HRT: a balanced look

HRT has had a rollercoaster reputation. Here is a calm summary of what the NHS and NICE (guideline NG23, updated in 2024 and again in 2026) say, so you can have an informed chat with your doctor. This is general information, not advice for you personally.

What it is

HRT replaces oestrogen. If you still have a womb, you also take a progestogen to protect the womb lining. Oestrogen alone raises the risk of womb cancer, which is why combined HRT is used if you have a womb. It comes as tablets, patches, gels or sprays. Vaginal oestrogen treats vaginal and urinary symptoms locally.

The NHS says that for people under 60 with menopause symptoms, who are not at high risk of breast cancer or blood clots, the benefits of HRT are likely to outweigh the risks. The older view that made many people afraid of it is now seen as out of date, because it did not weigh the benefits as well as the risks.

Benefits

• It is effective at relieving most perimenopause and menopause symptoms: hot flushes, night sweats, sleep problems, vaginal dryness and low mood or anxiety caused by menopause. Many people feel better within days to weeks.
• Fracture risk is lower while you take HRT. NICE says the benefit lasts during treatment and fades once you stop.
• It may help low mood that starts around the same time as other menopause symptoms.
• The evidence on muscle strength is limited, so exercise remains key.

Risks, in context

• Breast cancer: combined HRT slightly raises the risk, and the rise grows the longer you take it. The NHS figure is around 5 extra cases in every 1,000 women who take combined HRT for 5 years. NICE says the risk can last at least 10 years after stopping, and that it is lower with sequential than continuous combined HRT, but still higher than without HRT. Oestrogen-only HRT (for people without a womb) has very little or no increase. Exact numbers depend on your own risk, so ask for NICE’s discussion aid.
• Blood clots: HRT tablets can raise the risk, though it is still very low. NICE and the NHS say patches, gels and sprays (transdermal) do not.
• Stroke: tablets slightly raise the risk, higher with higher doses, longer use and older age at starting. Transdermal HRT is unlikely to. The baseline risk under 60 is very low.
• Heart disease: HRT does not increase the risk of coronary heart disease. But NICE says not to offer HRT to prevent heart disease or dementia, as it is not proven for that.
• Dementia: NICE says the risk might rise if combined HRT is started at 65 or over. For oestrogen-only HRT it is unlikely to rise.
• Vaginal oestrogen does not increase the risk of breast cancer or blood clots, and the NHS says it is safe to use long term.

Starting, reviewing and stopping

• NICE says to use the lowest effective dose and to talk about how long you might take it from the start.
• Irregular bleeding or spotting is common for the first 6 months, or within 3 months of changing your dose. Tell a GP if it continues beyond that.
• You should be reviewed after 3 months, then at least once a year.
• There is no fixed time limit, but it is best to take HRT only for as long as the benefits outweigh the risks. The NHS says people usually take it for 2 to 5 years, sometimes longer.
• When you stop, you can taper or stop straight away. Tapering may limit symptoms returning in the short term, but makes no difference in the long run.
• HRT is not contraception, except a hormonal coil used as the progestogen.