HRT and menopause in the UK: complete guide

HRT can be a very effective treatment for troublesome menopause and perimenopause symptoms, but the right choice depends on your symptoms, womb status, age, periods, risk factors and preferences. In the UK, most decisions are about oestrogen route, progestogen protection, vaginal symptoms, dose review and individual risk. The goal is not to put everyone on HRT; it is to make a balanced decision with enough information.

First, confirm what problem you are treating

Menopause is the final menstrual period, confirmed after 12 months without a period if there is no other cause. Perimenopause is the transition before that, when hormones fluctuate and symptoms can start while periods are still happening. Typical symptoms include hot flushes, night sweats, sleep problems, mood changes, brain fog, joint aches, vaginal dryness, painful sex, urinary symptoms and menstrual changes.

NICE guidance says FSH testing should not usually be used to diagnose menopause in people aged 45 or over with typical symptoms, and should not be used in people using combined hormonal contraception or high-dose progestogen.¹ Blood tests can still matter if symptoms are atypical, premature ovarian insufficiency is possible, or another condition such as thyroid disease, anaemia, pregnancy, depression, infection or medication effects may be contributing.

The first decision is symptom target. If the main problem is vaginal dryness, recurrent urinary symptoms or painful sex, local vaginal treatment may be enough. If hot flushes, night sweats and sleep disruption dominate, systemic HRT may be more relevant. If low mood, anxiety or trauma symptoms are central, HRT may help if menopause is driving them, but mental health assessment may still be needed.

The main HRT building blocks

Systemic HRT usually includes oestrogen. If you have had a hysterectomy, oestrogen-only HRT may be used. If you still have a womb, oestrogen without adequate progestogen can thicken the womb lining and increase endometrial cancer risk, so combined HRT is usually needed.⁴

Oestrogen can be taken as tablets, patches, gel or spray. NHS information lists tablets, skin patches, gel and spray as common HRT forms.⁴ The route matters. Oral oestrogen goes through the liver first. Transdermal oestrogen is absorbed through skin and is often considered when clot risk, migraine, triglycerides, liver issues or side effects make tablets less attractive.

Progestogen can be given cyclically, meaning part of the month, or continuously, meaning every day, depending on periods, age and time since last period. Some people use a levonorgestrel intrauterine system for endometrial protection as part of HRT. British Menopause Society guidance on progestogens and endometrial protection emphasises that progestogen dose and duration need to be adequate for the oestrogen dose.⁹

Vaginal oestrogen is different from full systemic HRT. NHS guidance says vaginal oestrogen is used for vaginal dryness, discomfort and urinary symptoms, and only a small amount is absorbed into the body.⁷ It can be continued long term if needed, with review, and is often underused because people assume all oestrogen has the same risk profile.

Benefits, risks and route choices

The main benefit of HRT is symptom relief. NHS menopause treatment guidance says HRT can help symptoms including hot flushes, night sweats, mood swings, vaginal dryness and reduced sex drive.² It can also help prevent bone loss in people at risk, but bone protection should be discussed alongside exercise, calcium, vitamin D, falls risk, smoking and alcohol.

Risk depends on age, time since menopause, route, dose, type of progestogen, personal history and family history. NHS HRT guidance explains that risks vary and should be discussed with a GP.³ For many healthy people under 60 or within 10 years of menopause, benefits may outweigh risks, but that does not make HRT risk-free or compulsory.

Eligibility and side effects also matter. NHS guidance lists situations where HRT may not be suitable, including some cancers, unexplained vaginal bleeding, blood clots and liver disease, depending on the individual case.⁵ It also describes side effects such as breast tenderness, headaches, mood changes, nausea and bleeding that may need review if persistent.⁶

Breast cancer risk is one of the most discussed areas. MHRA has advised that all systemic HRT except vaginal oestrogen is associated with a small increased risk of breast cancer, and risk differs by type and duration.⁸ Combined oestrogen and progestogen generally carries a higher breast cancer risk than oestrogen-only HRT. This needs a personal discussion, especially if you have previous breast cancer, strong family history or abnormal breast screening.

Blood clot and stroke risk also depend on route and background risk. Oral HRT tends to carry more clot risk than transdermal HRT, which is why patches or gel are often preferred in people with higher clot risk, migraine with aura, obesity or other factors. Do not choose the route based on convenience alone if you have significant medical history.

Review, bleeding and when to get specialist advice

HRT is not "start and forget". NHS guidance says HRT is usually reviewed after 3 months, then at least annually.³ The review should ask whether symptoms have improved, side effects have settled, bleeding is expected, dose is right, blood pressure and weight are monitored where relevant, and whether risks have changed.

Bleeding needs clear rules. Irregular bleeding can happen when starting or changing HRT, but persistent, heavy, new or unexpected bleeding should be reviewed. If you are postmenopausal and not on HRT, any vaginal bleeding needs medical assessment. If you are on HRT, ask what bleeding pattern is expected for your regimen and when ultrasound or urgent review is needed.

Specialist advice is worth considering for premature ovarian insufficiency, menopause under 40, complex medical history, previous hormone-sensitive cancer, high clot risk, uncontrolled symptoms despite treatment, high-dose oestrogen, persistent bleeding, or when testosterone is being considered. The British Menopause Society has warned about high-dose HRT prescribing outside licensed doses and emphasises careful endometrial protection and review.¹⁰

How to prepare for a GP appointment

Bring a symptom list, period pattern, contraception, womb status, previous hysterectomy or endometrial ablation, migraine history, clot history, breast history, blood pressure, smoking status, medicines, supplements and family history. Use Start Here to organise the timeline, the health library to understand linked conditions, insights to question hormone claims, and the stack builder to track HRT, supplements and medicines clearly.

Ask what success looks like. Fewer night sweats? Better sleep? Less vaginal pain? Improved quality of life? Also ask when to adjust. Many side effects settle, but persistent breast tenderness, nausea, headaches, mood change, bleeding or skin reactions may mean dose or formulation needs review.

This article is educational and does not constitute medical advice, diagnosis, or a treatment recommendation. Medication uses described as “off-label” are not licensed for that purpose in the UK and should only be considered under qualified clinical supervision. Always speak to your GP, pharmacist, or a registered specialist before starting, stopping, or changing any treatment. If you have severe or alarm symptoms - unintentional weight loss, blood in your stool, difficulty swallowing, persistent vomiting, a fever, or severe pain - seek urgent medical care.