HRT: types, benefits and risks

Hormone replacement therapy (HRT) comes in different forms for different symptoms. Systemic HRT gets into the bloodstream and works throughout the body. Low-dose vaginal oestrogen works only where it’s applied. It treats symptoms such as dryness and painful sex, but it doesn’t treat hot flushes.

What HRT can help with

NICE recommends offering HRT for hot flushes and sweats caused by menopause. It also lowers the risk of fragility fractures (bones that break easily) while you take it. That protection fades after you stop. Tell your clinician what you want relief from, and about your health history.

HRT is not contraception. If you need to avoid pregnancy, talk to your clinician about it separately.

Why having a womb affects the choice

If you have a womb, you usually need progestogen as well as systemic oestrogen. Progestogen helps protect against womb cancer. NICE recommends oestrogen-only HRT for people who have had a total hysterectomy (removal of the womb and cervix). Tell your prescriber what surgery you’ve had so you can talk about the right treatment.

Progestogen may come on its own 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 suits you.

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

The route changes some risks

You can take oestrogen as tablets, or absorb it through your skin from a patch, gel or spray. NICE calls the skin route transdermal. Tablets raise the risk of blood clots in the veins, but transdermal HRT doesn’t.

For oestrogen-only HRT, NICE also looks at stroke risk separately. Tablets raise it, but transdermal treatment is unlikely to. Patches still carry some of the risks of HRT. The MHRA’s advice on breast cancer covers systemic treatment taken by mouth and through the skin.

Low-dose vaginal oestrogen for dryness is a separate treatment. NHS information says you can use this low-dose treatment without progestogen, even if you have a womb. It treats vaginal symptoms. It doesn’t 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, give systemic oestrogen and can treat hot flushes. Ask your prescriber to confirm what your product is for and whether you need progestogen.

What UK guidance says about breast cancer risk

NICE’s comparisons of breast cancer risk apply to people who have never had breast cancer. If you have had breast cancer, ask your clinician which options suit your medical history.

UK NICE guidance says combined HRT raises breast cancer risk, and the risk rises the longer you use it. It describes a very small rise in deaths from breast cancer with combined HRT. For oestrogen-only HRT, it describes very little or no rise in breast cancer risk.

The MHRA’s safety notice is broader. It describes a higher breast cancer risk with all systemic HRT, and a higher risk for combined treatment than for oestrogen-only treatment. Ask your prescriber to explain the evidence for the treatment you’re considering.

What changed in US labels

This advice changed recently, and the wording on risk differs between countries. The FDA began changing labels in November 2025. In its February 12, 2026 announcement, it said it had approved changes for six hormone therapy products. These removed statements about heart and blood vessel disease, breast cancer and probable dementia from the boxed warning. The boxed warning is the FDA’s most prominent safety warning.

That announcement is about one part of US product labels. It doesn’t replace the UK risk information described above. Use the current leaflet for your medicine, and talk through its benefits and risks with your prescriber.

Body-identical and compounded HRT

BMS (British Menopause Society) information describes regulated body-identical hormones that can be prescribed for menopause symptoms. “Bioidentical” can mean either regulated products or compounded products, which are mixed by specialist pharmacies. Compounded products don’t go through the same MHRA approval process as standard medicines.

BMS doesn’t recommend compounded bioidentical HRT, because there isn’t enough evidence that it works or is safe. Ask whether a product you’re offered is a regulated medicine or a compounded one. NICE also says there isn’t 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 drooping of the face, 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 aren’t getting better or side effects carry on. Ask about specialist menopause advice if you need it. Get any vaginal bleeding after menopause checked, including a small amount or bleeding that happens once.

Ask your prescriber what bleeding pattern to expect with your treatment. Sequential HRT usually includes a planned bleed. Contact your prescriber soon (UK, US and elsewhere) about unplanned bleeding. This matters most if it is heavy or long-lasting, or first starts more than six months after starting HRT or three months after changing it. Don’t wait for your yearly review.

Bring the names of your products and say what change you want to talk about. Ask what follow-up is planned and who to contact about bleeding or other worries. Follow the medicine leaflet, and talk to your doctor before changing prescribed treatment.