Hormone Therapy Overview
CURRENT GUIDANCE UPDATE
HRT Safety & Effectiveness
Hormone Replacement Therapy (HRT) is considered safe and effective for most women under 60 years of age who are within 10 years of menopause, with benefits generally outweighing potential risks.
Transdermal HRT
Oestradiol-based transdermal HRT, including patches, gels and sprays, has a more favourable safety profile than oral conjugated equine oestrogen.
Body-Identical Progesterone
Micronised progesterone (body-identical progesterone) is associated with a lower breast cancer risk than synthetic progestogens when used in combined HRT regimens.
Personalised HRT Choice
The type, dose and route of HRT should be individualised based on symptoms, medical history, cardiovascular risk factors and patient preferences, with regular clinical review.
Introduction
Hormone Replacement Therapy (HRT)
Modern HRT is personalised according to menopausal status, medical history and individual risk factors. Body-identical hormones and transdermal therapies are increasingly preferred because of their favourable safety profile.
Available Treatment Options
- Oestrogen-only HRT for women after hysterectomy who do not require endometrial protection.
- Combined HRT (oestrogen + progestogen) for women with a uterus.
- Cyclical combined HRT provides a monthly withdrawal bleed and is suitable for perimenopausal women.
- Continuous combined HRT produces no bleed and is recommended after menopause.
How HRT Is Taken
- Oral tablets are convenient but undergo first-pass liver metabolism.
- Transdermal patches are preferred for women with VTE risk, migraines or metabolic concerns.
- Transdermal gels and sprays provide flexible daily dosing without first-pass metabolism.
- Vaginal oestrogen is used for local genitourinary symptoms with minimal systemic absorption.
Safer Hormonal Options
Oestradiol and micronised progesterone are chemically identical to naturally produced ovarian hormones. Current evidence suggests a superior safety profile, with transdermal oestradiol not increasing VTE risk at standard doses and micronised progesterone associated with a lower breast cancer risk than many synthetic progestogens.
Evidence-Based Advantages
- Highly effective relief of hot flashes and night sweats.
- Improves genitourinary syndrome of menopause.
- Better sleep quality and improved mood.
- Supports cognitive wellbeing.
- Protects bone density and helps prevent osteoporosis.
- May reduce cardiovascular events when started within 10 years of menopause.
Understanding the Evidence
- Breast Cancer: Combined HRT carries a small additional risk comparable to obesity or regular alcohol consumption. Oestrogen-only HRT does not increase breast cancer risk, while micronised progesterone has the lowest reported risk.
- Venous Thromboembolism (VTE): Oral oestrogen increases risk approximately 2–3 times, whereas transdermal oestrogen does not significantly increase VTE risk.
- Stroke: Oral oestrogen carries a small increase in stroke risk, while transdermal therapy has not shown the same increase.
Frequently Asked Questions
How long should I take HRT?
There is no arbitrary time limit for HRT. NICE 2023 states women should be able to make an informed choice about duration. HRT can be continued as long as the individual woman's benefit-risk balance supports continuation, with annual review.
Can I take HRT if I've had a blood clot?
Oral HRT is contraindicated with prior venous thromboembolism. Transdermal oestrogen does not increase VTE risk and may be used with haematological input.
Conclusion
HRT is effective, evidence-based, and for most women, safe. The previous culture of HRT fear was based on a misinterpretation of outdated evidence and has caused significant and unnecessary suffering for millions of menopausal women. Dr. Ruby Rashmi provides evidence-based, individualised HRT assessment and prescribing as part of her menopause care practice.
Sources & References
This article draws on guidance current at the time of writing from the following bodies and publications:
- NICE NG23 (updated 2023)
- BMS/IMS (2022 Global Consensus)
- RCOG (2023)
General reference bodies for women's health guidance:
RCOG
rcog.org.ukACOG
acog.orgFIGO
figo.orgWHO
who.intNICE
nice.org.uk⚠ IMPORTANT DISCLAIMER
This article is provided for general knowledge and reference purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. No medication, treatment, or change to your healthcare should be undertaken based on this content without first consulting a qualified doctor. Always seek the advice of your physician or another qualified health provider with any questions you may have regarding a medical condition.
