10 FAQs About HRT

1. How does HRT work?

Hormone Replacement Therapy (HRT) works by replacing or "topping up" the hormones that your body stops producing during perimenopause and menopause. During perimenopause, your levels of estradiol (a key type of estrogen) and progesterone can fluctuate wildly. As you enter menopause, these levels, along with testosterone, decline and stay low.

These hormones are vital chemical messengers that influence every cell and organ in your body. HRT provides these missing hormones to alleviate symptoms (like hot flashes, poor sleep, or mood changes) and to improve your future health, specifically by reducing your long-term risk of conditions like osteoporosis and heart disease. A typical HRT regimen will contain estradiol and progesterone (and sometimes testosterone), all of which are prescribed and dosed individually to match your specific needs.

2. Do I have to wait until my symptoms are bad or my periods have stopped before starting HRT?

No, you absolutely do not have to wait. Many women experience their most severe symptoms during perimenopause, before their periods have actually stopped. You do not have to wait for your periods to stop, nor do you have to wait for your symptoms to become severe.

In fact, the significant long-term health benefits of HRT (such as the reduction in heart disease and osteoporosis risk) are greatest if you start HRT earlier, during perimenopause or in the first few years of menopause. However, starting at any age can still provide benefits.

3. Which HRT is best?

There isn't one single "best" HRT; the best regimen is one that is individualized to you, taking into account your symptoms, medical history, and personal preferences.

That said, the safest and most regulated type, which is prescribed by the NHS, is "body identical" HRT. This means the hormones are structurally identical to the ones your body produces naturally.

• This typically includes estradiol (estrogen) delivered "transdermally" (through the skin) via a patch, gel, or spray.

• It is combined with micronised progesterone (often known as Utrogestan in the UK) if you still have your uterus.

• Testosterone is also available as a gel or cream. These body identical hormones are derived from plants, such as soy or yams.

4. What are the side effects of HRT?

HRT is generally very well tolerated, and few people experience side effects. When they do occur, they most commonly appear in the first few weeks and are known as the "four Bs":

• Bleeding: You may have irregular bleeding or spotting. If you're perimenopausal, your cycle may change. If you're menopausal (no periods), you might have some bleeding. This almost always settles within three to six months.

• Breasts: Your breasts may feel tender, painful, or more sensitive. This can be caused by either the estradiol or the progesterone and also usually settles with time.

• Bloating: You might experience a bloating sensation, which is usually related to the progesterone or progestogen part of your HRT. This typically improves.

• Blues: You might find your mood is affected or you feel more emotional. If this feeling persists, you may need to change your HRT dose or type.

If any side effects have not settled after 3-4 months, you should discuss them with your doctor. Often, a simple change—like switching brands, changing the delivery method (e.g., from a tablet to a patch), or adjusting the hormone type—will resolve the issue.

5. Can HRT cause weight gain or help with weight loss?

There is little to no evidence that taking HRT causes weight gain. The weight gain that many women experience during this time is typically due to the metabolic changes that occur as part of menopause itself, not the treatment.

In contrast, many women find that they may lose weight once they are on the right dose and type of HRT. This is often an indirect benefit: by replacing the missing hormones, HRT can improve symptoms like joint pain, muscle aches, poor sleep, and low mood. When these symptoms are relieved, you are more able to exercise, stay active, and eat a balanced diet, which can then lead to weight loss.

6. Can HRT cause cancer?

For the vast majority of women, the benefits of taking HRT outweigh any potential risks. It is crucial to know what type of HRT a study is referring to, as many headlines are based on older, synthetic hormones, not the body identical (natural) types commonly prescribed today.

Here are the facts based on modern evidence:

• Estrogen-only HRT is associated with a slight decrease in breast cancer risk.

• Older, synthetic combined HRT (estrogen + progestogen) may slightly increase the risk (an extra four cases per 1,000 women).

• There is no evidence that taking body identical estradiol with body identical micronised progesterone (Utrogestan) increases the risk of breast cancer.

• There is also no evidence of a negative effect of HRT on the prognosis of other cancers.

7. Can HRT stop periods?

This depends entirely on the type of HRT you are prescribed and whether you are in perimenopause or menopause.

• Cyclical/Sequential HRT: This is for women in perimenopause who are still having periods. You take estradiol every day, but progesterone for only part of the month. This often helps regulate your periods and many women find their periods become lighter.

• Continuous HRT: This is for women who are post-menopausal. You take both estradiol and progesterone every day. This regimen will usually stop your periods completely, though it can take a few months for bleeding to settle.

• The Mirena coil (which releases a progestogen) is also a very common way to protect the uterus and usually makes periods much lighter or stops them altogether.

8. Does it matter where I apply my patches/gel/spray?

Yes, you should apply your HRT to the specific areas as directed, because absorption can vary significantly on different parts of your body.

• Estradiol Gel: Rub into the outside of your upper arm or the inside of your upper thigh.

• Estradiol Spray: Use on the inner part of your forearm or the inner part of your thigh.

• Patches: Stick onto the skin below your waist, such as on your bottom or upper thigh.

• Testosterone Cream/Gel: Rub into the lower part of your tummy or your outer thigh.

It's a good idea to vary the exact spot you use every few days (e.g., switching thighs) to avoid minor skin irritation or, in the case of testosterone, the possible growth of a few dark hairs.

9. What do I do if I miss a dose?

If you just take or apply your medication a couple of hours late, it shouldn't make any difference.

If you miss a dose entirely:

• Do not double up on the next dose. This won't help and is more likely to cause side effects like a headache or breast tenderness.

• Missing an occasional dose isn't a huge issue, but missing progesterone can lead to breakthrough bleeding.

• If you forget your progesterone capsule (which often makes you drowsy), do not take it in the morning if you find it affects you this way. Just skip the missed dose and take your next one at the usual time.

If you are regularly forgetting, speak to your healthcare professional about finding a routine that works for you.

10. What do I do if my HRT stops working?

It is very common for women to need their HRT regimen altered over time. This is normal. You might find your initial improvement has plateaued, or some of your original symptoms (like hot flashes, anxiety, or brain fog) have started to return.

This does not mean HRT has failed. It may mean:

• You need a higher dose of estradiol.

• You need to try a different way of taking the hormone (e.g., switching from a patch to a gel).

• You need to try a different brand or type of hormone.

• You might benefit from adding testosterone.

Whatever the reason, you don't have to put up with it. Discuss it with your health professional or see a menopause specialist if you feel your treatment isn't optimized.