HRT gets talked about like it's either a miracle cure or a death sentence. The reality is far more boring and sensible: it's a medication that replaces hormones your body has stopped making, which can genuinely improve your quality of life during menopause.
This guide cuts through the mythology.
What HRT Actually Is
HRT (Hormone Replacement Therapy) replaces oestrogen and/or progesterone that your ovaries stop producing during perimenopause and menopause.
That's it. It's not a secret, not dangerous at normal doses, and not a long-term commitment.
Your body makes oestrogen and progesterone for 40+ years. At menopause, levels drop dramatically over 1–2 years. Some women sail through this. Many don't — hot flushes, night sweats, brain fog, mood changes, sexual dysfunction, joint pain, and bone loss kick in.
HRT puts hormones back, usually at lower doses than your body made naturally.
Types of HRT: The Main Options
Oestrogen-Only HRT
Who gets it: Women without a uterus (hysterectomy).
Why oestrogen only: If you have a uterus and take oestrogen without progesterone, the uterine lining builds up excessively (endometrial hyperplasia). This is bad. If you've had your uterus removed, there's no endometrial lining to worry about, so oestrogen alone is fine.
Forms:
- Patches (patches are brilliant — steady hormone levels, no liver metabolism)
- Creams/gels
- Tablets (less preferred because they go through your liver)
Combined HRT (Oestrogen + Progesterone)
Who gets it: Women with an intact uterus.
Why both: Progesterone protects your uterine lining from hyperplasia. You need it.
Regimens:
- Continuous combined: Low-dose oestrogen and progesterone daily. Most women like this because they stop having periods.
- Cyclical/sequential: Oestrogen daily, progesterone for 12–14 days per month. You still get periods (or bleeding). Less popular.
Forms:
- Patches (oestrogen) + oral progesterone, or
- Patches + transdermal progesterone, or
- All-in-one patches (some formulations combine both)
Bioidentical vs Synthetic: What Actually Matters
Bioidentical HRT: Identical at the molecular level to hormones your body makes. Examples: micronised progesterone (Utrogestan), oestradiol (Estrogel, patches).
Synthetic HRT: Slightly different molecular structure. Examples: Premarin (conjugated equine oestrogen — literally made from horse urine), norethisterone (a synthetic progestin).
The real story: Your body doesn't care if a hormone is "natural" — it cares about the molecule. Bioidentical and synthetic hormones work the same biologically. The reason many clinicians prefer bioidentical is that they've been studied more extensively and are easier to adjust.
Bottom line: Don't get hung up on bioidentical vs synthetic. Both work. Most modern HRT uses bioidentical, so you probably won't encounter the synthetic stuff anyway.
The 2002 WHI Study: Why Everyone's Confused
In 2002, a large American study (Women's Health Initiative) found that long-term HRT use was associated with small increases in breast cancer risk and blood clots. This terrified women and doctors.
What actually happened:
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The study was flawed. It used mostly synthetic hormones (Premarin + medroxyprogesterone), gave them to older women (average age 63) starting HRT long after menopause, and didn't use patches (which bypass first-pass liver metabolism and carry less clot risk).
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The actual numbers were small. For every 10,000 women on HRT for a year, there were perhaps 6 extra cases of breast cancer annually. Compare that to smoking (much higher cancer risk) or obesity (higher breast cancer risk than HRT).
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The findings don't apply to modern HRT. Current evidence shows that:
- Starting HRT in perimenopause or early menopause (not years later) is safer
- Using patches is safer than tablets
- Using bioidentical hormones is safer than synthetics
- The benefit-risk ratio improves the younger you are when you start
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The study led to undertreatment. Thousands of women suffered with severe menopause symptoms because doctors were afraid to prescribe HRT.
Modern consensus: The British Menopause Society, NICE, and major international organisations now say HRT is safe and beneficial for most women in perimenopause and menopause. Starting it early (ages 45–55) carries minimal risk and high benefit.
Current NICE Guidelines (2023 Update)
NICE (National Institute for Health and Care Excellence) updated its menopause guidance in 2023. Here's what it says:
- HRT is recommended for managing menopause symptoms
- Offer HRT to all women with symptoms, regardless of age
- Patches are preferred over tablets (lower clot risk)
- Bioidentical progesterone is preferred over synthetic progestins
- Combined HRT (oestrogen + progesterone) is recommended for women with a uterus
- No upper age limit — you can start HRT at any age if symptoms warrant it
- Individual risk assessment — don't refuse HRT based on blanket rules. Assess each woman's actual risk.
This is a major shift from previous guidelines and reflects modern evidence.
NHS Access to HRT: The Reality
In theory, you can get HRT on the NHS. In practice:
What makes it possible:
- Your GP can prescribe HRT
- Prescriptions cost the standard prescription fee (currently £9.90 in England, often free in Scotland/Wales)
- Some NHS menopause clinics (in major cities) are well-resourced
What makes it difficult:
- Many GPs are uncomfortable prescribing HRT (training gaps, residual fear from WHI study)
- Waiting times for NHS menopause clinics are often 6–12 months
- Not all GPs have the knowledge to dose HRT properly or manage side effects
- If your GP says no, it's hard to push back
How to try:
- Book a GP appointment
- Describe your menopause symptoms clearly (hot flushes, night sweats, mood, brain fog, libido loss)
- Ask for HRT referral or ask to be referred to the local NHS menopause clinic
- Bring NICE guidance printout (shows your GP the current evidence)
If your GP agrees: brilliant, you'll pay £9.90 per prescription. If they don't: private is your best option.
