Menopause and HRT: when is the right time to start?

The UK conversation about hormone replacement therapy has changed beyond recognition over the past five years.

What used to be a cautious, often reluctant prescription is now, in line with current NICE guidance and the British Menopause Society, a first-line treatment for moderate to severe menopausal symptoms in most women under 60, with a clear and favourable risk-benefit picture for the majority.

If you are hesitating because of what you remember from the early 2000s headlines, this article is for you.

If you are already on HRT and wondering whether you are on the right regimen, this is also for you.

What counts as menopause, and what comes before it

The average age of the menopause in the UK is 51. It is defined retrospectively as 12 consecutive months without a period. Perimenopause is the transition phase, typically starting in the mid-40s (sometimes earlier), during which hormone levels fluctuate wildly rather than simply fall. That fluctuation explains why perimenopause symptoms can be as bad as, or worse than, those after the menopause: the swings are dramatic. The British Menopause Society keeps an excellent set of tools that mirrors what we use in clinic.

Symptoms that deserve treatment

• Vasomotor: hot flushes, night sweats, palpitations.
• Sleep: early waking, fragmented sleep, insomnia.
• Mood and cognition: low mood, anxiety, irritability, poor concentration, word-finding difficulty ("brain fog").
• Genitourinary: vaginal dryness, painful sex, recurrent urinary tract infections, urinary urgency.
• Musculoskeletal: joint aches, frozen shoulder, new or worsening tendon pain.
• Other: migraine changes, skin and hair changes, reduced libido.

When is the right time to start HRT?

There is no need to wait for 12 months of amenorrhoea. If symptoms are affecting quality of life, HRT can be started in perimenopause. The NHS treatment page confirms this. Starting under the age of 60 (or within 10 years of the final period) is associated with the most favourable risk-benefit profile, including cardiovascular and bone benefits. Starting later is still possible, but the calculus shifts and the conversation becomes more individualised.

When HRT is urgent, not optional

Premature ovarian insufficiency (menopause before 40) and early menopause (before 45) need hormone replacement until at least the average age of menopause, not as symptom relief, but as protection for bone, heart, and brain.

This is a treatment gap that is still missed in UK practice.

How HRT actually works

HRT replaces the oestrogen your ovaries no longer produce. If you have a uterus, you must also take a progestogen, to protect the womb lining from oestrogen-driven thickening.

If you have had a hysterectomy, oestrogen alone is usually sufficient. Modern UK practice favours body-identical preparations: transdermal oestradiol (patch, gel, or spray) plus micronised progesterone.

They have the most favourable safety profile and closely mimic physiological hormones.

Oestrogen options

• Patches: oestradiol patches such as Evorel and Estraderm MX are changed once or twice weekly. Good for steady absorption, convenient, and avoid first-pass liver metabolism.
• Gels: Oestrogel is applied daily to the arms or thighs. Flexible dosing, popular in UK practice.
• Oral tablets: Elleste Solo and Zumenon are oral oestradiol. Convenient, but carry a higher VTE risk than transdermal routes, so are usually second choice.
• Vaginal: Vagifem pessaries and estriol cream treat genitourinary symptoms locally. Minimal systemic absorption, safe for long-term use, and can be combined with systemic HRT or used alone when that is the only issue.

Progestogen options

Micronised progesterone (Utrogestan) is body-identical and has the most favourable breast and cardiovascular profile. It is taken at night because it has a mild sedative effect, which many women find a welcome bonus for sleep. Utrogestan is the UK standard. Cyclical regimens (12 days a month) preserve monthly bleeds and suit perimenopause; continuous regimens (daily) give no bleed and suit postmenopause.

Combined fixed-dose preparations

For women who prefer one product, fixed-dose combinations are convenient. Femoston and Femoston Conti are oral sequential and continuous combined tablets. Evorel Conti is a combined transdermal patch. Kliofem, Kliovance, and Indivina are continuous combined tablets suited to postmenopausal women. Livial (tibolone) is a synthetic steroid with oestrogenic, progestogenic, and weak androgenic activity, useful when libido is a dominant complaint in postmenopause.

