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HRT: hormone replacement therapy explained

HRT (hormone replacement therapy) replaces the estrogen, and usually the progesterone, that fall at menopause. It's the most effective treatment for hot flashes and night sweats, cutting them by about 75%, and it also helps sleep, mood, vaginal dryness and bone loss. You take estrogen as a pill, patch, gel or spray, plus a progestogen if you have a uterus. For most women under 60, the benefits outweigh the risks.

What HRT is, who it's for, estrogen and progesterone options (patch, gel, pill), benefits, real risks by age, and how to get it prescribed.

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Video: HRT, explained: benefits, risks and the real numbers

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My friend said HRT causes cancer. My aunt said it saved her life. My doctor said, let's look at the numbers.

Good doctor. Let's do exactly that: what hormone therapy is, what it helps, what the big study really found, the risks in plain numbers, and how to choose. One topic a week, every number sourced. Subscribe, and the next one finds you.

Hormone therapy replaces the estrogen your ovaries are making less of. If you still have a uterus, you also take a progestogen, because estrogen on its own can thicken the uterine lining. Estrogen comes as a patch, a gel, a spray or a tablet. The progestogen can be a tablet, such as micronized progesterone, or a hormonal IUD. Separate from all of this is low-dose vaginal estrogen, a cream, tablet or ring for dryness and bladder symptoms, which works mostly where it's applied.

For hot flashes and night sweats, it's the most effective option: estrogen cuts how often they happen by about seventy-five percent. Guidelines also list sleep problems, and low mood and anxiety that start with menopause, among the symptoms it can relieve. For vaginal dryness, low-dose vaginal estrogen improves symptom severity by sixty to eighty percent. And it protects bone. In SWAN, women lost more than seven percent of their spine bone density in just the three years around the final period. While you take hormone therapy, your risk of fractures is lower.

So why are so many women afraid of it? In 2002, the Women's Health Initiative trial stopped early, headlines linked hormone therapy with breast cancer and heart attacks, and use dropped sharply around the world. But that trial gave an older type of estrogen tablet, with a synthetic progestin, to women whose average age was sixty-three, older than most women who start it for symptoms. Eighteen years of follow-up later, the picture is calmer. Deaths from any cause: 27.1 percent with hormones, 27.6 percent with placebo. No difference in deaths from heart disease or cancer. And women who started in their fifties did better than women who started in their seventies.

Here are the risks that remain, in real numbers. Breast cancer. With combined hormone therapy, the UK health service estimates around five extra cases for every thousand women who take it for five years. With estrogen alone, for women without a uterus, there's little or no increase. Blood clots. Estrogen tablets raise the risk, by about one and a half times in a study of more than eighty thousand women with clots. Patches, gels and sprays didn't raise it at all. Put together, in the big US trial, combined hormones in women aged fifty to fifty-nine meant twelve extra serious health events per ten thousand women a year, about one in eight hundred. With estrogen alone in that age group, there were nineteen fewer. For healthy women under sixty, or within ten years of their last period, the Menopause Society finds the benefits generally outweigh the risks.

How it's given matters. If you have risks for clots, such as a past clot or a higher weight, patches, gels and sprays are usually preferred. Start with the lowest dose that controls your symptoms. If you have a uterus, the progestogen matters too: micronized progesterone or a hormonal IUD are common choices. You'll also hear about bioidentical hormones. Regulated bioidentical estradiol and progesterone already exist on prescription. Custom-compounded creams and pellets are different: they aren't FDA-approved, and their doses aren't standardized. In a US survey, eighty-six percent of women didn't know that.

Hot flashes often start to ease within days to weeks, and it can take up to three months to feel the full effect. Breast tenderness, headaches and spotting are common at first and usually settle within about three months. Irregular spotting can last three to six months on a new regimen. If side effects don't settle, the dose, the type or the route can be changed. Give each change three months, and keep a short symptom diary for your review.

Talk it through carefully with your doctor if you've had breast cancer, a blood clot, a stroke or liver disease. And on hormone therapy, a few things need checking promptly: pain or swelling in one leg, a new breast lump, or bleeding that continues after six months. Chest pain or sudden breathlessness: call 911.

Hormone therapy isn't right for everyone, and it isn't the danger the old headlines made it. It's a decision you can make with real numbers. Find your stage in two minutes at perimenostage.com, and bring your questions to your doctor.

