Menopausal Hormone Therapy: Who It Helps and Who It Doesn't

Menopausal hormone therapy is treatment with oestrogen, plus a progestogen if you still have a uterus, to put back the hormones your ovaries stop making. It relieves hot flushes, night sweats and vaginal dryness, and it protects your bones while you take it. It is not right for everyone, and the decision follows a structure you can see.

What menopausal hormone therapy is

Menopausal hormone therapy is oestrogen given as a medicine, with a progestogen added when the uterus is still there, at a dose that replaces roughly what the ovaries made before the transition. The older name is hormone replacement therapy, or HRT. In German-speaking countries the same treatment is called Hormonersatztherapie, and increasingly menopausale Hormontherapie. Doctors in the Netherlands say hormoontherapie, in Poland HTZ, in Italy terapia ormonale sostitutiva. Four names, one treatment.

The word replacement is the point, and it is also where most misunderstandings start. This is not a tonic, a boost or a cure for ageing. It gives back a hormone that has stopped arriving, at the lowest effective dose, and the dose is reviewed as you go. NICE NG23 states that the benefits and risks it describes apply to hormone therapy taken within licensed doses. Above that range, the safety data simply does not exist.

Two hormones are involved and they do different jobs. Oestrogen drives most of the symptom relief and the bone protection. A progestogen exists to protect the lining of the uterus from oestrogen alone, which is why people who have had a total hysterectomy take oestrogen on its own.

Who it helps

The strongest evidence concerns vasomotor symptoms, meaning hot flushes and night sweats. NICE NG23 tells clinicians to offer hormone therapy to people who have them, and to discuss poor sleep, low mood, joint and muscle pain, reduced sexual desire and genitourinary symptoms before any decision is made.

Four benefits are well established:

• Hot flushes and night sweats become less frequent and less severe.
• Sleep improves indirectly, because the flushes that wake you become rarer.
• Genitourinary symptoms respond to vaginal oestrogen: dryness, soreness, pain during sex and recurrent urinary discomfort.
• Fragility fracture risk falls while treatment continues, which matters most for people who went through menopause early.

Vaginal oestrogen deserves its own sentence because it is underused. It is offered to people with genitourinary symptoms, including people already taking systemic therapy, and it works locally on tissue that systemic doses reach poorly. The 2019 Lancet meta-analysis of worldwide prospective studies found that every type of hormone therapy except vaginal oestrogens carried an excess breast cancer risk; vaginal oestrogens were the exception.

What it does not do

Setting expectations is part of a fair consultation, and four limits are worth knowing before you start.

• It is not contraception. If you could still become pregnant, you need a method as well, and that includes a combined pill if a clinician suggests one.
• It does not reliably fix mood. Depressive symptoms that meet the criteria for depression need their own assessment and treatment, not a dose increase.
• It does not permanently protect bone. The reduction in fracture risk fades after you stop.
• It does not stop ageing, and it is not a treatment for skin, hair or weight.

Who should not take it, or needs a specialist first

Most people can take hormone therapy. A few groups need a different conversation, and NICE names them.

• A personal history of breast cancer, or a high risk of it, calls for information on every option and a referral to a clinician with menopause expertise.
• A personal history of coronary heart disease or stroke should be discussed with such a specialist, who can offer treatment where it is appropriate.
• An increased risk of a blood clot, including a body mass index over 30, points to transdermal oestrogen rather than tablets.
• Unexplained vaginal bleeding needs investigating before treatment starts, not after.
• A hormone-sensitive cancer is the clearest contraindication, and treatment is not offered unless the cancer team says otherwise.

The four questions that shape the prescription

The consultation is shorter than people expect, because four questions do most of the work.

1. Do you still have a uterus? If yes, combined therapy. If you have had a total hysterectomy, oestrogen alone.

2. Which symptoms are you treating? Vasomotor symptoms point to systemic therapy; dryness and urinary symptoms point to vaginal oestrogen, which can be added to anything.

3. What raises your risk? Clot history, blood pressure, BMI, migraine, family history and age at starting all change the route and the dose.