What HRT is genuinely good at

• Vasomotor symptoms: 80 to 90 percent reduction in hot flushes and night sweats within 4 to 8 weeks.
• Sleep and mood: substantial improvement when driven by hormonal fluctuation.
• Vaginal and urinary symptoms: local oestrogen is transformative.
• Bone: HRT prevents postmenopausal bone loss and reduces fracture risk.
• Cardiovascular: when started under 60, transdermal oestradiol does not increase, and may slightly reduce, cardiovascular risk.

The risk conversation, done properly

The headline numbers from the BNF summary:

• Breast cancer: combined HRT is associated with a small increased risk that rises with duration, of the order of 4 extra cases per 1000 women over 5 years of use. Oestrogen-only HRT (after hysterectomy) is not associated with a meaningful increase. Micronised progesterone has a better breast profile than synthetic progestogens. For context, this risk is comparable to drinking 2 units of alcohol per day or being overweight.
• Venous thromboembolism: oral HRT doubles baseline VTE risk. Transdermal HRT does not. For most women, this makes patches or gel the safer first choice.
• Stroke: oral HRT carries a small increased risk; transdermal does not.
• Endometrial cancer: risk is eliminated by adequate progestogen in women with a uterus.
• Ovarian cancer: very small absolute increase in long-term users.

Contraindications and cautions

HRT is contraindicated in current or recent breast cancer, undiagnosed vaginal bleeding, active VTE, active liver disease, and uncontrolled hypertension.

Previous VTE, migraine with aura, and stable hypertension are not absolute bars to transdermal HRT; they need individualised assessment.

A personal history of hormone-sensitive cancer calls for specialist input.

How long should you stay on HRT?

Current UK guidance is that there is no arbitrary time limit. Continue HRT for as long as the benefits outweigh the risks, reviewed annually.

For many women, that is 5 to 10 years; for some, lifelong. Stopping abruptly often returns symptoms; a gradual taper over 3 to 6 months is usually smoother.

See our full HRT range within the broader women's health category.

What I usually suggest in clinic

For most women under 60 with troublesome symptoms and a uterus, I start with oestradiol patch or gel plus micronised progesterone.

If periods are still occurring, cyclical progesterone 200 mg at night for 12 days a month.

If periods have stopped for a year, continuous progesterone 100 mg at night daily.

Review at 3 months to check symptoms and side effects, adjust dose, then review annually. For vaginal symptoms alone, local oestrogen is enough.

For women with low libido that persists on adequate oestrogen, a small trial of testosterone cream may be considered, per BMS guidance.

The honest summary

HRT is not a cosmetic or a luxury.

For women with troublesome menopausal symptoms, it is the single most effective intervention available, with a favourable risk profile when started under 60 and prescribed as transdermal oestradiol plus micronised progesterone.

The old fears, largely driven by early interpretations of the Women's Health Initiative, have been revised in the light of better trials and better preparations.

If you are suffering and hesitant, a frank, up-to-date conversation with a menopause-trained GP is the single most useful next step.

the Prescriptsy editorial team.. This article is general medical information and does not replace personal medical advice.

Questions I am asked most often in clinic

"Does HRT cause breast cancer?"

The honest, nuanced answer: combined HRT (oestrogen plus progestogen) is associated with a small increased risk of breast cancer that rises with duration of use and returns to baseline after stopping.

The increase is comparable to the effect of drinking 2 units of alcohol per day, being 5 kilograms overweight, or drinking less than the recommended alcohol threshold.

Oestrogen-only HRT, used after hysterectomy, does not appear to increase breast cancer risk meaningfully, and some data suggest a small protective effect.

Micronised progesterone has a better breast profile than older synthetic progestogens.

For most women, the quality-of-life benefit clearly outweighs this small increment, but the choice is yours to make with full information.

"Will HRT help me lose weight?"

Not directly. HRT does not cause weight loss. It also does not, contrary to another common belief, cause weight gain as a class.

