HRT for Menopause: Benefits, Risks and Pros and Cons
Hormone replacement therapy (HRT) is one of the main treatment options for menopause and perimenopause symptoms. It can help relieve symptoms such as hot flushes, night sweats and vaginal dryness, while also helping to protect bone health.
However, HRT is not the same for everyone. The potential benefits and risks depend on factors such as your age, symptoms, medical history, type of HRT and how it is taken.
Understanding the benefits, risks and pros and cons of HRT can help you have a more informed conversation with a healthcare professional about whether it may be suitable for you.
What is HRT for menopause?
Hormone replacement therapy replaces hormones that become lower during perimenopause and menopause, primarily oestrogen. Depending on whether you have a womb and your individual circumstances, treatment may also include a progestogen.
If you have a womb, oestrogen is generally prescribed alongside a progestogen to help protect the lining of the womb. If you have had a total hysterectomy, oestrogen-only HRT may be appropriate.
HRT can be used during perimenopause as well as after menopause. You do not necessarily need to wait until your periods have stopped completely before discussing treatment.
There are different forms of HRT, including tablets, patches, gels and sprays. Local vaginal oestrogen may also be prescribed for symptoms affecting the vagina and urinary system.
What are the benefits of HRT?
The main reason for using HRT is to manage troublesome menopause symptoms. NICE recommends offering HRT to people experiencing menopause-associated vasomotor symptoms such as hot flushes and night sweats.
Relief from menopause symptoms
HRT can improve a range of symptoms associated with changing hormone levels, including:
- hot flushes and night sweats
- sleep problems associated with menopause
- vaginal dryness and discomfort
- some mood-related symptoms associated with menopause
- other symptoms related to declining oestrogen levels
The extent of improvement varies between individuals, and it can sometimes take time to find the most appropriate type and dose of treatment.
Support for bone health
Lower oestrogen levels after menopause can contribute to a reduction in bone density. HRT can help prevent osteoporosis while it is being taken, which can be particularly relevant for women who experience menopause earlier than expected.
If you experience early menopause, it is particularly important to discuss hormone replacement with a healthcare professional because the benefits and considerations may differ from those for someone experiencing menopause at the usual age.
Potential improvement in quality of life
Menopause symptoms can affect sleep, concentration, work, relationships and everyday activities. For some women, reducing troublesome symptoms with HRT can make a meaningful difference to their overall quality of life.
However, HRT should be considered as part of an individual treatment plan rather than as a single solution for every symptom.
What are the risks of HRT?
HRT is not completely risk-free. The level of risk depends on factors including the type of HRT, whether it contains oestrogen alone or oestrogen with a progestogen, the route of administration, duration of treatment and individual health factors.
This is why the decision to use HRT should be personalised.
Breast cancer risk
Combined HRT, which contains oestrogen and a progestogen, is associated with a small increase in breast cancer risk. The risk varies according to factors including the type and duration of treatment. Oestrogen-only HRT has a different risk profile.
This does not mean HRT is unsuitable for everyone. Your individual circumstances, family history and other risk factors should be considered when discussing treatment.
It is also important to continue attending breast screening appointments when invited.
Blood clots
The route of HRT can affect blood-clot risk. Oral HRT can increase the risk of blood clots, whereas transdermal oestrogen, such as patches, gels or sprays, is not associated with the same increased risk.
If you have risk factors for blood clots, your healthcare professional can take these into account when deciding which form of HRT may be appropriate.
Stroke
Oral HRT is associated with a small increase in stroke risk, while this increased risk is not seen in the same way with transdermal oestrogen delivered through patches, gels or sprays.
Your age and personal risk factors are important when considering this.
Side effects
Some women experience side effects when starting HRT. These can include headaches, breast tenderness, nausea, spotting or unexpected vaginal bleeding. Side effects are often mild and may improve as the body adjusts to treatment.
If side effects continue or are troublesome, your healthcare professional may be able to adjust the dose, change the type of HRT or change the way it is administered.
HRT pros and cons at a glance
The advantages and disadvantages of HRT are different for every woman, but the following provides a useful overview.
Potential benefits include:
- relieving troublesome menopause symptoms
- reducing hot flushes and night sweats
- helping with vaginal symptoms
- improving sleep when sleep disruption is related to menopause symptoms
- helping prevent bone loss and osteoporosis
- potentially improving quality of life when symptoms significantly affect daily life
Potential considerations or risks include:
- a small increase in breast cancer risk with some forms of HRT
- increased risk of blood clots with oral HRT
- a small increase in stroke risk with oral HRT
- possible side effects such as headaches, breast tenderness or bleeding
- the need to use progestogen alongside oestrogen if you have a womb
- the need for regular review of your treatment
The balance between these factors is individual. NICE recommends discussing the benefits and risks of HRT so that treatment decisions can be made based on the person’s circumstances and preferences.
What types of HRT are available?