My friend, my aunt, my doctor. The numbers were the tiebreaker.

Next week: lifting weights in perimenopause, and what one trial found for hot flashes. Subscribe so it finds you.

Every number in this video is sourced in the YouTube description.

HRT: what women expect vs what research shows

What people often expect

“HRT is dangerous and causes breast cancer, so it's best avoided”

What the evidence shows

That fear dates from early-2000s Women's Health Initiative results in women with an average age of 63. For women under 60 without specific risks, the NHS says the benefits are likely to outweigh the risks: combined HRT adds around 5 breast cancer cases per 1,000 women over 5 years, and patches and gels don't raise clot risk. In November 2025 the FDA began removing warnings about heart disease, breast cancer and dementia from HRT labels.

Hormone replacement therapy explained: types, benefits and risks

What is HRT?

Hormone replacement therapy replaces the hormones estrogen and progesterone, which fall to low levels as you approach menopause. Estrogen does most of the work: it relieves hot flashes, night sweats, sleep problems, mood swings, anxiety and vaginal dryness, and it protects bone. If you still have a uterus, you also need a progestogen to protect the uterine lining. After a hysterectomy, you can take estrogen on its own.

Learn more →

Types of HRT: estrogen-only, sequential and continuous

Estrogen-only HRT is for women who've had a hysterectomy. Everyone else takes combined HRT, estrogen plus a progestogen. If you still have periods, sequential HRT gives the progestogen for 12 to 14 days of each cycle and causes a monthly bleed. Once you're postmenopausal, continuous combined HRT gives both hormones every day, usually without bleeding, although spotting in the first months is common.

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HRT forms: pills, patches, gels, sprays and vaginal estrogen

Estrogen comes as daily tablets, patches changed once or twice a week, a daily gel or a daily spray. Patches, gels and sprays go through the skin, so they don't carry the extra clot risk of tablets. The progestogen can be a tablet, part of a combined patch, or a hormonal IUD. Low-dose vaginal estrogen, as a cream, insert or ring, treats dryness and urinary symptoms locally with very little absorbed into the body.

Learn more →

HRT benefits: what it treats

Systemic estrogen cuts hot flash frequency by about 75%, and it's the most effective treatment for hot flashes and genitourinary symptoms. HRT also helps sleep problems, anxiety and low mood caused by menopause, and it prevents bone loss and fractures, which matters especially if menopause comes before 45. The NHS notes it can help muscle strength too. It isn't recommended to prevent heart disease.

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HRT risks by age and type

Risks depend on your age, the type of HRT and how long you take it. For women under 60 or within 10 years of menopause, the benefit-risk balance is favorable. Combined HRT slightly raises breast cancer risk, around 5 extra cases per 1,000 women over 5 years; estrogen-only HRT has little or no effect. Tablets slightly raise the risk of clots and stroke; patches, gels and sprays don't raise clot risk.

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Who shouldn't take HRT

HRT may not be suitable if you've had breast, ovarian or uterine cancer, have liver disease, or have untreated high blood pressure, which needs to be controlled first. If you've had a blood clot, patches or gels are usually used instead of tablets. HRT isn't a contraceptive, so under 50 you need contraception until 2 years after your last period, and over 50 for 1 year. Non-hormonal options exist if HRT isn't right for you.

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Bioidentical hormones: what's regulated and what isn't

Estradiol and micronized progesterone have the same chemical structure as the hormones your body makes, and FDA-approved versions are widely prescribed. Custom-compounded bioidentical creams and pellets are different: they aren't FDA-approved and lack data on safety and effectiveness. In one survey, 86% of women didn't know compounded hormones aren't FDA-approved. Up to 2.5 million US women may use them. Their use should be limited to women who need a dose or form that isn't available as an approved product.

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The FDA label change on HRT

In November 2025 the FDA began removing boxed warnings about cardiovascular disease, breast cancer and probable dementia from menopausal HRT labels, keeping the warning about uterine cancer for estrogen taken without a progestogen by women with a uterus. The first six updated labels were approved in February 2026, and 29 drug companies have submitted changes. The warnings were based on WHI results in women with an average age of 63.

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How to get HRT and what happens next

You can start HRT through your own doctor, a gynecologist, a menopause specialist or a telehealth service. If you're over 45 with typical symptoms, you usually don't need blood tests. You'll normally start on a low dose, see a doctor again after 3 months, then once a year. Symptoms improve within days to weeks, and most side effects settle within 3 months. There's no fixed limit on how long you can take it.