Perimenopause and postmenopause are associated with a shift in fat distribution toward the abdomen and some decrease in muscle mass, driven by oestrogen decline combined with ageing and reduced activity.

HRT may slightly favour a more premenopausal fat distribution, but calorie balance, protein intake, strength training, and sleep are the real drivers.

"I have had a breast cancer scare, can I still take HRT?"

If you have had a confirmed hormone-sensitive breast cancer, systemic HRT is generally contraindicated, and non-hormonal options (SSRIs, clonidine, cognitive behavioural therapy) are used for symptoms. Local vaginal oestrogen is often still possible after discussion with the oncology team. If you have had benign breast changes or a biopsy that was clear, there is no bar to HRT.

"Can I start HRT if I am still having periods?"

Yes. Perimenopausal HRT typically uses cyclical progesterone (12 nights a month) to preserve a monthly bleed while providing oestrogen.

This is the most physiological approach for women who are still cycling.

If periods have been absent for at least 12 months, continuous combined HRT gives no bleed and is usually preferred for convenience.

"What about testosterone?"

Testosterone is not formally licensed for female use in the UK, but prescribing off-label at low physiological doses is endorsed by the British Menopause Society when low libido persists despite optimal oestrogen replacement.

Evidence supports benefit for sexual desire and, to a lesser extent, energy and cognition. Side effects at recommended doses are uncommon. Blood levels should be monitored.

"How will I know HRT is working?"

Vasomotor symptoms usually improve within 2 to 4 weeks and are at least 80 percent reduced by 8 to 12 weeks. Sleep improves in parallel.

Mood and brain fog often take a little longer, 8 to 16 weeks.

Genitourinary symptoms on local oestrogen take 6 to 12 weeks to settle and do best on continued maintenance.

If vasomotor symptoms have not meaningfully improved by 12 weeks, the dose or route is usually adjusted upward.

A starter plan for the hesitant

1. Consultation: book a double appointment with a GP known to take menopause seriously, or a British Menopause Society-accredited specialist. Bring a symptom list and a menstrual history.
2. Initial prescription: for most women under 60 with a uterus, start transdermal oestradiol (patch or gel) at a moderate dose plus micronised progesterone. For vaginal symptoms alone, start local oestrogen.
3. Three-month review: assess symptom control and side effects. Adjust oestrogen dose up or down as needed. Review bleeding pattern.
4. Annual review: check blood pressure, discuss breast awareness, confirm benefit continues to outweigh risk, and renew for another year.

Non-hormonal alternatives

HRT is not for everyone, and some women cannot or prefer not to take it.

Evidence-supported alternatives include SSRIs (citalopram, paroxetine) and SNRIs (venlafaxine) for vasomotor symptoms, gabapentin at night for hot flushes and sleep, clonidine (modest effect), and cognitive behavioural therapy specifically for menopausal symptoms.

Cognitive behavioural therapy reduces hot flush frequency by around 40 percent and has no hormonal risks.

Black cohosh and phytoestrogens have variable quality control and inconsistent evidence; some women benefit, some do not, and none of these substitute for bone and cardiovascular protection.

Bone, heart, and brain: the long view

HRT started in the window under 60 reduces fracture risk, appears to be at worst neutral and possibly beneficial for cardiovascular risk when given transdermally, and has a complex relationship with cognition (neutral to beneficial in early starters, possibly unfavourable when started many years after menopause).

The so-called "timing hypothesis", that HRT is protective when started early and neutral-or-harmful when started late, is increasingly supported by modern data.

This is a powerful argument for not hesitating unnecessarily if symptoms begin in your late 40s.

One last word

If you have been dismissed with "it's just the change" or "you're too young for HRT" or "the risks are too high", consider a second opinion from a menopause-trained clinician.

UK menopause care has made real progress, but access is uneven, and confident, up-to-date clinicians exist in most areas.

You do not have to white-knuckle your way through a decade of poor sleep, low mood, and hot flushes.