There are several ways HRT can be prescribed. The most appropriate option depends on your symptoms, whether you still have periods, whether you have a womb and your medical history.
Oestrogen-only HRT
Oestrogen-only HRT may be appropriate for women who have had a total hysterectomy. It is not usually suitable for someone with a womb because unopposed oestrogen can increase the risk of the womb lining becoming too thick.
Combined HRT
Combined HRT contains both oestrogen and a progestogen. The progestogen helps protect the womb lining from the effects of oestrogen.
Depending on whether you are still having periods, you may be offered sequential or continuous combined HRT.
Transdermal HRT
Oestrogen can be delivered through the skin using patches, gels or sprays. This can be particularly relevant when considering blood clot risk because transdermal oestrogen is not associated with the same increased risk of venous thromboembolism as oral HRT.
Vaginal oestrogen
Low-dose vaginal oestrogen can help symptoms such as vaginal dryness, discomfort and some urinary symptoms. It is different from systemic HRT because only a small amount is absorbed into the rest of the body.
Vaginal oestrogen has a different risk profile from systemic HRT because only a small amount is absorbed into the rest of the body. It can also be used long term when needed for vaginal symptoms.
Who might benefit from HRT?
HRT may be an option if menopause or perimenopause symptoms are affecting your quality of life.
It can be particularly useful when symptoms such as hot flushes, night sweats, sleep disruption or vaginal symptoms are persistent or difficult to manage.
However, whether HRT is appropriate depends on your individual circumstances. Some medical conditions and previous health problems may affect which treatment can be prescribed, while in some situations HRT may not be recommended.
For example, your healthcare professional may need to consider a history of certain cancers, blood clots, liver disease or uncontrolled high blood pressure before recommending treatment.
If you’re unsure about the difference between perimenopause and menopause, understanding the two stages can also help you know what to discuss with a healthcare professional.
What should you consider before starting HRT?
Choosing whether to start HRT is not simply a matter of weighing a standard list of pros and cons. Your circumstances matter.
A healthcare professional may consider:
- your age and stage of menopause
- the symptoms you are experiencing
- whether you still have periods
- whether you have had a hysterectomy
- your personal and family medical history
- your risk of breast cancer
- your risk of blood clots and cardiovascular disease
- the type and route of HRT
- your preferences and treatment goals
The aim is to find an approach where the potential benefits are appropriate for your symptoms and circumstances while taking relevant risks into account.
This is particularly important because the balance of benefits and risks can change over time. NICE states that, for people aged 45 and over, overall life expectancy is unlikely to be affected by either combined or oestrogen-only HRT.
How long can you take HRT?
There is no universal fixed time limit for HRT. How long you continue treatment depends on your symptoms, age, health risks and whether the benefits continue to outweigh the risks.
Your treatment should be reviewed regularly, with an annual review recommended, although you may need to speak to your healthcare professional sooner if you experience significant side effects or changes in your health.
Some women may choose to stop HRT when their symptoms improve, while others may continue for longer when the benefits remain relevant.
Stopping HRT should also be discussed with a healthcare professional, particularly if your symptoms return.
Is HRT right for you?
There is no single answer to whether HRT is right for every woman.
For some, the improvement in troublesome menopause symptoms can make a significant difference to daily life. For others, medical history or individual risk factors may mean that a different approach is more appropriate.
If you are considering HRT, a personalised discussion can help you understand which options may be suitable and what the potential benefits and risks mean in your particular circumstances. Specialist menopause and perimenopause care can provide support when you need help assessing your symptoms and treatment options.
Final thoughts
HRT can be an effective treatment for many menopause and perimenopause symptoms and can also provide benefits such as helping to protect bone health. At the same time, it has potential risks and side effects that should be considered before and during treatment.
The most important point is that HRT is not a one-size-fits-all treatment. The type, dose and route of HRT, as well as your personal medical history and treatment goals, all matter.
If you’re considering HRT, discussing your options with a qualified healthcare professional can help you make an informed decision based on your own circumstances.
Frequently asked questions
What are the main benefits of HRT?
The main benefit of HRT is relief from menopause symptoms, including hot flushes and night sweats. It can also help with vaginal symptoms and may help prevent bone loss and osteoporosis.
What are the risks of HRT?
The risks depend on the type of HRT and individual circumstances. Some forms of HRT are associated with a small increase in breast cancer risk, while oral HRT can increase the risk of blood clots and stroke. The absolute risks are low for many women, but individual factors need to be considered.
How long can you take HRT?
There is no fixed limit for how long HRT can be taken. Treatment should be reviewed regularly, with the decision to continue based on whether the benefits continue to outweigh the risks for you.
About the Author
Dr Sandar Hlaing is a GP with a special interest in women’s health, hormonal wellbeing, medical weight management, hair loss concerns and healthy ageing. Through a personalised, evidence-based approach, she helps patients understand the underlying factors affecting their health and develop realistic treatment plans tailored to their individual needs.