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HRT by the numbers

From the studies on this page

  • reduction in hot flash frequency with systemic estrogen, alone or with a progestogen

    75%

5 per 1,000

extra breast cancer cases in women taking combined HRT for 5 years

2 million

US women aged 46 to 65 got a hormone therapy prescription in 2020, out of about 41 million aged 45 to 64

3 months

is when your first HRT review usually happens and when most side effects have settled

Risk figures apply to women starting HRT around menopause. Starting after 60 or more than 10 years after menopause carries higher absolute risks of heart disease, stroke, clots and dementia.

Browse HRT topics

36 guides.

FormsEstradiol patch

Estradiol patches deliver 25 to 100 mcg of estrogen a day through the skin, changed once or twice a week. Where to put them, side effects…

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MedicationsEstradiol

Estradiol is the main estrogen your ovaries make and the one in most HRT. Pills, patches, gels and vaginal forms, typical doses and side…

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Non-hormonalHot flash treatment

HRT is the most effective hot flash treatment. Non-hormonal options include fezolinetant, SSRIs, gabapentin and oxybutynin. How well each…

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MedicationsMenopause medications

Every prescription option for menopause symptoms in one table: estrogen, progestogens, tibolone, fezolinetant, SSRIs, gabapentin,…

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Benefits & risksHRT side effects

Breast tenderness, bloating, spotting and headaches are common in the first 3 months and usually settle. Serious risks by type and age, and…

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MedicationsEstradiol dosage chart

Patch doses run from 25 to 100 mcg a day, with 50 mcg a common starting dose. Equivalent gel and pill doses, when to increase, signs of too…

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Benefits & risksHRT benefits and risks

HRT relieves hot flashes, sleep and mood symptoms and protects bone. Breast cancer, clot and stroke risk depend on type, route and age. The…

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FormsEstrogen face cream

Topical estrogen can boost skin collagen and thickness, but prescription and cosmetic 'estrogen' creams differ. What studies show, safety,…

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MedicationsEstradiol side effects

Breast tenderness, nausea, bloating, headaches and spotting are the most common estradiol side effects. Which pass, which need a doctor,…

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Benefits & risksHRT and hair loss

Estrogen can slow hair thinning, but some progestogens may worsen it. Which HRT types are hair-friendly, and treatments to combine with

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FormsHRT pellets

Pellets are implanted under the skin and release hormones for 3 to 6 months. Why compounded pellets aren't FDA-approved, the risk of high…

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Cost & accessEstrogen patch shortage

Why estradiol patches are hard to find, what the FDA says about supply, which companies make them, and equivalent gel, spray or pill doses…

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Cost & accessStopping HRT

Stopping estrogen can bring hot flashes and sleep problems back within weeks. Tapering vs stopping at once, how long symptoms last, and…

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Non-hormonalLynkuet vs Veozah

Lynkuet and Veozah both block the brain signal behind hot flashes. Dose, results, liver tests, sleepiness, interactions and cost side by…

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Cost & accessHRT for perimenopause

You don't have to wait until periods stop to start HRT. Which regimens suit perimenopause (cyclical vs continuous), and how to ask your…

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A–Z

HRT guides

HRT options for menopause compared

  • Combined HRT (estrogen plus progestogen)

    Strong evidence

    For women with a uterus. Estrogen relieves symptoms and the progestogen protects the uterine lining from cancer. Sequential regimens suit women who still have periods; continuous combined suits women more than a year past their last period. Micronized progesterone and the hormonal IUD are common progestogen choices.

    Related guide →

  • Estrogen-only HRT

    Strong evidence

    For women who've had a hysterectomy. It works as well for symptoms as combined HRT and has little or no effect on breast cancer risk. In the WHI trial, estrogen alone didn't increase breast cancer, and there were 19 fewer adverse events per 10,000 women a year aged 50 to 59 than on placebo.

    Related guide →

  • Transdermal HRT: patches, gels and sprays

    Strong evidence

    Estrogen through the skin avoids the liver. In a large UK study, transdermal HRT wasn't linked with blood clots (odds ratio 0.93), while tablets raised the risk (1.58). Transdermal HRT is the usual choice if you're overweight or have had a clot, and gel and spray doses are easy to adjust.

