Menopause & HRT

Hormone replacement therapy replaces the oestrogen your body has stopped producing, usually as a patch, gel, spray or tablet, with progestogen added if you still have a womb.

Testosterone is sometimes added where low libido persists despite adequate oestrogen.

Worth booking if you have

• Hot flushes or night sweats
• Sleep that has broken down, or waking at 3am regularly
• Brain fog, poor concentration or memory lapses
• Low mood, irritability or anxiety that feels unlike you
• Joint aches, vaginal dryness or reduced libido
• Periods that have changed pattern in your forties

On the risk conversation

The breast cancer figures that get quoted are almost always relative risk, which sounds alarming and tells you very little. What matters is your absolute risk, which depends on your age, the type of HRT and how long you take it.

Twenty minutes is enough to go through that properly instead of leaving you to decide from a headline.

1. Diagnosis is usually clinical

In women over 45 with typical symptoms, menopause is diagnosed on history. Blood tests are often unnecessary and can be actively misleading, because levels swing week to week.

Under 45, or with irregular cycles, testing genuinely helps.

2. Choosing a preparation

Patch, gel, spray or tablet, with progestogen added if you still have a womb. Transdermal options carry a lower clot risk than tablets, which matters for some women and not others.

3. Give it three months

Breast tenderness, bloating and irregular bleeding are common early and usually settle. Judging HRT at three weeks is judging it too soon.

4. Review and adjust

Dose and preparation are frequently changed at least once. That is normal, not a failure.

Three months, then a year

• Around three months — the important one. Early side effects have usually settled by then, so the dose can be judged properly rather than prematurely
• Annually thereafter, or sooner if something changes

Judging HRT at three weeks is judging it too soon, and a great many women stop in that window believing it has not worked.

What is reviewed

• Symptoms, all of them — not only flushes, but sleep, mood, concentration, joints, libido and vaginal symptoms, since these improve at different rates
• Bleeding pattern, which is the thing that most often needs acting on
• Blood pressure and weight
• Whether the preparation still suits you. Dose and route are frequently changed at least once, and that is normal rather than a failure
• Whether local symptoms have settled. Vaginal oestrogen is often needed alongside systemic HRT, and this is very commonly missed

Bleeding — what is expected and what is not

• Unscheduled bleeding in the first three to six months of starting or changing HRT is common and usually settles
• Bleeding that starts after six months, or that returns after a settled period, needs assessment — not adjusting the dose and hoping
• Any bleeding after a year without periods, in a woman not on HRT, is urgent and needs investigation on a two-week-wait pathway

Do not assume bleeding is "just the HRT". That assumption is how endometrial problems get missed.

What HRT does not need

Routine blood monitoring is not required for standard HRT. Oestrogen levels are not checked as a matter of course, and a service that sells you regular hormone panels is generally selling tests rather than providing care.

Testosterone is the exception — where it is used, levels are checked to ensure they stay within the female range.

Come back sooner if

• Calf pain or swelling, chest pain, breathlessness — possible clot, needing urgent assessment
• Severe headache with visual disturbance, or weakness on one side — 999
• A new breast lump or nipple change
• Bleeding as described above

Screening continues regardless

HRT does not replace breast or cervical screening, and it does not exclude you from either. Keep attending both.

Stopping

There is no fixed maximum duration, and no age at which HRT must automatically stop — it is a yearly conversation about benefit and risk. Many women taper rather than stop abruptly, which reduces the rebound in symptoms.

The most under-used treatment in menopause

Vaginal oestrogen — for dryness, painful sex, urinary urgency and recurrent UTIs. It is a tiny fraction of the HRT dose, carries none of the systemic risk, needs no progestogen, and can be used alongside HRT or by many women who cannot take HRT at all.

It is very commonly missed in women already on HRT whose local symptoms have not settled.

Non-hormonal medication that genuinely works

• Certain SSRIs and SNRIs reduce hot flushes meaningfully, and are a real option where HRT is contraindicated — particularly after breast cancer
• Fezolinetant, a newer non-hormonal treatment specifically for vasomotor symptoms
• Clonidine and gabapentin, older options with more modest effect
• Vaginal moisturisers and lubricants, which help symptoms without restoring tissue — best used alongside vaginal oestrogen rather than instead of it

Cognitive behavioural therapy

CBT has good evidence for hot flushes, sleep and mood in menopause, which surprises people. It does not stop the flushes but changes how much they interfere — and it is available free through NHS talking therapies, self-referral, no GP needed.

What else might explain the symptoms

Worth excluding rather than assuming. Thyroid disease, iron deficiency, sleep apnoea — badly under-diagnosed in women and a common cause of the 3am waking and daytime fog attributed to menopause — depression, and ADHD, which frequently becomes unmanageable in perimenopause and is diagnosed late in women.

Testosterone

Considered where low libido persists despite adequate oestrogen — not as a general tonic, and not for fatigue or mood, where the evidence does not support it. There is no licensed female product in the UK, so it is prescribed off-licence at a female dose, and levels are monitored.

