HRT: types, benefits and risks

Hormone replacement therapy (HRT) comes in different forms for different symptoms. Systemic HRT reaches the bloodstream and acts throughout the body, while low-dose local vaginal oestrogen treats symptoms such as dryness and painful sex. Local vaginal oestrogen does not treat hot flushes.

What HRT can help with

NICE recommends offering HRT for hot flushes and sweats associated with menopause. It also reduces the risk of fragility fractures while it is being taken, although that protection decreases after treatment stops. Tell your clinician what you want relief from and about your health history.

HRT is not contraception. Discuss pregnancy prevention separately with your clinician if it is relevant to you.

Why having a womb affects the choice

If you have a womb, you generally need progestogen alongside systemic oestrogen. The progestogen helps protect against womb cancer. NICE recommends oestrogen-only HRT for people who have had a total hysterectomy. Tell your prescriber which surgery you have had so you can discuss the treatment that fits.

Progestogen may come separately or as part of a combined product. Options include tablets, combined patches and a suitable hormonal coil. Your GP or doctor can advise which combination fits your circumstances.

Sequential, also called cyclical, combined HRT is usually considered when you still have periods. Continuous combined HRT is usually used after menopause. These are different treatment plans; follow your own leaflet and prescriber’s instructions.

The route changes some risks

Oestrogen can be taken as tablets or absorbed through the skin from a patch, gel or spray. NICE calls the skin route transdermal. Tablets increase the risk of blood clots in veins, while transdermal HRT does not increase that risk.

For oestrogen-only HRT, NICE also distinguishes stroke risk: oral treatment increases it, while an increase is unlikely with transdermal treatment. Patches still carry some HRT risks. MHRA’s breast cancer advice covers systemic treatment taken orally and through the skin.

Low-dose local vaginal oestrogen for dryness is a separate treatment. NHS information says this low-dose local therapy can be used without progestogen even if you have a womb. It treats vaginal symptoms. It does not treat hot flushes or sleep problems. Ask your clinician about your own history before choosing it.

Some vaginal rings used in the US, such as Femring, deliver systemic oestrogen and can treat hot flushes. Ask your prescriber to confirm your product’s purpose and whether you need progestogen.

What UK guidance says about breast cancer risk

NICE’s breast cancer comparisons apply to people without a personal history of breast cancer. If you have had breast cancer, ask your clinician which options suit your medical history.

UK NICE guidance says breast cancer risk increases with combined HRT and rises with longer use. It describes a very small increase in death from breast cancer with combined HRT. For oestrogen-only HRT, it describes very little or no increase in breast cancer risk.

MHRA’s safety communication uses broader wording: it describes increased breast cancer risk across systemic HRT, with a higher risk for combined treatment than oestrogen-only treatment. Ask your prescriber to explain the evidence for the specific treatment being considered.

What changed in US labels

Advice has changed recently, and risk wording differs between countries. The FDA began its label-change process in November 2025. In its February 12, 2026 announcement, it reported approval of changes for six hormone therapy products, removing cardiovascular disease, breast cancer and probable dementia statements from the boxed warning, its most prominent safety warning.

That announcement concerns a particular part of US product labelling. It does not replace the UK risk tables described above. Use the current leaflet for your medicine and discuss its benefits and risks with the prescriber.

Body-identical and compounded HRT

BMS information describes regulated body-identical hormones that can be prescribed for menopause symptoms. Bioidentical can describe either regulated products or compounded preparations made by specialist pharmacies. Compounded preparations do not follow the same MHRA regulatory pathway as conventional products.

BMS does not recommend compounded bioidentical HRT, citing a lack of evidence for effectiveness and safety. Ask whether a proposed product is a regulated medicine or a compounded preparation. NICE also says there is not enough evidence to say whether breast cancer risk differs between micronised progesterone and other progestogens.

When to get help or arrange a review

Call 999 now (UK), or your local emergency number (US and elsewhere), if you have chest pain with breathlessness, or sudden facial droop, arm weakness or difficulty speaking.

Contact an urgent GP service or NHS 111 now (UK), or your doctor or urgent care service (US and elsewhere), if you have pain, redness or swelling in one leg.

Book a GP appointment in the UK, or see your doctor in the US and elsewhere, if symptoms are not improving or side effects continue. Ask about specialist menopause advice when needed. Arrange a check for vaginal bleeding after menopause, including a small amount or a single episode.

Ask your prescriber which bleeding pattern is expected with your regimen; sequential HRT usually includes a planned bleed. Contact your prescriber promptly (UK, US and elsewhere) about unscheduled bleeding, especially if it is heavy or prolonged, or first appears more than six months after starting HRT or three months after changing it. Do not wait for your annual review.

Bring the names of your products and describe the change you want to discuss. Ask what follow-up is planned and who to contact about bleeding or other concerns. Follow the medicine leaflet; discuss any change to prescribed treatment with your doctor.