HRT explained — what it is and who it's for

HRT is one of the most talked-about — and most misunderstood — treatments in women's health. The conversation swings between headlines about risk and headlines about lost benefit, and the practical questions patients actually have get squeezed out. This guide is a plain-English walk through what HRT is, what it's for, the main formats, how continuous and sequential regimens differ, and the framework a UK clinician uses to decide whether it's appropriate for you.

What HRT is — and what it isn't

The ovaries produce oestrogen throughout the reproductive years. As you approach menopause the ovaries wind down, oestrogen levels fall, and the body loses the signalling that regulated temperature control, sleep, mood, bone turnover, vaginal tissue and — for many women — day-to-day cognitive comfort. HRT replaces the missing oestrogen, in most cases with a progestogen alongside it, so the body has something close to the hormonal environment it had before.

HRT is not a fertility treatment, not a general anti-ageing product, and not the same across every regimen. What a clinician prescribes depends on whether you still have a womb, whether you are still having periods, what your main symptoms are, and what your personal risk factors look like.

Why menopausal symptoms drive the need

The symptoms that push most women to consider HRT are the vasomotor ones: hot flushes and night sweats. Roughly three in four women experience these to some degree around menopause, and for a meaningful minority they are severe enough to disrupt sleep, work and relationships for years. Alongside vasomotor symptoms sit sleep disturbance, low mood, anxiety, brain fog, joint aches, and the genitourinary syndrome of menopause — vaginal dryness, urinary urgency and recurrent thrush or UTIs.

All of this is driven by falling oestrogen. That doesn't mean every woman needs HRT — many manage well with lifestyle measures, CBT and topical treatments — but it does mean that when symptoms are significant, replacing the missing hormone is often the most direct route to relief. For a wider look at symptoms and the treatment pathway, see our companion piece on understanding menopause and treatment pathways.

The two components — oestrogen and progestogen

Modern HRT uses body-identical or near-body-identical hormones. Oestrogen (usually oestradiol) does the symptom-relief work. It also protects bone: women who use HRT around menopause have a lower risk of osteoporotic fracture.

Progestogen has one main job in HRT — protecting the endometrium (the lining of the womb). Unopposed oestrogen thickens the lining and raises the risk of endometrial cancer. Adding a progestogen keeps the lining stable. Women who have had a hysterectomy don't need a progestogen and can usually take oestrogen alone.

Testosterone is sometimes added, off-label in most cases, for persistent low libido after other menopausal symptoms have been treated. It is initiated and monitored by a clinician with experience of menopause management.

Delivery routes — oral, transdermal, vaginal

Oestrogen can be delivered orally as a tablet, transdermally as a patch, gel or spray, or locally to the vagina. The route matters because it changes how the hormone is metabolised and, in turn, the risk profile.

Oral tablets are convenient and effective, but oral oestrogen passes through the liver first (first-pass metabolism), which is associated with a small increase in the risk of venous thromboembolism (blood clots).

Transdermal oestrogen — patches, gels and sprays — bypasses first-pass metabolism and is not associated with that additional clot risk. NICE NG23 flags transdermal as the preferred route for women at higher baseline VTE risk, including women with a raised BMI. Common examples include Evorel patches and Oestrogel pump gel.

Combined transdermal preparations deliver oestrogen and progestogen from the same patch. Evorel Conti is a continuous combined preparation; Evorel Sequi is a sequential preparation. Both are patch-based options a clinician may consider.

Vaginal oestrogen — creams, tablets and rings — treats the local genitourinary symptoms (dryness, urinary urgency, painful sex) with minimal systemic absorption. It can be used alongside systemic HRT or on its own if local symptoms are the main issue.

Continuous vs sequential regimens

The way oestrogen and progestogen are combined depends on where you are in the menopause transition.

Sequential (cyclical) HRT gives oestrogen every day and progestogen for part of each month. It usually produces a monthly withdrawal bleed. It is the regimen typically used in perimenopause, when a woman is still having periods, and continued for around 12 months after the last natural period.

Continuous combined HRT gives oestrogen and progestogen every day and aims to be bleed-free. It is used after menopause is established — commonly defined as at least 12 months without a period, or at age 54 and above. Some breakthrough bleeding is expected in the first 3 to 6 months and usually settles. Persistent bleeding warrants review. Our article on what causes bleeding on continuous HRT covers this in more detail.

Choosing between sequential and continuous — and moving between them at the right time — is a clinical decision. Your clinician will advise based on your individual circumstances.

Benefits and risks — the framework

The NICE menopause guideline (NG23) sets out the UK framework. The headline points are:

• HRT reliably relieves vasomotor symptoms and improves quality of life for women with troublesome menopausal symptoms.
• HRT reduces the risk of osteoporotic fracture while it is being taken.
• The small increase in breast cancer risk associated with combined HRT is dose- and duration-related, and does not apply to oestrogen-only HRT to the same degree.
• Oral oestrogen carries a small increased risk of blood clots; transdermal oestrogen does not appear to.
• Starting HRT close to menopause is associated with a better overall risk profile than starting many years later.

These are population-level statements. Your personal balance depends on your age, health history, family history and what your symptoms are doing to your life. A clinician talks through your individual picture rather than applying a blanket rule.

Who is and isn't typically suitable

HRT is generally suitable for women with menopausal symptoms who don't have a specific reason to avoid it. It is not suitable — or needs specialist input — where there is active or recent breast cancer, untreated endometrial cancer, active liver disease, unexplained vaginal bleeding, or a recent venous thromboembolism. Long-standing well-controlled hypertension, migraine, and a family history of breast cancer are usually discussed rather than being automatic reasons to say no.

For women who can't or don't want HRT, there are non-hormonal options — CBT for vasomotor symptoms and sleep, SSRIs/SNRIs used off-label, clonidine, and vaginal moisturisers and lubricants for local symptoms. Our menopause treatment pathways article covers these in detail. You can also browse other Women's Health articles in the Women's Health category.

Working with your Farmeci clinician

The most useful thing you can bring to an HRT consultation is a clear picture: what symptoms you're having, how long they've been going on, how they affect your life, and any relevant history — periods, previous HRT, contraception, breast health, clots, migraines, and family history. The clinician uses that to work out whether HRT is appropriate, which route makes sense for you, and which regimen fits where you are in the transition. If it takes a couple of adjustments to get the balance right, that's normal — the goal is a regimen that manages your symptoms with the smallest sensible dose over time.