Hormones & HRT - Working with a clinician
The right questions to ask about HRT
Last updated 30 September 2026. How we write this .
A useful HRT conversation covers what you want treated, which type you would be offered and why, your own risks as numbers out of 1,000, the alternatives, and when the plan will be reviewed.
Start here A useful HRT conversation covers what you want treated, which type you would be offered and why, your own risks as numbers out of 1,000, the alternatives, and when the plan will be reviewed.
By the end, you will understand What should I write down before the appointment? Which type would I be offered, and why that one? What are my risks, as numbers out of 1,000? Key words used in this lesson Placebo An inactive comparison given so that the effect of expectation can be separated from the effect of the intervention itself. Without one, improvement over time cannot be attributed to the treatment. Full plain-English glossary
Where this information comes from Claim-cited evidence. Central research claims on this lesson are linked to specific studies or official guidance.
This lesson links the specific studies and guidance used for its central claims.
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The most useful questions about hormone replacement therapy (HRT) are specific to you: what you want it to fix, which type you would be offered and why, what your own risks look like as numbers, what else you could try, and how the plan will be checked. This lesson follows the conversation in the order it usually runs, using NHS information and NICE's menopause guideline, NG23, which was largely rewritten in 2024 and amended again in April 2026.
What should I write down before the appointment?
Start with the symptoms, not the treatment. Note which ones bother you most and what they stop you doing, from hot flushes in meetings to night sweats, low mood or pain with sex. Write down how your periods have changed in recent months, and list every medicine, supplement and herbal remedy you take. The NHS suggests exactly this, and it gives you a baseline to measure progress against.
You may not need a blood test. NICE says perimenopause and menopause can be identified from symptoms and period changes alone in otherwise healthy people aged 45 or over, and it advises against hormone tests such as oestradiol or anti-Mullerian hormone in that age group. Under 45, a blood test is more likely to be part of the picture. The NHS is also clear that you do not need to wait until symptoms are severe, or until periods have stopped, before asking about HRT.
Which type would I be offered, and why that one?
The first fork is whether you have a womb. NICE says people with a uterus should be offered combined HRT, meaning oestrogen plus a progestogen, because oestrogen on its own raises the risk of cancer of the womb lining. People who have had a total hysterectomy are offered oestrogen-only HRT. The NHS describes sequential combined HRT, with progestogen for part of each month, as the type for people who still have periods, and continuous combined HRT as the type for after periods have stopped.
The second fork is how the oestrogen gets in: as a tablet, or through the skin as a patch, gel or spray. NICE states that the risk of blood clots in the veins rises with HRT tablets but not with HRT through the skin, and that stroke risk rises with oral oestrogen but is unlikely to with skin preparations. NICE suggests clinicians consider the skin route for anyone at higher risk of clots, including people with a BMI over 30. So a fair question is: given my weight, blood pressure and family history, why this route for me?
If your main problem is vaginal dryness or soreness, ask about vaginal oestrogen. NICE notes that only a minimal amount reaches the bloodstream, and the NHS says it does not raise the risk of breast cancer or clots.
What are my risks, as numbers out of 1,000?
Ask for absolute numbers, and ask over what period. NICE publishes a discussion aid built for this conversation. For breast cancer, it estimates that 59 in every 1,000 women who never take HRT will be diagnosed between the ages of 50 and 69. Among women who take combined HRT for 5 years from age 50, the figure is 79, which is 20 more. After 10 years of combined HRT it is 92, or 33 more. For oestrogen-only HRT the equivalent figures are 69 and 71.
Much of this rests on a 2019 Lancet analysis by the Collaborative Group on Hormonal Factors in Breast Cancer, which pooled data on 108,647 women who developed breast cancer. Every type of HRT raised risk except vaginal oestrogen, and some excess lasted more than 10 years after stopping. For 5 years of use from age 50, the authors estimated about 1 extra case for every 50 users of oestrogen with daily progestogen, 1 in 70 with progestogen for part of the month, and 1 in 200 with oestrogen alone. The NHS website quotes a lower figure, around 5 extra cases per 1,000 women taking combined HRT for 5 years. When two numbers disagree, ask what time window each one covers.
