If you’re currently i the throes of the menopausal transition (perimenopause) you may be considering Hormone Replacement Therapy (HRT) to manage your menopause symptoms. It can be a little overwhelming to say the least, as three are many options out there. From hot flushes and joint pain to anxiety and vaginal dryness, there’s a lot to think about. But don’t worry—I’m here to break it down and help you figure out the best HRT treatment for your needs.

This guide walks you through a typical HRT consultation you may have with your GP, focusing on the various preparations that might work for you, depending on your symptoms and medical background. It’s designed for women who are generally healthy, with no major family or personal health concerns.

What Is HRT?

Hormone Replacement Therapy (HRT) helps alleviate menopausal symptoms by supplementing the hormones that naturally decline as you go through menopause. In the UK, when we talk about HRT, we’re usually referring to the systemic form—this means it works throughout your body to help with symptoms like hot flushes, sleep disturbances, and brain fog.

There’s also topical HRT, which is applied directly to the vaginal area for issues like vaginal dryness or Genitourinary Syndrome of Menopause (GSM). Although I prefer the term Menopausal Hormone Therapy (MHT)—as it feels less like something needs to be “replaced”—I’ll stick with HRT here, as that’s the common term used across the UK.

What Happens to Your Hormones During Menopause?

During the menopause transition, which can start as early as your late 30s or early 40s, your hormone levels, particularly oestrogen and progesterone, begin to fluctuate and gradually decrease.

Here’s what typically happens as egg quality declines:

• Progesterone -levels become very erratic rather than cyclical as cycles become less regulated by high quality eggs, which can lead to symptoms similar to PMS—such as mood swings, anxiety, lower energy and erratic painful and heavy bleeding. Many women in the UK find it feels like an exaggerated version of PMS/Periods from their teenage years.
• As oestrogen levels drop further, you may start experiencing classic menopausal symptoms like hot flushes, joint aches, trouble sleeping, and brain fog. These symptoms often overlap, and the intensity can vary from woman to woman.

What Type of HRT Is Right for You?

When considering HRT treatment in the UK, the type of HRT you’ll need depends on whether you still have your womb or have had a hysterectomy.

• If you have a womb (or endometriosis), you’ll need a combination of oestrogen and progesterone:
  • Cyclical HRT: Oestrogen is taken continuously, but progesterone is taken for part of the month, followed by a break when you may have a scheduled bleed known as a withdrawal bleed.
  • Continuous HRT: Both hormones are taken continuously, with no scheduled bleed.
• If you’ve had a hysterectomy, you’ll only need oestrogen since there’s no need to protect the womb lining with progesterone.

Your doctor will help recommend the best HRT regime for you, depending on whether you’re still menstruating and what your menopausal symptoms are. Many women in the UK also ask about how to navigate HRT when they’ve been taking contraception or after treatments for heavy periods, which can make it harder to know your natural menstrual cycle and track where you are in your cycle. In these cases, a detailed medical history or hormone blood tests may help guide your treatment.

Do I Need Both Oestrogen and Progesterone?

If you have a womb, yes, you’ll need both oestrogen and progesterone as part of your HRT. Oestrogen helps with symptoms like hot flushes and night sweats, but without progesterone, it could over-stimulate the womb lining, increasing the risk of endometrial cancer.

For women in the UK, oestrogen is the active ingredient in HRT that relieves most menopausal symptoms, but progesterone plays a protective role, particularly for the womb. If you’ve had a hysterectomy, you won’t need the progesterone component unless you have endometriosis.

How Can Oestrogen Be Taken?

There are several ways to take oestrogen in the UK, and it’s important to know your options to find what suits your lifestyle best:

• Oral HRT (tablets): These can contain just oestrogen or a combination of oestrogen and progesterone. While convenient, oral HRT has become less popular in recent years as it’s linked to a slightly higher risk of blood clots, high blood pressure and stroke in women over 60. If you’re younger and don’t have these risk factors, oral HRT can still be a good option.
• Patches: These are a common choice in the UK, as they release oestrogen (sometimes combined with progestogens) directly through the skin. You apply them to your lower abdomen or buttock once or twice a week, depending on the brand. However, some women find patches can cause skin irritation or fall off when swimming or sweating. It’s worth trying different brands if you don’t get one with one type though, as they all contain different adhesives.
• Gels and Sprays: If you’d prefer not to take pills or use patches, oestrogen gels (like Oestrogel or Sandrena) or sprays (like Lenzetto) are also popular options in the UK. Gels are alcohol based and applied daily, usually to the thighs or lower body, and sprays are applied to the forearms. They’re fast-absorbing, but gels take a little longer to dry, which may not be ideal for everyone. . If you’re requiring high doses of estrogen you may also prefer a patch or pill as you’ll be rubbing in quite high volumes of the gel otherwise.

How Is Progesterone Taken?

If you need progesterone as part of your HRT treatment, there are several ways to take it:

• Oral progesterone pills: In the UK, these are often the go-to for women who want the “body identical” version, as these are a direct replica of the hormone your body naturally produces.
• Oral Progestogen pills: These are the synthetic version of the body’s progesterone. They are much better at controlling bleeding but are not suitable for all women for various medical reasons.
• Mini Contraceptive Pill: Taking a double dose of one of the newer generation mini pills can also be used to protect the womb- it’s a great choice if you’re also requiring contraception or having some issues bleeding while on HRT.
• Intrauterine devices (IUDs): Many UK women choose the Mirena coil to fulfil the progesterone component of their HRT. It’s especially useful if you also need contraception or have previously had heavy periods.
• Combination patches or tablets: Some patches or tablets combine oestrogen and progesterone to make things simpler. However, there aren’t any standalone progesterone patches in the UK—only pills and coils for this hormone.

For women who are sensitive to progesterone, your doctor may recommend vaginal preparations, which are gentler on the system. Your medical history and any previous experience with hormonal treatments will help guide the choice.

How Long Should I Take HRT?

In the UK, HRT is used to help manage menopause symptoms, but it’s not something you need to take forever. Typically, I like to review patients after three months to see how well the HRT is working and whether any adjustments are needed.

There’s no set time to stop HRT, but most women in the UK discontinue use in their 50s or 60s, as continuing beyond this can slightly increase the risks of blood clots and breast cancer. As your body fully transitions through menopause, the need for oestrogen decreases, and your doctor will guide you on when it might be time to taper off.

Final Thoughts on HRT and Menopause

I hope this guide helps clear up some of the confusion around Hormone Replacement Therapy (HRT) in the UK. Whether it’s easing hot flushes, improving sleep quality, or addressing vaginal dryness, managing menopausal symptoms with HRT can significantly improve your quality of life.

Remember, every woman’s experience with menopause is unique, so finding the right HRT preparation may take a little time. If you have further questions or are curious about topics like progesterone vs progestogens or HRT side effects, feel free to explore more resources or book a consultation with myself or your GP.