A Comprehensive Guide to HRT: Types, Benefits and Side Effects

What is HRT?

HRT replaces the hormones — mainly oestrogen and progesterone, and sometimes testosterone — that fall as the ovaries wind down. Replacing them relieves menopause symptoms like hot flushes, night sweats, brain fog, joint aches, low mood, anxiety, disturbed sleep and vaginal dryness, and reduces the long-term risk of osteoporosis and cardiovascular disease when started around the time of menopause.

The two main hormones in HRT

Oestrogen — the symptom-treating hormone

Oestrogen is the hormone that treats menopause symptoms. It can be given as a patch, gel, spray or tablet. In the UK, current guidance from the British Menopause Society recommends transdermal oestrogen (through the skin) as first-line because it bypasses the liver and does not raise the risk of blood clots or stroke.

Progesterone — the womb-protecting hormone

If you still have your uterus, oestrogen alone would thicken the womb lining, so a progestogen is added to protect it. Micronised progesterone (Utrogestan) is body-identical, taken as a capsule at night, and is the option most closely matched to the progesterone your body once made. Alternatives include the Mirena coil, which delivers progestogen directly to the womb and also acts as contraception.

Testosterone — often the missing piece

Testosterone can be prescribed off-licence in the UK when low libido persists on adequate oestrogen. Many women also report improvements in energy, mood and mental clarity.

Body-identical vs synthetic HRT

Body-identical HRT (transdermal oestradiol plus micronised progesterone) has the same molecular structure as your own hormones and is the regimen most current evidence supports. Older synthetic combinations — oral conjugated oestrogens and synthetic progestogens — carry higher clot and breast risk and are rarely used first-line today.

Benefits you can expect

• Fewer and milder hot flushes and night sweats, usually within 4–8 weeks.
• Better sleep, mood and concentration.
• Relief from joint and muscle aches.
• Improved vaginal comfort, urinary symptoms and libido.
• Protection against osteoporosis and fragility fractures.
• Emerging evidence for cardiovascular and long-term brain-health benefits when started under 60 or within 10 years of menopause.

Common side effects — and how to manage them

Most side effects appear in the first few weeks as your body settles into the new hormone levels, and resolve by 8–12 weeks.

• Breast tenderness: usually short-lived; a small oestrogen dose reduction or splitting the dose often helps.
• Nausea or bloating: more common with oral routes — switching to a patch or gel usually resolves it.
• Spotting or irregular bleeding: common in the first 3–6 months, especially on continuous regimens; persistent bleeding should always be reviewed.
• Headaches: a steadier transdermal dose is usually better tolerated than tablets.
• Low mood or PMS-like symptoms on progesterone: the dose, timing or route of progesterone can be adjusted; the Mirena coil is an alternative.

Side effects are almost always a signal to fine-tune your regimen rather than stop HRT altogether. Reviews at 3 months and then annually make sure your dose, route and symptoms stay in balance.

Is HRT safe?

For most healthy women under 60, the benefits of HRT clearly outweigh the risks. Transdermal oestrogen does not increase the risk of blood clots or stroke. Micronised progesterone is associated with a lower breast-cancer risk than older synthetic progestogens. HRT is not suitable for everyone, and every prescription should follow an individualised assessment of your medical history.

Frequently asked questions