In short
- The most effective treatment there is for hot flushes and night sweats. Nothing else comes close.
- Body identical, regulated. Transdermal oestradiol with micronised progesterone, not compounded mixtures.
- The route changes the risk. Patch, gel or spray showed no excess clot risk in meta-analysis, even with a clotting mutation or a high body mass index.
- The numbers are small. For women in their fifties on combined therapy, about 3 extra breast cancers per 1000 over five years, comparable to the effect of obesity or inactivity.
- Timing matters. Started within ten years of menopause the profile is favourable. Started after 60 it is not.
Treatment Overview
What HRT actually replaces
Oestrogen. As the ovaries stop producing it, the symptoms follow, and systemic oestrogen is the most effective treatment available for hot flushes and night sweats.
Sleep disturbance, mood changes and, in some women, joint aches also respond to it.
Where you still have a uterus, progesterone is given alongside to protect the lining of the womb. That is not optional.
Which preparations are used here
| Component | What is used | Why |
|---|---|---|
| Oestrogen | Transdermal 17-beta oestradiol as a patch, gel or spray | Avoids the first pass through the liver, and with it the clot risk that comes with tablets |
| Progesterone | Micronised progesterone | Now the progestogen of choice for most experts, with a better clot and probably breast profile than older synthetic progestins |
| Local treatment | Vaginal oestrogen where dryness or urinary symptoms dominate | Acts locally and suits many women who cannot or prefer not to take systemic therapy |
The numbers, since nobody publishes them plainly
These are the absolute figures per 1000 women, over five years of use, starting between 50 and 59.
| Outcome | Oestrogen plus progestogen | Oestrogen alone |
|---|---|---|
| Coronary heart disease | 2.5 more | 5.5 fewer |
| Invasive breast cancer | 3 more | 2.5 fewer |
| Stroke | 2.5 more | 0.5 fewer |
| Pulmonary embolism | 3 more | 1.5 more |
| Hip fracture | 1.5 fewer | 1.5 more |
| Death from any cause | 5 fewer | 5.5 fewer |
Two things stand out. The absolute numbers are small, and all cause mortality was lower on treatment in both arms.
For context, the size of the breast cancer effect with combined therapy is comparable to the effect of obesity or low physical activity.
Why the route and the progestogen matter so much
- Tablet oestrogen raises clot risk. Transdermal oestrogen did not, in a meta-analysis of observational studies, even in women with a clotting mutation or a high body mass index.
- The progestogen makes a difference too. Clot risk appears higher with medroxyprogesterone acetate and likely lower with micronised progesterone.
- The famous trial used neither of the modern options. Those numbers above come from oral conjugated equine oestrogen with medroxyprogesterone acetate, which is no longer the preferred regimen. The modern combination is expected to look better, not worse.
Timing changes everything
Started within ten years of menopause, or between 50 and 59, there was no excess coronary risk and possibly a reduction.
In women aged 70 and above the picture reverses sharply, and starting HRT at 65 or older is not advised. That is not the age group that presents with new symptoms anyway.
HRT is also not used to prevent heart disease. It is used to treat symptoms, and the cardiovascular data is about safety rather than benefit.
Who Is a Good Candidate?
- You have moderate to severe hot flushes, night sweats or sleep disruption.
- You are within about ten years of menopause, or under 60, where the risk profile is most favourable.
- Mood, joint aches or vaginal dryness are affecting your daily life.
- You went through menopause early, where treatment is usually recommended rather than optional.
- You want the actual numbers before deciding.
- You have had breast cancer, or an oestrogen dependent cancer.
- You have unexplained vaginal bleeding that has not been investigated.
- You have active liver disease, or a history of blood clots or stroke that has not been assessed.
- You are 65 or older and have not been on HRT. Starting at that age is not advised.
- You want compounded bioidentical hormones. They are not regulated for dose, purity or effectiveness and are not prescribed here.
What Happens During the Consultation
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1
Symptoms and cycle
What has changed, how severe it is and what it is costing you. Cycle pattern, last period, and which symptoms bother you most, because that decides whether systemic or local treatment is the right start.
-
2
Risk assessment
Personal and family history of breast cancer, blood clots, stroke and heart disease. Migraine pattern, liver disease, previous surgery, blood pressure, weight and smoking. This is what selects the route and the preparation.
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3
The numbers, applied to you
What the absolute risks and benefits look like for your age and your history, rather than a newspaper headline. Screening status for breast and cervix confirmed.
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4
The prescription and the plan
Preparation, dose and route, how to use it, what to expect in the first weeks including irregular bleeding, and a review at three months.
Program Structure & Follow-Up
The first three months
- Flushes and night sweats usually improve within a few weeks.
- Sleep and mood often follow.
- Irregular bleeding or spotting is common early and settles. Bleeding that persists beyond that is investigated rather than accepted.
- Breast tenderness and bloating are common at the start and usually pass, and often respond to a dose or preparation change.
