HRT: Benefits, Risks & Who Should Take It (2024)

HRT replaces the hormones your ovaries stop making. For most women, that means estrogen, paired with progesterone if you still have a uterus (to protect the uterine lining). Some protocols add low-dose testosterone for libido and energy.

HRT is not a "menopause cure." It is symptom relief and long-term risk modification, dosed to your body and circumstances. Two hormones, six delivery routes, decades of evolving evidence. The right protocol for you depends on your symptoms, medical history, and life stage.

The 2022-2024 consensus from NICE, The Menopause Society, and the International Menopause Society: HRT benefits outweigh risks for most women under 60 or within 10 years of their final period — the so-called "window of opportunity."

Strongest-benefit groups:

• Women with moderate to severe hot flashes or night sweats
• Women with menopausal insomnia — body-identical progesterone at night is particularly effective
• Women with genitourinary symptoms (vaginal dryness, urinary urgency, painful sex) — localised vaginal estrogen has virtually no systemic risk
• Women with premature menopause (before 40) or early menopause (40-45) — HRT here replaces hormones that should still be present and is protective
• Women with fragile bones or high fracture risk
• Women with clear cyclical perimenopausal anxiety or mood symptoms

Headlines from the original WHI trial overstated risks because the cohort was older (average 63), used oral conjugated equine estrogens (not modern body-identical preparations), and studied synthetic progestin. Reanalysis by age and route tells a very different story.

Breast cancer — combined HRT (estrogen + synthetic progestin) for 5+ years is associated with about 8 extra cases per 10,000 women per year — lower than the extra risk from obesity, 2+ drinks/day, or inactivity. Estrogen-only HRT shows no increase and may slightly reduce risk. Micronised (body-identical) progesterone appears safer than older synthetic progestins.

Blood clots and stroke — transdermal estrogen (patches, gels, sprays) carries no measurable increase in VTE or stroke risk. If you are over 60, obese, or have a clotting history, transdermal is the safer route.

Cardiovascular disease — started within the window of opportunity, HRT is broadly cardioprotective — reducing coronary disease incidence by roughly 30%. Started in your seventies, the signal reverses.

Endometrial cancer — estrogen without progesterone in a woman with a uterus is a clear risk. Combined regimens neutralise it.

Body-identical (also called "bioidentical" in the US) means the molecule is structurally the same as what your ovaries produce. Body-identical 17β-estradiol and micronised progesterone are regulated pharmaceuticals — the same stuff, prescribed by regular doctors, covered by standard insurers.

The marketing term "bioidentical hormone replacement therapy" (BHRT), as sold by compounding pharmacies and wellness clinics, often refers to unregulated custom mixes with unclear dosing. Medical societies oppose unregulated compounded BHRT.

Regulated body-identical HRT is the current standard of care when available. That is what you want.

• Transdermal estrogen (patch, gel, spray) — preferred default. No first-pass liver effect, lowest clot risk, flexible dosing.
• Oral estrogen — cheaper, simpler, but higher clot risk. Fine for lower-risk women under 60.
• Micronised progesterone (oral capsule at night) — current standard for endometrial protection, also helps sleep.
• Vaginal estrogen (cream, ring, tablet) — for genitourinary symptoms only. Minimal systemic absorption. Safe for most women including many breast cancer survivors.
• Combined patches — estrogen + progestogen in one patch. Convenient, less flexible for dose tuning.
• Low-dose testosterone — transdermal cream, off-label in many countries, prescribed for persistent low libido after estrogen optimisation.
• Mirena IUS — can provide the progestogen component while also acting as contraception.

Absolute contraindications:

• Current or recent estrogen-sensitive breast cancer (some localised vaginal forms remain possible — discuss with your oncologist)
• Unexplained vaginal bleeding
• Active clotting disorder or recent venous thromboembolism
• Active liver disease
• Untreated severe hypertension
• Pregnancy

Relative contraindications (transdermal is usually still possible): previous VTE, severe migraine with aura, active lupus, gallbladder disease, high BMI.

Older age alone is not a contraindication. The decision is individualised.

When HRT is not suitable or not enough:

• SSRIs and SNRIs (escitalopram, venlafaxine, paroxetine) — for hot flashes and mood; venlafaxine and paroxetine double as hot flash treatment
• Fezolinetant (Veozah) — FDA-approved 2023, targets NKB neurons directly for hot flashes
• Gabapentin — useful when night sweats dominate
• CBT for menopause symptoms — reduces distress from hot flashes, sleep, and mood by up to 70%
• Lifestyle levers — strength training, protein, fixed wake time, delayed caffeine (see the morning cortisol guide)

These are not second-class options — many women combine them with HRT for best results.

Your first HRT appointment does not have to feel like an interrogation. Bring:

1. A symptom log (2-4 weeks minimum) — hot flash frequency, sleep disruption, mood patterns, cycle irregularity
2. Your personal risk factors — family history of breast cancer and VTE, current medications, BMI, blood pressure, smoking status
3. Your priorities — symptom relief, bone protection, libido, cognition
4. The three questions that matter: "Am I a candidate? Which formulation do you recommend for my profile? What is our review schedule?"

Start on a standard regimen (transdermal estradiol + micronised progesterone for most women with a uterus), review at 3 months, adjust from there. Most women know within 3 months whether HRT is right for them.