    Related guide →

  • Vaginal estrogen HRT

    Strong evidence

    Low-dose cream, inserts or a ring treat vaginal dryness, painful sex and urinary symptoms, improving them by about 60% to 80%. Very little gets into the bloodstream, so the NHS says it doesn't increase the risk of breast cancer or clots and can be used long term, alone or with systemic HRT.

    Related guide →

  • Non-hormonal alternatives to HRT

    Strong evidence

    If you can't or don't want to take hormones, SSRIs, SNRIs and gabapentin cut hot flashes by about 40% to 65%, and fezolinetant and elinzanetant block the brain signal behind hot flashes. CBT helps too. None of these protect bone the way estrogen does. They're the main option after hormone-sensitive breast cancer.

    Related guide →

  • Compounded hormones and pellets

    No good evidence

    Custom-mixed creams, troches and pellets aren't FDA-approved and haven't been tested for safety or effectiveness the way licensed HRT has. In one clinic study, women on hormone pellets had side effects far more often than women on FDA-approved HRT (57.6% vs 14.8%), with very high estradiol levels.

    Related guide →

When to talk to a doctor about HRT

  • Menopause symptoms affecting your sleep, work or relationships

    Talk to a doctor about HRT. If you're over 45, you usually won't need blood tests to start.

    More →

  • Menopause symptoms before 45

    See a doctor. It may be early menopause, and hormone treatment until at least 51 protects bones and heart.

    More →

  • Bleeding on HRT that lasts more than 6 months or starts after you'd stopped bleeding

    See your doctor to rule out other causes before adjusting your HRT.

    More →

  • Urgent: Leg pain or swelling, chest pain with breathlessness, or stroke signs on HRT

    Leg pain, redness or swelling can be a clot: call a doctor now. Chest pain with breathlessness, trouble speaking or a drooping face: call 911.

HRT: questions women ask

What is HRT?

HRT, or hormone replacement therapy, is a treatment that replaces estrogen, and usually progesterone, which fall at menopause. It relieves hot flashes, night sweats, sleep problems, mood swings and vaginal dryness, and it helps prevent osteoporosis. You take estrogen as a tablet, patch, gel or spray, plus a progestogen if you have a uterus.

Is HRT safe?

For most women under 60 who start around menopause, the benefits outweigh the risks. Combined HRT adds around 5 breast cancer cases per 1,000 women over 5 years, tablets slightly raise clot and stroke risk, and patches and gels don't raise clot risk. Risks are higher if you start after 60 or more than 10 years after menopause.

Related →

What is the best hormone replacement therapy for menopause?

There's no single best HRT. Transdermal estradiol (patch, gel or spray) is often preferred because it doesn't raise clot risk, and micronized progesterone or a hormonal IUD are common progestogen choices. Tablets are simple and effective. The right type depends on whether you have a uterus, still have periods, and your clot and breast cancer risk.

Can you take HRT in perimenopause?

Yes. You don't need to wait until your periods stop. While you still have periods, sequential HRT is usually used, with a progestogen for part of each cycle and a monthly bleed. HRT isn't contraception, so you'll need contraception too, or a 52 mg hormonal IUD can do both jobs, providing contraception and protecting the uterine lining.

Related →

What is natural hormone replacement therapy?

People usually mean bioidentical hormones, which have the same structure as your own. FDA-approved estradiol and micronized progesterone fit that description and are standard HRT. Compounded 'natural' hormones and herbal products are different: they aren't FDA-approved, and herbal remedies aren't recommended for hot flashes.

Related →

How long does HRT take to work?

Hot flashes and night sweats often improve within a few days to weeks. It can take up to 3 months for HRT to work fully, which is why your first review is usually at 3 months. Vaginal estrogen can also take up to 3 months to reach its full effect.

Related →

How long can you stay on HRT?

There's no fixed limit. Most women take it for 2 to 5 years, but it can be longer. You'll review it with your doctor once a year. When you stop, symptoms may come back briefly; reducing the dose gradually makes that less likely.

Related →

Does HRT cause weight gain?

No. A Cochrane review found no difference in weight gain between women taking estrogen or combined HRT and women not taking it. Weight tends to rise around menopause whether or not you take HRT, and in one Danish trial women on HRT gained slightly less fat.

Related →

What are the common side effects of HRT?

Headaches, breast tenderness, nausea, leg cramps, mood changes and irregular bleeding or spotting are the most common. They're usually mild and improve within 3 months, so it's worth continuing that long if you can. If they don't settle, changing the dose, the type of HRT or switching from tablets to patches usually helps.

