HRT: essential reading on the side effects, benefits and potential risks of hormone replacement therapy

Eight out of ten women experience physical or emotional symptoms around the time of the menopause – from hot flushes and night sweats to mood swings and memory loss.

And while we know that HRT (hormone replacement therapy) can help menopausal women hugely, choosing the right option for you – and weighing up the pros and cons – can be confusing.

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What are the most common HRT side effects?

The hormones used in HRT (oestrogen and progesterone) can cause side effects in some women.

However, it's important to remember that for most women these are temporary and improve within three months of starting treatment, so it’s worth persevering. Plus, HRT can provide brilliant benefits for women going through the menopause, which is key to bear in mind.

If you have severe side effects, or they don’t improve after three months, switching to a different type (e.g. from tablets to a patch) can sometimes help.

Common side effects of HRT include

• bloating and swelling
• breast tenderness
• abdominal pain
• back pain
• vaginal bleeding
• leg cramps
• headaches
• nausea
• indigestion
• acne
• mood swings
• depression

The benefits of HRT include

For most women, the benefits outweigh the side effects because they help to reduce or reverse unpleasant symptoms of menopause and improve sleep, sex and mood.

• better sleep, with fewer night sweats
• fewer hot flushes
• higher sex drive
• less vaginal dryness and discomfort during sex
• fewer urine infections
• better mood
• better concentration
• more energy
• less joint pain and muscle aches
• better skin and hair

Because oestrogen is important for healthy bones, HRT can also help keep your bones and teeth strong, and guard against osteoporosis.

MORE:The best tactics for dealing with menopause hot flushes

What are the different types of HRT?

There are two main types of HRT – oestrogen-only, or oestrogen and progesterone (this is also called combined HRT). Most women have combined HRT, because oestrogen-only can increase your risk of womb or endometrial cancer. It’s safe to have oestrogen-only if you have had a hysterectomy to remove your womb.

Hormones can be delivered using a number of different methods. The main types of treatment are tablets, skin patches and gels.

Tablets are the most popular type of HRT because they’re convenient and easy to use, but they can slightly increase some of the risks, like blood clots and stroke.

Patches have to be stuck to your skin and replaced every few days. They’re good for women who find it difficult to remember to take a tablet every day and they don’t increase your risk of blood clots or stroke.

Oestrogen gel has to be applied once a day so it can be absorbed through the skin. Like patches, it won’t increase your risk of blood clots or stroke. However, you’ll also have to take progesterone separately unless you’ve had a hysterectomy.

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HRT patches

Patches contain a fixed dose of hormones (oestrogen-only or combined oestrogen and progesterone) which is absorbed into your bloodstream through your skin. You usually stick them on your tummy or buttock. They have to be worn continuously for three or four days and then replaced.

Patches are a good alternative to tablets for women who struggle to remember to take a tablet every day. Unlike tablets, patches won’t increase your risk of stroke or blood clots. They’re also less likely to give you side effects like indigestion.

HRT tablets

Many women find tablets the most convenient way of taking HRT. They’re usually taken once a day, and you can get oestrogen-only or combined tablets. Tablets carry a higher risk of side effects like indigestion, blood clots and stroke than patches and gels, but the risk is still small.

The most popular HRT tablets

You can take a course of oestrogen-only or combined tablets. Most women take combined tablets unless they have had a hysterectomy, as oestrogen-only can increase your risk of womb cancer.

Combined tablets can be taken cyclically, which means you take oestrogen every day but add progesterone for 12-14 days a month to mimic a natural menstrual cycle, or continuously, which means you take both oestrogen and progesterone every day. Most women start off with cyclical HRT and switch to continuous combined after a year or two.

The most popular combined tablets include Angeliqâ, Climagestâ, Climesseâ, Clinoretteâ, Elleste-Duetâ, Evorelâ Conti or Sequi, FemSevenâ Conti, Kliofemâ and Novofemâ.

Bio-identical HRT

Bioidentical HRT is a treatment made from plant extracts thought to be similar or even identical to human hormones. Some people claim that bioidentical hormones are safer and more natural, but they’re not typically recommended by the NHS because they are unregulated and there isn’t enough evidence to support their safety or effectiveness.

HRT cream

A vaginal cream, pessary or ring that contains oestrogen can help to relieve vaginal dryness and make sex more comfortable. Unlike some other forms of HRT, it won’t increase your risk of cancer, blood clots or stroke. However, it won’t help with other menopause symptoms.

What are the main HRT risks?

Some types of HRT can slightly increase your risk of serious conditions like breast cancer, ovarian cancer, womb cancer, heart disease, stroke and blood clots.

Breast cancer: For every 1,000 women on combined HRT, there are about five more cases of breast cancer. The increased risk disappears about five years after you stop taking HRT. Oestrogen-only HRT doesn’t significantly increase your risk of breast cancer.

Ovarian cancer: For every 1,000 women on HRT, there is about one more case of ovarian cancer.

Womb cancer: Oestrogen-only HRT increases your risk of womb or endometrial cancer. Choosing a combined HRT method mostly eliminates this increase in risk.

Heart disease and stroke: HRT doesn’t seem to significantly increase your risk of heart disease, especially if you start taking it before you turn 60. Oestrogen-only HRT can actually help to reduce your risk of heart disease, but it can slightly increase your risk of having a stroke.

Blood clots: Combined HRT slightly increases your risk of DVT (deep vein thrombosis) and PE (pulmonary embolism).

Is HRT safe?

The NHS and current NICE guidelines say that the most recent evidence suggests the risks are small and are usually outweighed by the benefits.

How long does HRT take to work?

It can take a few weeks before you notice the benefits. Hot flushes and night sweats usually stop within the first few weeks. You’ll usually notice other menopause symptoms – including issues with vaginal dryness, mood, sleep and concentration – improve within the first three months.

If your symptoms don’t improve in the first three months, your GP might suggest changing the type you’re taking or increasing your dose. In some cases, it can take up to a year to see the full benefits.

What does HRT do?

HRT works by increasing the amount of oestrogen in your body. Oestrogen levels drop when you go through the menopause because your ovaries stop producing it. Most of the symptoms of menopause, including hot flushes, night sweats, mood swings and vaginal dryness, are caused by low or fluctuating oestrogen levels.

HRT alternatives

If you don’t want to take HRT, lifestyle changes like getting more exercise, eating more healthily, quitting smoking and cutting back on spicy foods, alcohol and coffee can help to improve menopause symptoms.

A medicine called tibolone is sometimes prescribed for women who can’t or don’t want to take HRT, but it may not be as effective and carries similar risks.

A non-hormonal medicine called clonidine can help with hot flushes and night sweats, but it’s less effective and can cause side effects like a dry mouth, constipation, drowsiness and depression.

Herbal remedies like black cohosh and St John’s Wort can help some women with symptoms like hot flushes, but the NHS warns that many complementary therapies aren’t supported by scientific evidence.