the outset, and to rediscuss the benefits and risks of continuing at every review. Reviews are booked at 3 months to assess efficacy and tolerability, then annually, unless something changes sooner. Continuing, changing the dose, changing the route or stopping are all live options at that appointment.
The guideline sets no maximum number of years. It also does not promise a minimum. What it does is build in a regular moment to reconsider, which is the practical answer to how long you can take HRT.
Can you take HRT for more than five years?
The five-year figure people repeat comes from risk patterns, and it is worth knowing where it sits. NICE finds that stroke risk increases with combined HRT containing oral oestrogen, and that the increase rises with a higher oestrogen dose and with longer duration of treatment, for example if used for more than 5 years. Breast cancer risk with combined HRT also climbs with the number of years you take it.
So five years is a point at which the arithmetic changes, not a date when treatment must end. It is also a reason the route matters. The same duration on a patch is a different calculation from the same duration on a tablet, and the guideline treats them differently. None of that closes the question of how long you can take HRT: it is reviewed each year, not settled once.
Age at the start changes the arithmetic too. NICE finds that the increase in stroke risk with oral oestrogen is greater in people who start HRT after the age of 60, and that dementia risk might increase with combined HRT started at 65 or over. Starting in your early forties is a different situation again: NICE says the benefits and risks for people in early menopause, aged 40 to 44, lie between those for premature ovarian insufficiency and those for people aged 45 or over.
Which form is easier on clots and stroke?
NICE separates oral oestrogen from transdermal oestrogen, which enters through the skin as a patch, gel or spray.
| Outcome | Oral oestrogen | Patch, gel or spray |
|---|---|---|
| Clot risk (venous thromboembolism) | Greater than with transdermal | Not increased |
| Stroke risk | Increases, more with higher doses and longer use | Unlikely to increase |
| Preferred when | Your clot risk is not raised | You are at increased risk of clots, including BMI over 30 |
NICE recommends considering transdermal rather than oral HRT for anyone at increased risk of venous thromboembolism, including people with a body mass index over 30. It also suggests referring people at high clot risk, such as a strong family history or a hereditary thrombophilia, to a haematologist before HRT starts.
What if your symptoms are mild?
HRT is offered for symptoms, so the size of the symptoms is the first thing to measure. Keep a two-week note of flushes, night sweats and broken sleep. If they are mild and occasional, HRT is still an option, but so is menopause-specific cognitive behavioural therapy, which NICE considers for vasomotor symptoms, sleep problems and depressive symptoms linked to menopause. For genitourinary symptoms alone, vaginal oestrogen does the job without systemic treatment.
Many people are told by a friend or a clinician that they should be on HRT because everyone is. That is not how the guideline reads. The decision is yours, made with the benefits and risks in front of you, and it can be revisited at the next review.
Before the appointment, four things make the conversation shorter:
- Two weeks of symptoms: how many flushes a day, how many nights woken, what time of the month.
- Your own risk list: previous clots, migraine with aura, high blood pressure, weight, smoking, family history of breast cancer or clots.
- The route you would prefer, and why: tablet, patch, gel or spray.
- The questions you want answered: likely duration, what happens at the 3-month review, what would make you stop.
How do you stop HRT?
NICE offers a choice: reduce gradually or stop immediately. Gradual reduction may limit the return of symptoms in the short term. Over the longer term, the guideline says, gradual and immediate stopping make no difference to symptoms. Either way, symptoms may return when HRT is stopped, and treatment can be restarted if necessary.
Vaginal oestrogen follows the same logic. Symptoms often return when it is stopped, and you can start it again.
What happens at the three-month review?
Three things are checked: whether symptoms improved, whether side effects are tolerable, and whether the dose is the lowest that works. NICE recommends using the lowest effective dosage. If you have a womb, expect questions about bleeding. Vaginal bleeding is common during the first 6 months of systemic HRT, and within 3 months of any change of dose or preparation.
The review is also the place to mention anything that makes you want to stop: weight, mood, headaches, a new diagnosis, or a scan that changed your risk. A review that ends with a different plan is working as intended. If treatment has not improved your symptoms, or side effects continue, NICE asks for a referral to someone with expertise in menopause rather than another round of the same prescription.
When to see a doctor:
- Unscheduled vaginal bleeding after the first 6 months of HRT, or more than 3 months after a change in dose or preparation.
- A new breast lump, a change in the skin of the breast, or nipple discharge.
- Painful swelling in a calf, sudden breathlessness or chest pain.
- A severe headache unlike your usual ones, or any sudden change in vision, speech or strength.
- Symptoms that have not improved after 3 months, or side effects you cannot live with.
- A diagnosis of breast cancer: systemic HRT is stopped.