Free routes

HRT is available on the NHS, and in England the HRT Prescription Prepayment Certificate covers unlimited HRT prescriptions for about the price of two. If cost is a factor, that is worth knowing before paying privately.

What you pay us

• £40 for the consultation — a full twenty minutes, which is what this subject actually needs
• £40 for the three-month review, and for the annual review after that
• Blood tests where genuinely indicated, quoted before they are arranged

What you pay the pharmacy

HRT itself is inexpensive. Most standard preparations are relatively cheap as private prescriptions, and we earn nothing from what is prescribed. Ring around — prices still differ between pharmacies.

The saving worth knowing about

In England, the HRT Prescription Prepayment Certificate covers unlimited NHS HRT prescriptions for roughly the cost of two. It is one of the best-value things in the NHS and it is under-claimed.

If you can get HRT from your NHS GP, that route is almost certainly cheaper than private prescribing. We would rather say so.

Prescriptions are free in Scotland, Wales and Northern Ireland.

What we will not sell you

• Routine hormone blood panels. Menopause over 45 is diagnosed on history, levels swing week to week, and repeated testing is usually selling tests rather than providing care
• Compounded "bioidentical" hormones. Not regulated, not quality-assured, and not recommended by the British Menopause Society or the RCOG. Regulated body-identical HRT is available on prescription and is what we use
• Supplements, creams and "menopause support" products. We sell nothing

Where the private fee genuinely buys something

Time. Twenty minutes to go through symptoms properly, discuss risk in absolute rather than relative numbers, and choose a preparation deliberately.

What it does not buy is a different medicine — the HRT is the same HRT.

Do I need a blood test to diagnose menopause?

Usually not. Over 45 with typical symptoms, it is diagnosed on history — and hormone levels swing so much week to week that a test can be actively misleading.

Testing genuinely helps under 45, or where the picture is unclear.

Does HRT cause breast cancer?

The honest answer is more nuanced than either headline.

Oestrogen-only HRT — for women without a womb — shows little or no increase in breast cancer risk. Combined HRT carries a small increase that rises with duration of use, and it falls again after stopping.

The numbers quoted in the press are almost always relative risk, which sounds alarming and tells you nothing about your own position. In absolute terms, the increase is comparable to that from drinking a couple of units of alcohol daily or being significantly overweight.

Twenty minutes is enough to go through your actual numbers rather than leave you deciding from a headline.

Is HRT safer as a patch or gel than as a tablet?

For clot and stroke risk, yes — that is a real and well-established difference. Transdermal oestrogen does not carry the increased clot risk that tablets do.

That is why patches and gels are often preferred, and why they may be an option for women who cannot take tablets — including those with migraine with aura, raised BMI, or a history of clot.

How long can I stay on it?

There is no fixed limit and no age at which it must automatically stop. It is a yearly conversation weighing benefit against risk.

The old advice about stopping at a certain age has been superseded, but arbitrary continuation is not the answer either — it should be an actual decision each year.

Will HRT help my brain fog?

Often, yes — and it is one of the symptoms women most want addressed.

But do not assume all of it is menopause. Thyroid disease, iron deficiency, sleep apnoea, depression and undiagnosed ADHD all present this way, and all are treatable in their own right.

I am still having periods. Am I too young for HRT?

No. Perimenopause can begin years before periods stop, and treatment during it is entirely appropriate. The preparation differs — a cyclical regimen, or the combined pill in some cases.

Symptoms in your early forties are frequently attributed to stress, work or motherhood for years before anyone considers hormones.

Does HRT act as contraception?

No, and this catches people out. HRT is not contraception, and pregnancy remains possible in perimenopause.

Contraception is generally advised until 55, or for two years after the last period under 50 and one year over 50. Discuss it at the appointment — see contraception.

What about "bioidentical" hormones?

Two different things share that name, and it matters.

Regulated body-identical HRT — micronised progesterone and oestradiol — is standard, quality-assured, and what we prescribe.

Compounded "bioidentical" preparations from private clinics are unregulated, not quality-assured, and not recommended by the British Menopause Society or the RCOG. They are usually expensive, and often sold alongside unnecessary hormone testing.

Can I take HRT after breast cancer?

Generally not systemic HRT, and that must be a decision with your oncology team.

Non-hormonal options work — certain SSRIs and SNRIs, fezolinetant, and CBT. Vaginal oestrogen is often possible even after breast cancer, but again as a joint decision with your specialists.

I am on HRT but still have vaginal dryness and UTIs. Why?

Because systemic HRT frequently does not resolve local symptoms, and this is very commonly missed.

Vaginal oestrogen is used in addition to HRT. It is a tiny dose, it needs no progestogen, and it substantially reduces recurrent UTIs after the menopause.

Should I have my hormone levels checked while on HRT?

Not routinely. Standard HRT is monitored on symptoms rather than blood levels.

Testosterone is the exception, where levels are checked to keep them in the female range. A clinic selling you regular hormone panels is generally selling tests.