4. How will you take it? Tablet, patch, gel or spray. NICE advises considering transdermal oestrogen when clot risk is raised, because venous thromboembolism risk is increased with oral therapy and not with transdermal.

The fifth item is a date rather than a question. NICE sets the first review at three months, to judge efficacy and tolerability, and annually after that unless something needs checking sooner.

The evidence, in one table

Age changes more than the product does

Timing is the variable that alters the risk conversation most. NICE notes that the baseline population risk of stroke in women under 60 is very low, and that stroke risk with oral oestrogen rises with higher dosage, with use beyond about five years, and with greater age at first starting. Starting later is not forbidden; it is a different calculation.

After about 60, most symptoms have settled on their own, so the balance shifts. The practical pattern is a lower dose and a transdermal route rather than a tablet. Dementia risk is the one outcome where age at starting is decisive in the guidance: NICE states that dementia risk might increase with combined therapy if it is started at 65 or over.

Early menopause is the opposite case. If menopause came before the age of 40, which clinicians call premature ovarian insufficiency, NICE offers hormone therapy or a combined hormonal contraceptive and advises continuing until at least the age of natural menopause. The reason is bone and heart protection over decades, not symptom relief alone, and the baseline risks at that age are very low.

The breast cancer question

This is the question that stops most people, and the honest answer is a small increase in risk, not a large one. NICE states that with combined therapy the increase in breast cancer 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. Sequential combined therapy carries a lower risk than continuous combined therapy.

The 2019 Lancet meta-analysis pooled individual participant data from prospective studies and found that excess risk rose steadily with duration of use and was greater for oestrogen plus progestogen than for oestrogen alone. That study is why the phrase "duration matters" appears in every current guideline.

Where the judgement stopped being proportionate was 2002, when the first Women's Health Initiative results were reported and widely read as proof that hormone therapy caused breast cancer and heart attacks. Prescriptions collapsed. NICE revised its tables on combined therapy as recently as 2024, and the shapes of the current statements are narrower than the headlines people remember.

How long to take it, and how to stop

There is no fixed limit. The guidance is to continue while the benefits outweigh the risks, with a review each year. Vaginal oestrogen is treated differently, because it works locally, and it can continue for as long as it is needed.

When you decide to stop, NICE says you should be offered a choice between reducing gradually and stopping at once. Gradual reduction may limit symptoms coming back in the short term. In the longer term, the two approaches make no difference. A taper over a few months is common, but it is not a rule you can fail.

Symptoms often return when treatment stops, and that is expected rather than a relapse. Bleeding has its own timetable: NICE explains that it is common during the first six months of systemic therapy, and within any three months after a change of dose or product. Bleeding outside those windows should be reported promptly.

If your doctor says no

Sometimes the answer is no and the reasoning is sound: you have a history that needs a specialist, or your symptoms do not need hormones. Sometimes the answer is driven by the 2002 headline rather than by the current guideline. The difference matters, and you can ask about it directly.

NICE recommends referring people to a clinician with expertise in menopause when treatments do not improve their symptoms or when side effects continue. That referral is part of the pathway, not a complaint against your doctor. Ask which option is being weighed and why, what the plan is if the first product does not work, and which bleeding you should report. Ask for the referral if the first answer is no and none of the reasons above applies.

What not to do is buy hormone creams or capsules online, or take a compounded product from an unregulated source. The safety data behind every figure in this article comes from licensed products at licensed doses. Unregulated products sit outside that evidence entirely.

When to see a doctor:

• Vaginal bleeding that starts after the first six months of therapy, or more than three months after a change of dose or product.
• Heavy or persistent bleeding at any point.
• Sudden breathlessness, chest pain or a swollen, painful leg, which need urgent assessment for a possible clot.
• A new breast lump, skin change or nipple discharge.
• Symptoms that have not improved after a fair trial, or side effects you cannot live with.
• Any new diagnosis, surgery or medicine that might interact with your treatment.
• Menopause symptoms before the age of 40, which need assessment for premature ovarian insufficiency.