Website last updated 29/06/2025
HRT
Key Considerations
- Oestrogen carries a risk of endometrial cancer if used in women with a uterus. Add a progestogen to decrease this risk.
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- Key benefits of HRT include :
- control of menopausal symptoms
- maintenance of bone mineral density
- reduced risk osteoporotic fractures.
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- The safety of HRT largely depends on age. Healthy women younger than 60 years should not be concerned about the safety profile of HRT.
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- Patients should be reviewed every 12 months.
Other considerations
- Side effects usually improve over time, so it's best to trial any new HRT treatment for at least 3 months if possible
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- Treatment varies depending on symptoms, stage of menopause and if patient has a uterus
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- It takes around 4 weeks of HRT therapy before symptoms start improve
Choosing the right treatment
​​If the patient's last bleed was less than 12 months ago (perimenopausal) , offer sequential HRT.
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If the patient would prefer not to have a monthly bleed and it’s less than 6-12 months since their last period. Offer the Mirena (coil)
Most women experience no or minimal bleeding with a Mirena, which lasts for five years. It also provides contraception and useful for patients with heavy periods.
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If there has been 12 months since the patient's last period, you can start continuous combined HRT – (no bleed). Mirena can also be offered.
Which form of HRT to prescribe?
Dosing and review
- Patient's should generally be started on the lowest dose
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- Consider increasing the dose at the 3 month review if some benefit seen
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- Consider an alternative HRT if no improvement seen or patient asks to change their HRT
Vaginal bleeding
- This is a common side effect of HRT and usually settles down within the first 6 months.
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- Bleeding patterns vary based on the type of HRT used.
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- If unscheduled bleeding is still present after the first 3 months, offer to do an internal examination to rule out other causes and offer to change the HRT.
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- If patient complains of very heavy or prolonged bleeding, this should be investigated, even if within the first 3 months.
- If the unscheduled bleeding occurs for more than 6 months, refer pt for an urgent USS and potentially gynaecology.
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- Patients at a higher risk of endometrial cancer may be referred for an ultrasound before the 6 month mark. Factors that increase the risk are
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Being very overweight (BMI greater than 40)
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Having a genetic disorder (Lynch/Cowden syndrome)
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Having a womb but not taking progesterone treatment for 6 months or more
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Using sequential combined HRT for more than 5 years.
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Being diabetic
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Prescribing options for unscheduled vaginal bleeding: ​​​
- Offer a 52 mg LNG-IUD; this preparation reduces episodes of unscheduled bleeding when compared to all other preparations.
- Oral preparations cause higher rates of amenorrhea than transdermal options and can be offered if there are no thrombosis risk factors
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-Offer vaginal estrogens if symptoms are related to vaginal atrophy
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Safety netting
- The patient should be informed of the risks prior to prescribing HRT
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​- Endometrial cancer (if oestrogen only given when uterus present).
- DVT/PE risk if oral HRT used.
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- CHD risk. Possible increase when combined HRT started in older women(>60), or with pre-existing CHD.
- Stroke: Increased when oral HRT started in older women (> 60 years).
- Breast cancer. Probably increased slightly after a minimum of 5 years’ use of combined HRT
FAQ's
How long should a patient be on HRT?
Patients should generally pause treatment after 2-5 years or until the patient is 55 to see if symptoms have improved.
Should patients continue using contraception?
COC should be stopped prior to commencing HRT. However POP is usually safe to continue.
Does HRT cause weight gain?
No it does not. Weight gain is likely a symptom of menopause.