You haven’t slept properly in months. The hot flushes arrive at the worst possible moments, your mood feels thinner than it used to, and someone has suggested HRT. Then you read one headline about breast cancer and put the idea away again.
Is HRT safe? It is the question I am asked most often, and for most women who start it near the menopause, the answer is yes. For most healthy women under 60, or within ten years of their last period, the benefits of hormone replacement therapy outweigh the risks. That is the NHS position. The British Menopause Society supports HRT for women in this group, and NICE recommends offering it for troublesome symptoms after a discussion of the benefits and risks.
But I want us to move away from asking whether HRT is safe in general. A better question is whether a particular type of HRT, started at a particular time, is safe for you. That question has a real answer.
The fears most women carry are twenty years old
The HRT scare of the early 2000s came largely from the Women’s Health Initiative study. Its participants had an average age of 63, and they took older synthetic oral hormones that are rarely a first choice today.
Most women now start HRT in their late forties or early fifties, often with patches or gels and body-identical progesterone. That is a very different treatment in a very different group of women, and the risks are different too.
Timing matters as much as the product. Starting HRT before 60, or within ten years of your last period, gives the best balance of benefit and risk. For some women, menopause comes much earlier: around 1 in 100 reach it before 40, which is known as premature ovarian insufficiency. For them, HRT is usually advised until at least the average age of menopause (51), to protect the bones and heart. It is simply replacing what the body would normally still be making.
You can also start during perimenopause, while your periods are still coming. If you are over 45, you usually do not need a hormonal blood test first, because the diagnosis is made from your symptoms.
Which HRT you take changes the picture
HRT replaces the oestrogen that falls around the menopause. If you still have a womb, a progestogen is added to protect its lining. How each one is given changes the safety picture.
Patches, gels and sprays. Oestrogen absorbed through the skin bypasses the liver. At standard doses, it is not linked to a higher risk of blood clots. Where it suits the woman in front of me, this is what I prescribe.
Tablets. They work well and are convenient, but they carry a small increase in the risk of clots and stroke. For many women under 60, whose background risk is low, they remain a reasonable option.
Micronised progesterone and dydrogesterone. The British Menopause Society advises that these are likely to carry a lower risk of breast cancer than other progestogens, and are unlikely to increase the risk of clots.
Vaginal oestrogen. It is used for dryness, pain and urinary symptoms, and very little reaches the bloodstream. It is safe for long-term use and suitable for many women who cannot take other forms of HRT.
Testosterone may also be considered for low sexual desire that persists despite HRT. A testosterone cream for women was licensed in the UK in 2025 for postmenopausal women with low sexual desire. Using it before the menopause, or using products designed for men at a lower dose, is off-label.
HRT remains the most effective treatment for hot flushes and night sweats, often within weeks. Better sleep usually follows, and with it more energy and a steadier mood. Many women find their concentration improves as sleep and hot flushes settle. HRT also eases vaginal dryness and protects bone density, lowering the risk of fracture while treatment continues. My article on how long HRT takes to work explains what to expect in the first weeks and months.
HRT is not a contraceptive, and it is not a weight-loss treatment. If there is any chance you could still conceive, contraception is generally advised until 55, even if your periods have become irregular. Bleeding on HRT cannot tell you whether you have reached menopause. The hormonal coil can do two jobs here: contraception and protection for the womb lining.
Is HRT safe? The risks are real, and usually small
An honest conversation about risk is part of good care (and you deserve one, not a list of frightening words).
Breast cancer. This is what most women are really worried about, so it deserves a proper answer. Combined HRT is linked to a small increase in risk, which rises the longer it is taken. The risk falls after stopping, although some increase can remain for more than ten years, as the MHRA has highlighted. Oestrogen-only HRT, for women without a womb, is linked to little or no change, and vaginal oestrogen does not increase risk. For context, alcohol, carrying extra weight after the menopause and inactivity all raise breast cancer risk too.
Clots and stroke. Tablets increase the risk of clots and slightly increase the risk of stroke. At standard doses, patches, gels and sprays do not raise clot risk above that of women not taking HRT.
Heart health. HRT is not prescribed to prevent heart disease. When it is started under 60, it does not increase cardiovascular risk. Oestrogen-only HRT is linked to no change in, or a lower, risk of coronary heart disease, and combined HRT to little or no increase. Risk factors such as high blood pressure do not rule HRT out if they are well managed.
Side effects. Breast tenderness, bloating, headaches or irregular bleeding can appear in the first few months. They usually settle, or improve with a change of dose or type (I know those early weeks can test your patience!). Any new breast change should always be checked. So should bleeding that carries on beyond the first three to six months, or any bleeding that starts after it had settled.
There is no fixed time limit on HRT, and no need to stop at a particular birthday. I review treatment three months after starting, then once a year. Each time I look at your symptoms, your blood pressure, your screening and whether the type or dose is still right for you.
If HRT isn't right for you, you still have options
HRT may be unsuitable, or need specialist input, if you have had:
- a hormone-sensitive cancer such as breast cancer
- a blood clot, a known clotting disorder, or a recent heart attack, stroke or angina
- active liver disease or uncontrolled high blood pressure
- unexplained vaginal bleeding
Even then, it is rarely a simple no. Vaginal oestrogen or non-hormonal treatment may still be possible after discussion with me and your wider medical team. A family history of breast cancer does not rule HRT out either. It simply means a more detailed conversation about your own risk.
Cognitive behavioural therapy designed for the menopause can help with hot flushes and night sweats.
NICE now recommends fezolinetant, a non-hormonal tablet, for moderate to severe hot flushes and night sweats in women for whom HRT is not suitable, or who do not wish to take it. It is not recommended if you have current breast cancer or another oestrogen-dependent cancer. It is not used alongside oestrogen HRT, although vaginal oestrogen can be. You will need a liver blood test before you start and monthly for the first three months, then as your doctor advises. It is not suitable if you have, or are at high risk of, liver disease.
A second non-hormonal medicine, elinzanetant, is licensed in the UK for moderate to severe hot flushes, including in women taking hormone treatment after breast cancer. It is not yet available on the NHS, and is best discussed with your oncology team.
I would urge caution with compounded “bioidentical” hormones sold by some clinics. NICE advises that their safety and effectiveness are unknown, and the British Menopause Society does not recommend them. They are not the same as the regulated body-identical HRT available on prescription.
Your own history should decide, not a headline
Before your appointment, write down three things:
- the symptom that bothers you most, such as the night sweats that wake you at 3am
- any personal or family history of breast cancer, clots or stroke, such as “my mother had breast cancer at 62”
- the one fear about HRT you most want answered
It takes five minutes, I promise, and it turns a vague worry into a conversation we can actually have.
You should not have to make this decision based on a study from twenty years ago, or on the last headline you happened to read. That is why I offer a dedicated menopause consultation. Whether HRT is safe for you is a question with a real answer, and you deserve to hear it.
In one unhurried 45-minute consultation at 10 Harley Street, Dr Katy Kasraie will look at your health history, your goals and every suitable option, including approaches that do not involve medication. No referral needed, and most major insurers are accepted. Click here to book your appointment.