Private Access: The Realistic Route
Most women in the UK access HRT privately because it's faster and the clinicians are actually trained.
Newson Health (menopausedoctor.co.uk)
The biggest and most reputable. Founded by Dr Mendy (Dr Mendy Menopause), this is where most informed women go.
What they do:
- Virtual consultations with trained menopause specialists
- Full hormone testing (if needed)
- HRT prescription and dosing
- Ongoing monitoring and adjustment
Cost: £200–300 for initial consultation, then prescriptions (roughly £30–80 per month depending on type).
Vibe: Professional, evidence-based, efficient. They get it right.
Timeline: Book consultation within days, start HRT within 1–2 weeks.
Stripes (stripes.health)
A newer UK menopause telehealth service.
What they do:
- Consultations and HRT prescriptions
- Comparable to Newson in terms of evidence-based approach
Cost: Similar pricing to Newson.
Vibe: Slightly more modern/app-based interface, but same clinical quality.
GP + Private Pharmacies
You can also see a private doctor (not a menopause specialist, but a general private doctor) and get an HRT prescription filled at Superdrug Online Doctor or similar private pharmacies.
Cost: Cheaper consultation (£100–150) but less specialised knowledge.
Vibe: Hit-or-miss. Some private doctors understand menopause well; others don't.
Practical Steps to Get HRT
Route 1: NHS (Best Case)
- Book GP appointment and describe menopause symptoms
- Ask about HRT or NHS menopause clinic referral
- If GP agrees: Get prescription
- If GP refers: Wait for clinic (6–12 months potentially), then get started
Route 2: NHS + Private Clinic (Hybrid)
- Book NHS menopause clinic referral (join waiting list)
- While waiting, see private clinic (Newson Health) for faster assessment and start HRT
- Once NHS clinic comes through, transfer back to NHS if you prefer (NHS can manage HRT maintenance)
This combines speed of private with lower long-term cost of NHS.
Route 3: Full Private (Fastest)
- Book Newson Health or Stripes (takes days to weeks)
- Virtual consultation, describe symptoms
- Prescribing (if appropriate — they won't prescribe HRT if you don't have menopause symptoms)
- Start HRT within 1–2 weeks
Total cost first year: £200–300 (consultation) + £360–960 (prescriptions at ~£30–80/month × 12) = roughly £600–1200.
Cost subsequent years: Just prescriptions, so £360–960 per year.
What to Expect on HRT
First 4 Weeks
- Hot flushes: Start improving, though may not fully resolve
- Sleep: Often improves first (because night sweats ease)
- Mood: Often improves week 2–3
- Vaginal symptoms: Improve over 4–6 weeks
Weeks 4–12
- Hot flushes: Usually mostly resolved (80–90% improvement is typical)
- Brain fog: Improves
- Energy: Improves
- Libido: Starts improving (takes longer)
Months 3–6
- Full effects emerge: Most symptoms substantially improved
- Joint pain: Often improves
- Bone: Not immediately visible, but HRT is protecting it (reversing bone loss)
- Skin: Often improves (oestrogen supports skin collagen)
Side Effects
At appropriate doses, HRT side effects are minimal:
- Breast tenderness: Possible first 2–4 weeks, usually resolves
- Nausea: Uncommon with patches, more common with tablets
- Bloating: Possible, usually mild
- Headaches: Possible but uncommon with patches
- Bleeding: If on cyclical HRT, you'll bleed during the progesterone days (this is normal)
Most side effects are dose-related and improve with adjustment or resolve naturally.
Dosing: Start Low, Titrate Slowly
Standard starting doses:
- Oestrogen patch: 0.5–1.0 mg per day (very modest)
- Progesterone: 100–200 mg daily (micronised)
Why start low: You want the lowest dose that controls your symptoms. More isn't better. Higher doses mean slightly higher clot/breast cancer risk.
Timeline: Start at low dose, assess after 4 weeks, increase if symptoms aren't controlled. Most women are comfortable at standard or slightly-below-standard doses.
Duration: How Long to Stay on HRT
There's no fixed answer. You stay on HRT as long as it's helping and you want to continue.
Typical duration: 5–10 years is common, some women use it for 15+ years.
Coming off: If you decide to stop, you taper slowly (over weeks, not abruptly) to avoid symptom rebound.
Long-term safety: Current evidence suggests HRT is safe long-term if you're an appropriate candidate. This contradicts old fears about "needing to come off at some point."
The Bottom Line
HRT is an evidence-based, safe, and often highly effective treatment for menopause symptoms. Modern NICE guidance supports its use. The old fears from the 2002 WHI study don't apply to how HRT is used now.
You have two realistic paths: NHS (free or £9.90 per prescription, but potentially slow) or private (fast, well-trained clinicians, £600–1200 first year, £400–1000 yearly after).
If you're in perimenopause or menopause and suffering, try your GP first. If they're not helpful, book a private clinic (Newson Health is your best bet). You deserve to feel good through this transition, and HRT can genuinely deliver that.
Start conservative (low doses), give it 4–6 weeks to work, adjust as needed, and retest annually. Done properly, it's one of the most reliable and helpful medicines available.