Navigating hormone replacement therapy (HRT)
The transition through perimenopause and menopause is a natural stage of life, marked by a decline in the body's production of hormones, particularly oestrogen. This hormonal shift can lead to a wide range of symptoms that can affect daily life, including hot flushes, night sweats, mood changes, sleep problems, joint aches, and vaginal dryness. Hormone replacement therapy (HRT) is a treatment designed to supplement these declining hormone levels to provide relief from these symptoms.1
This guide provides detailed information on the HRT medications that may be prescribed, helping you understand how they work, how to use them safely, and what to expect during your treatment journey.
The key hormones in HRT:
HRT typically involves one or more of the following key hormones:
• Oestrogen (estradiol or estriol): This is the primary hormone used in HRT to relieve most menopausal symptoms. It helps to regulate body temperature (easing hot flushes), support mood, maintain bone density, and keep vaginal and urinary tissues healthy. The forms used in modern HRT, such as estradiol, are 'body-identical', meaning they have the same molecular structure as the oestrogen produced naturally by the body.
• Progestogen (progesterone, dydrogesterone, or norethisterone): This hormone plays a critical "protective" role. Taking oestrogen on its own can cause the lining of the womb (the endometrium) to thicken, which over time increases the risk of endometrial cancer. A progestogen is therefore essential for any woman taking systemic HRT who has not had a hysterectomy (womb removal), as it keeps the womb lining thin and protected. This fundamental safety principle is the single most important factor in determining the type of HRT you will be prescribed. If you have a uterus, you will need a combined HRT (oestrogen plus progestogen). If you have had a hysterectomy, you will typically only need oestrogen.
• Testosterone: This hormone is important for both men and women, contributing to energy levels, mood, cognitive function, and sex drive (libido). It is sometimes prescribed as an additional treatment for women experiencing low sexual desire that has not improved with oestrogen-based HRT.
Types of HRT and how they are taken
HRT can be delivered to the body in several ways, and your treatment plan will be tailored to your specific needs and medical history. The medications covered in the available Numan Safety Information pages are summarised in the table below:
Drug name | HRT type | Active ingredient(s) | Formulation | Typical use case |
Elleste Solo | Oestrogen-only | Estradiol | Tablet | Systemic; for women without a uterus |
Lenzetto | Oestrogen-only | Estradiol | Transdermal spray | Systemic; for women without a uterus |
Evorel | Oestrogen-only | Estradiol | Transdermal patch | Systemic; for women without a uterus |
Femoston | Sequential combined | Estradiol, Dydrogesterone | Tablet | Systemic; for perimenopausal women with a uterus, causes a bleed |
Elleste Duet | Sequential combined | Estradiol, Norethisterone | Tablet | Systemic; for perimenopausal women with a uterus, causes a bleed |
Evorel Sequi | Sequential combined | Estradiol, Norethisterone | Transdermal patch | Systemic; for perimenopausal women with a uterus, causes a bleed |
Bijuve | Continuous combined | Estradiol, Progesterone | Capsule | Systemic; for post-menopausal women, no bleed (body-identical) |
Femoston-conti | Continuous combined | Estradiol, Dydrogesterone | Tablet | Systemic; for post-menopausal women, no bleed |
Evorel Conti | Continuous combined | Estradiol, Norethisterone | Transdermal patch | Systemic; for post-menopausal women, no bleed |
Utrogestan | Progestogen-only | Micronised Progesterone | Capsule | Add-on for women with a uterus using separate oestrogen |
Vagifem and Estriol | Local oestrogen | Estradiol/Estriol | Vaginal tablet/pessary/cream | Localised symptoms (e.g., vaginal dryness) |
The method by which the hormone enters your body is an important factor in your treatment. Systemic HRT can be taken orally (tablets) or transdermally (through the skin via patches, gels, or sprays).
When oestrogen is taken via the oral route (e.g. as a tablet), it is processed by the liver. This "first-pass metabolism" affects clotting factors and is associated with a small but significant increase in the risk of blood clots, or venous thromboembolism (VTE).
In contrast, transdermal methods deliver oestrogen directly into the bloodstream through the skin, bypassing the liver. This means they do not have the same effect on clotting factors, and are not associated with the same level of risk of blood clots compared to the general population (but still carries a degree of risk). However, this reason is often why a transdermal preparation may be recommended, particularly for women who have other risk factors for blood clots.
Your HRT journey, ongoing care, and stopping treatment
A partnership with your clinician
Starting on HRT is a collaborative process between you and your doctor. The goal is to find the right type, dose, and delivery method that effectively manages your symptoms while minimising risks. It is not always a case of finding the perfect fit on the first try, and your treatment plan may need to be adjusted over time.
A follow-up appointment is essential three months after starting or changing any HRT regimen. This allows your clinician to assess how effective the treatment has been, discuss any side effects you may be experiencing, and make any necessary adjustments.
Once you are established on a stable treatment, you should have a review at least once a year. This annual check-up is an opportunity to re-evaluate your individual situation and discuss the benefits and risks of continuing with HRT.
Duration of treatment
There are no arbitrary time limits on how long you can take HRT. The decision to continue or stop is an individual one, made each year in discussion with your clinician. For as long as the benefits of symptom control and improved quality of life are felt to outweigh any potential risks, treatment can continue.
For women who experience premature ovarian insufficiency (menopause before the age of 40), it is recommended that they take HRT at least until the average age of natural menopause (around 51) to protect their long-term bone and cardiovascular health.
When and how to stop HRT
When you and your doctor decide it is the right time to stop HRT, it is generally recommended to reduce the dose gradually. Stopping suddenly can cause a rebound of menopausal symptoms, particularly hot flushes. A gradual withdrawal over a period of three to six months can help to minimise this.
Strategies for gradually reducing your dose include:
Switching to a lower-strength tablet or patch.
Reducing the frequency of your dose, for example, by taking a tablet every other day instead of daily.
For patches, it may be possible to cut them to gradually reduce the dose, though this should only be done after discussing it with your doctor.
Even with a gradual reduction, some symptoms may return temporarily as your body adjusts. If these symptoms are severe or persistent, you should speak to your doctor, as it may be necessary to restart treatment at a lower dose for a period.
References:
NICE Guideline NG23: Menopause: identification and management (Last updated 07 November 2024)
The British Menopause Society: HRT - Guide. Authors: Dr Julie Ayres and Dr Heather Currie in collaboration with the medical advisory council of the British Menopause Society (Review date July 2025)
The British Menopause Society: HRT preparations and equivalent alternatives. Author: Mr Haitham Hamoda in collaboration with the medical advisory council of the British Menopause Society (Review date March 2025).
The British Menopause Society: Testosterone replacement in menopause. Author: Professor Nick Panay in collaboration with the medical advisory council of the British Menopause Society (Review date December 2025)