Related →

Did the FDA remove the black box warning on HRT?

Yes. In November 2025 the FDA began removing boxed warnings about heart disease, breast cancer and dementia from HRT labels, and approved the first six updated labels in February 2026. The warning about uterine cancer stays for estrogen-only products used by women with a uterus.

Related →

How do I get HRT?

Ask your doctor, gynecologist or a menopause specialist, or use a telehealth menopause service. Bring notes on your symptoms and periods. Over 45, HRT can usually be started based on symptoms alone, and you'll have a review after 3 months.

Related →

Is HRT covered by insurance?

Coverage depends on your plan's drug list (formulary), so check it before you start. FDA-approved HRT, including generic estradiol tablets and patches, is a standard prescription medicine. Compounded hormones and pellets aren't FDA-approved products, and there's no evidence they work better. Our cost guide compares prices with and without insurance.

Related →

Sources

  1. NHS. About hormone replacement therapy (HRT).
  2. Crandall CJ, Mehta JM, Manson JE. Management of Menopausal Symptoms: A Review. JAMA. 2023;329(5):405-420.
  3. NHS. Benefits and risks of hormone replacement therapy (HRT).
  4. NHS. Types of hormone replacement therapy (HRT).
  5. US Food and Drug Administration. HHS advances women's health, removes misleading FDA warnings on hormone replacement therapy. November 10, 2025.
  6. Women's Health Concern / British Menopause Society. Fact sheet: HRT types, doses and regimens.
  7. The North American Menopause Society. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767-794.
  8. Vinogradova Y, Coupland C, Hippisley-Cox J. Use of hormone replacement therapy and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases. BMJ. 2019;364:k4810.
  9. NICE. Menopause: identification and management (NG23). Updated 2024.
  10. Stuenkel CA. Compounded bioidentical hormone therapy: new recommendations from the 2020 National Academies of Sciences, Engineering, and Medicine. Menopause. 2021;28(5):576-578.
  11. Pinkerton JV. Concerns About Compounded Bioidentical Menopausal Hormone Therapy. Cancer J. 2022;28(3):241-245.
  12. Pinkerton JV, Santoro N. Compounded bioidentical hormone therapy: identifying use trends and knowledge gaps among US women. Menopause. 2015;22(9):926-36.
  13. US Food and Drug Administration. FDA approves labeling changes to menopausal hormone therapy products. February 12, 2026.
  14. NHS. When to take hormone replacement therapy (HRT).
  15. Manson JE, Chlebowski RT, Stefanick ML, et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women's Health Initiative randomized trials. JAMA. 2013;310(13):1353-68.
  16. The North American Menopause Society. The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause. 2023;30(6):573-590.
  17. Prescribing information: Lynkuet (elinzanetant capsules). Bayer HealthCare, 2026. DailyMed, US National Library of Medicine.
  18. Jiang X, Bossert A, Parthasarathy KN, et al. Safety assessment of compounded non-FDA-approved hormonal therapy versus FDA-approved hormonal therapy in treating postmenopausal women. Menopause. 2021;28(8):867-874.
  19. NHS. Hysterectomy: considerations.
  20. NHS. Side effects of hormone replacement therapy (HRT).
  21. NHS. Oestrogen tablets, patches, gel and spray: side effects.
  22. National 911 Program. 911.gov.
  23. Women's Health Concern (British Menopause Society). Contraception for women over the age of 40. Fact sheet, 2025.
  24. NHS. Oestrogen tablets, patches, gel and spray: common questions.
  25. NHS. Vaginal oestrogen: common questions.
  26. Norman RJ, Flight IH, Rees MC. Oestrogen and progestogen hormone replacement therapy for peri-menopausal and post-menopausal women: weight and body fat distribution. Cochrane Database Syst Rev. 2000;1999(2):CD001018.
  27. Jensen LB, Vestergaard P, Hermann AP, et al. Hormone replacement therapy dissociates fat mass and bone mass, and tends to reduce weight gain in early postmenopausal women: a randomized controlled 5-year clinical trial of the Danish Osteoporosis Prevention Study. J Bone Miner Res. 2003;18(2):333-42.
  28. US Food and Drug Administration. NASEM study on the clinical utility of treating patients with compounded "bioidentical" hormone therapy.

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