Menopause Mini-Series: Part 3 — Hormone Replacement Therapy (HRT): understanding the benefits and risks | Rodolico Health
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This article is the final part of a short series on menopause and perimenopause, designed to provide clear, evidence-based information across what can often feel like a complex and confusing area. We began by looking at what menopause is and how it presents, before exploring practical approaches to managing symptoms. Here, we focus on hormone replacement therapy (HRT), including its benefits, risks, and who it may be right for.
You may also see this treatment referred to as hormone therapy (HT), particularly in international guidance. In practice, both terms refer to the same group of treatments.
Hormone Replacement Therapy (HRT): understanding the benefits and risks
A starting point
Hormone replacement therapy is one of the most effective treatments we have for menopausal symptoms.
For many women, it can be genuinely life changing: improving sleep, stabilising mood, reducing hot flushes, and helping them feel more like themselves again.
At the same time, it’s completely natural to want a clear understanding of safety.
Much of the concern around HRT comes from older studies, which highlighted potential risks without always placing them in context. This understandably led to caution, both in prescribing and in how HRT has been perceived. Our understanding has moved on significantly. We now know:
- the benefits of HRT often outweigh the risks for many women
- the risks of serious side effects are generally very low
- and the balance depends on your individual situation
In particular, if you are under 60, have menopausal symptoms, and do not have significant risk factors such as a history of breast cancer or blood clots, HRT is often a safe and effective option to consider.
What is HRT?
HRT replaces hormones, primarily oestrogen, that fluctuate and decline during perimenopause and menopause.
Depending on your situation, it may include:
- oestrogen alone (if you’ve had a hysterectomy)
- or oestrogen combined with a progestogen (to protect the lining of the uterus)
It’s also worth knowing that HRT comes in different forms, patches, gels, tablets, and vaginal treatments, and these can have different risk profiles.
What are the benefits?
Relief of menopausal symptoms
The main benefit of HRT is that it is highly effective at relieving common symptoms, including:
- hot flushes
- night sweats
- sleep disturbance
- anxiety or low mood related to menopause
- vaginal dryness
Many women notice an improvement within a few weeks, particularly in sleep and vasomotor (hot flushes and night sweats) symptoms.
Bone health
Oestrogen plays an important role in maintaining bone strength.
After menopause, bone loss accelerates, increasing the risk of osteoporosis and fractures.
HRT helps to slow this process and is particularly important in women who experience early menopause.
Muscle strength and physical function
It is common to lose muscle strength during midlife.
HRT may help maintain muscle function, although this works best alongside regular strength based exercise.
Vaginal and urinary symptoms
Low-dose vaginal oestrogen can be very effective for:
- vaginal dryness
- discomfort during sex
- urinary symptoms
Because the dose is low and absorption into the bloodstream is minimal, it is considered safe for long-term use in most women.
Understanding risk: a clearer way to think about it
It’s completely natural to feel uncertain when reading about risks.
One of the difficulties with HRT is that earlier studies focused heavily on potential harms, without always balancing these against the benefits. This has contributed to understandable concern.
What we now know is that for most healthy women in their 50s, the overall risks remain small, and the balance between benefit and risk is often favourable.
Risk is not the same for everyone. It depends on:
- your age
- how close you are to menopause
- the type of HRT used
- your individual health profile
With that in mind, it’s helpful to look at the main risks in a straightforward way.
What are the main risks?
Breast cancer
Some types of HRT are associated with a small increase in breast cancer risk, particularly when oestrogen is combined with a progestogen.
However:
- the increase in risk is small for most women: there are around 5 extra cases of breast cancer in every 1,000 women who take combined HRT for 5 years (based on NHS guidance)
- it is much lower with oestrogen only HRT
- it relates to how long HRT is used
- and it reduces again after stopping treatment
Attending regular breast screening (mammograms) and lifestyle measures remain important. I have previously written about breast cancer screening and early diagnosis.
Blood clots
HRT taken as tablets can slightly increase the risk of blood clots.
- the overall risk remains small
- patches and gels do not carry the same increased risk
For this reason, transdermal HRT is often preferred where possible.
Stroke
There is a small increase in stroke risk with some forms of HRT (not patches or gels), particularly with increasing age. For women under 60, this risk remains low.
Heart disease
The relationship between HRT and heart health is influenced by when treatment is started. Beginning HRT around menopause does not appear to increase risk, and may be beneficial for some women. Starting later in life is associated with a slightly higher risk, which is why timing is an important part of the discussion.
Other considerations
There are small increases in some other conditions, such as gallbladder disease.
For others, such as dementia or ovarian cancer, the evidence is still evolving, and any potential risks appear to be small and influenced by when treatment is started.
For women with uterus or history of endometriosis, oestrogen is used in combination with progesterone to reduce the risk of endometrial cancer (cancer of the lining of the womb). This is an important preventative step to reduce risks of unopposed oestrogen.
Why timing matters
One of the most important insights from more recent research is that when HRT is started makes a difference.
Starting treatment around the time of menopause is associated with a more favourable balance of benefit and risk. In contrast, beginning HRT later, particularly after the age of 60 or more than 10 years after menopause, is associated with higher risk, which is why timing forms an important part of the discussion.
This is sometimes referred to as a “window of opportunity”.
Does the type of HRT matter?
Yes: and this is often reassuring. Modern HRT is not one uniform treatment.
- patches and gels may carry a lower risk of blood clots than tablets
- lower doses may reduce risk further
- different types of progesterone may have different profiles
This is why treatment is now much more individualised than it used to be.
Who is HRT suitable for?
HRT may be particularly helpful if:
- symptoms are affecting your quality of life
- you are in your 40s or 50s
- you are close to the time of menopause
It may not be suitable for some women, particularly those with:
- a history of breast cancer
- previous blood clots
- certain cardiovascular conditions
In these situations, alternative approaches can be explored.
A balanced view
Across large studies and clinical guidance, a consistent message emerges:
- HRT is the most effective treatment for menopausal symptoms
- risks are generally small in younger, healthy women
- benefits often outweigh risks when used appropriately
The most important step is not making a decision in isolation, but having a thoughtful discussion about your individual situation.
How we approach HRT at Rodolico Health
Our approach is always individual. We consider:
- your symptoms
- your medical history
- your risk factors
- your preferences
Where appropriate, we often use:
- transdermal oestrogen (patch or gel)
- the lowest effective dose
- regular review and adjustment
Final thoughts
HRT is not the right choice for everyone, but it is also not something to approach with undue fear. For many women, it offers a safe and effective way to feel more like themselves again.
The aim is not simply to treat menopause, but to support wellbeing through this stage of life, with clear information, careful judgement, and decisions that feel right for you.
If you would like to discuss any symptoms you are experiencing, or discuss HRT in more detail, you are very welcome to get in touch or book an appointment.
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