Review schedule
- Three months after starting, for symptom control, side effects, bleeding pattern and blood pressure.
- Then annually, as an annual hormone review rather than a repeat prescription.
- Screening for breast and cervix arranged through the right service and kept up to date.
How long you stay on it
There is no fixed stopping date. The decision is revisited each year against your symptoms, your age and how long you have been on treatment.
Many women continue for years because the symptoms return when they stop. Some come off after a few. Both are reasonable, and the choice is yours with the numbers in front of you.
What is not part of this
Compounded bioidentical hormones, blood or saliva hormone level monitoring to titrate the dose, and testosterone for general wellbeing in women. Symptom response guides the dose, not a level.
Benefits, Limits & Safety
What HRT does well
- Hot flushes and night sweats, better than anything else available.
- Sleep disturbance and mood changes linked to the transition.
- Vaginal dryness and discomfort, particularly with local oestrogen.
- Bone protection, with fewer osteoporotic fractures overall.
- All cause mortality was lower on treatment than on placebo in women in their fifties.
The risks, in absolute terms
- Breast cancer. With combined therapy, about 3 additional cases per 1000 women over five years starting in the fifties. Oestrogen alone reduced breast cancer in the trial data. Your baseline risk raises or lowers that absolute number.
- Clots. Oral oestrogen raises the risk. Transdermal did not show an excess, even in women with a clotting mutation or a high body mass index.
- Stroke and coronary events. Small absolute increases with combined oral therapy in the trial. No excess in women starting within ten years of menopause.
What HRT is not for
- Preventing heart disease. It is not recommended for that, in primary or secondary prevention.
- Starting at 65 or older, which is advised against.
- Long term use without annual review.
When to contact the practice
- Bleeding that continues beyond the first few months, or new bleeding after it had settled.
- A new breast lump or change.
- Calf swelling or pain, sudden breathlessness or chest pain.
- New or worsening migraine with aura.
The absolute numbers
Per 1000 women over five years starting at 50 to 59 on combined therapy: about 3 more breast cancers, 2.5 more coronary events, 3 more pulmonary emboli, 1.5 fewer hip fractures, and 5 fewer deaths from any cause.
How you are followed
Review at three months for symptoms, bleeding and blood pressure, then annually. Breast and cervical screening kept up to date. Hormone levels are not used to titrate the dose.
When it is not used
Breast or other oestrogen dependent cancer, unexplained vaginal bleeding, active liver disease, and untreated clot or stroke history. Starting at 65 or older is advised against.
Cost & Program Investment
Cost depends on the preparation, the dose and the follow up your case needs, so a single number on a website would be misleading. You get the full figure in the consultation before anything is prescribed, and there are no charges you have not been told about. The reviews are part of the treatment rather than an optional extra.
Frequently Asked Questions
Combined oestrogen and progestogen therapy carries a small increase: about 3 additional cases per 1000 women over five years for those starting in their fifties. That is comparable in size to the effect of obesity or low physical activity. Oestrogen alone actually reduced breast cancer in the trial data.
Started within ten years of menopause or between 50 and 59 there was no excess coronary risk, and possibly a reduction. In women aged 70 and above the risk was clearly increased. HRT is not used to prevent heart disease either way.
Because tablet oestrogen raises clot risk while transdermal oestrogen showed no excess in meta-analysis, even in women with a clotting mutation or a high body mass index. It avoids the first pass through the liver.
Body identical means regulated, licensed products with the same molecular structure as your own hormones: transdermal oestradiol and micronised progesterone. Compounded bioidentical preparations are mixed to order and are not regulated for dose, purity or effectiveness. Only the first is prescribed here.
If you still have a uterus, yes. It protects the lining of the womb from the effect of oestrogen, and it is not optional. Micronised progesterone is used because its clot and probably breast profile is better than older synthetic progestins.
Flushes and night sweats usually improve within a few weeks, with sleep and mood often following. Irregular bleeding and breast tenderness are common at the start and settle.
There is no fixed stopping date. The decision is reviewed each year against your symptoms, your age and how long you have been on it. Many women continue for years because symptoms return when they stop.
No. The dose is guided by symptom response, not by a blood level. Levels fluctuate and do not predict who feels better.
Local vaginal oestrogen is usually the better answer for that. It works where it is applied and suits many women who cannot or prefer not to take systemic therapy.
Then treatment is usually recommended rather than optional, and generally continued at least to the average age of menopause. The risk calculations that apply to women in their sixties do not apply to you.
Starting at 65 or older is advised against, because the vascular risk profile changes with age and time since menopause. Non hormonal options and local vaginal treatment are discussed instead.
It depends on the preparation, the dose and the follow up, so a single figure would be misleading. You get the full cost in the consultation before anything is prescribed.
Evidence
Where this information comes from
Every figure on this page is taken from the sources below. All of them are free to read, so you can check them yourself.
This page is general medical information and does not replace a personal consultation. Trial results are averages across large groups, not a prediction for any one person.