Benefits come as numbers too. In NICE's aid, 60 in 1,000 women who never take HRT have a fragility fracture between 50 and 54, against 40 in 1,000 who take HRT for those 5 years. Over 10 years the figures are 127 and 80. Then ask where you sit against these averages. A past clot, heart disease or stroke, breast cancer in you or your family, liver disease or uncontrolled blood pressure can all change the picture, and some warrant a specialist's view first.
These figures carry real uncertainty. Most come from observational studies, which can only show links, and the main trial tested an older tablet combination. They are a fair starting point, not a forecast for one person.
Does the old HRT scare still apply to me?
The Women's Health Initiative (WHI) trial of combined HRT recruited 16,608 women aged 50 to 79 in the United States and was stopped in 2002 after an average of 5.2 years, when breast cancer cases crossed a pre-set safety line. For every 10,000 women each year, the HRT group had 8 more invasive breast cancers, 7 more heart disease events, 8 more strokes and 8 more clots in the lung, alongside 6 fewer bowel cancers and 5 fewer hip fractures. The NHS notes that findings like these made many people reluctant to take or prescribe HRT.
Later analyses added age to the picture. The women in the WHI trials averaged 63 when they joined. In a 2013 breakdown by age, combined HRT produced 12 extra harmful events per 10,000 women a year among those aged 50 to 59, against 38 among those aged 70 to 79. With oestrogen alone, women in their 50s had 19 fewer events. In 2017 the team reported 18 years of follow-up on all 27,347 women: 27.1% of those given hormones had died, against 27.6% on placebo, a gap small enough to be chance. NICE now tells clinicians to explain that HRT is unlikely to change life expectancy.
What WHI did settle is that HRT is a treatment for symptoms, not a way to prevent disease. NICE advises against offering it to prevent heart disease or dementia. Starting combined HRT at 65 or over may raise dementia risk: in NICE's aid, 18 in 1,000 over 4 years, against 9 without HRT.
What else could I try?
NICE suggests menopause-specific cognitive behavioural therapy (CBT), a structured talking therapy, as an option for hot flushes, for sleep problems linked to night sweats and for low mood, either alongside HRT or instead of it. NICE also recommends fezolinetant, a non-hormonal medicine, as an option for moderate to severe hot flushes when HRT is unsuitable. It advises against routinely using SSRI or SNRI antidepressants, or clonidine, as the first treatment for hot flushes alone.
Ask about anything you have read online, too. NICE says the safety and effectiveness of unregulated hormone preparations are unknown, and that herbal products such as black cohosh vary and can interact with other medicines.
How will we know it is working, and when do I stop?
Agree the review plan before you leave. NICE recommends a check at 3 months to see whether the treatment works and is tolerable, then once a year unless problems come up sooner. If symptoms are not improving, or side effects persist, NICE says you should be referred to someone with expertise in menopause.
Ask what bleeding to expect. Since NICE's April 2026 amendment, the guideline says unscheduled vaginal bleeding is a common side effect in the first 6 months of HRT, and in the 3 months after any change of dose or preparation. Bleeding outside those windows needs checking promptly. HRT is also not a contraceptive, so ask whether you still need contraception.
There is no fixed time limit. The NHS says to take HRT for as long as the benefits outweigh the risks, reviewed each year. When you stop, NICE says tapering gradually may limit the short-term return of symptoms but makes no difference in the longer term, and symptoms can come back. Keep going to breast screening throughout.
This lesson is general education about HRT, not medical advice. Whether to take HRT, and which type, is a decision for you and a clinician who knows your full history.
Related in this classroom The studies behind this page Menopause: identification and management. Recommendations - NICE guideline NG23, updated 2024, amended April 2026HRT and the likelihood of some medical conditions: a discussion aid for healthcare professionals and patients - NICE guideline NG23 resourceBenefits and risks of hormone replacement therapy (HRT) - NHSAbout hormone replacement therapy (HRT) - NHSType and timing of menopausal hormone therapy and breast cancer risk: individual participant meta-analysis of the worldwide epidemiological evidence - The Lancet, 2019Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial - JAMA, 2002Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women's Health Initiative randomized trials - JAMA, 2013Menopausal hormone therapy and long-term all-cause and cause-specific mortality: the Women's Health Initiative randomized trials - JAMA, 2017Sources for this classroom
Educational content only. Not medical advice, diagnosis or treatment. Always consult a qualified healthcare professional before changing your health regimen.