Menopause happens when your ovaries begin producing less oestrogen and progesterone. This process can happen overnight - in the case of surgical menopause - or over several years if it’s a natural menopause.

Menopause symptoms are caused by fluctuating or low levels of oestrogen. HRT treats these symptoms by replacing declining oestrogen.

HRT is the most effective form of treatment available for menopause symptoms. Large studies have repeatedly demonstrated its beneficial effects.

However, it’s important to be sure that your symptoms really are due to menopause before starting treatment. It can be all too easy to blame menopause for your problems when it could be caused by something else entirely.

It’s important to see your doctor for a proper assessment before taking the plunge with HRT. They may want to do some further tests to exclude any other potential diagnoses before prescribing.

HRT comes in a number of different forms, depending on whether you need systemic or topical therapy.

Topical HRT is used to treat genitourinary syndrome of menopause (GSM) such as vaginal atrophy. It comes in the form of vaginal gels, creams and pessaries.

Systemic HRT is used for all other menopause symptoms. This can be taken orally, or transdermally  - as a patch, spray or gel. Find out more about the different types of HRT here.

Oestrogen is essential for HRT as it is replacing this hormone that treats your symptoms. The most common oestrogen used for systemic HRT is now body identical estradiol (E2). This is identical in structure to the estradiol found in the human body. Estradiol for HRT is mainly produced from plant sources, so is free from the animal welfare issues associated with earlier forms of HRT, including Premarin. Find out more about bioidentical hormones here.

Vaginal oestrogens use estriol (E3), which is also bioidentical.

If you still have your womb, you will also need to take a form of progesterone. This is because unopposed oestrogens can cause endometrial hyperplasia and even endometrial cancer. Taking an appropriate progesterone effectively removes this risk. You can take progesterone either as part of a combined HRT product or separately, as a tablet or intrauterine system like the Mirena coil. Body-identical progesterone is also available in the form of micronised progesterone - Utrogestan.

Testosterone is also sometimes used to treat low libido associated with menopause. This can be considered if you’ve been on standard HRT for three months and your symptoms are still ongoing.

This depends on your personal preferences and medical background.

For systemic treatment, doctors will generally recommend transdermal oestrogen - with or without progesterone - as a first choice. This is because transdermal oestrogens are associated with no increased risk of venous thromboembolism (VTE). This is in contrast to oral oestrogens, which were associated with a 70% increased risk (Vinogradova 2019).

Body-identical estradiol is also a good first choice. This is now thought to have less of an impact on your VTE risk than older, conjugated oestrogens like Premarin (Vinogradova 2019).

If you need progesterone, the Mirena coil - or its newer cousin Levosert - is popular. This is because it provides a reliable contraceptive, tends to lighten or stop your periods, and needs replacing every four to five years at most. Body-identical micronised progesterone tablets (Utrogestan) are also favoured at present.

If you are only really struggling with genitourinary symptoms, topical oestrogens are a very good option. As well as being an effective treatment for GSM symptoms, topical oestrogens have the added benefit of causing very minimal systemic uptake, making this the lowest-risk form of HRT available.

This may all sound confusing, but your doctor will be able to help you make the best choice for you.

Modern preparations are low-risk and suitable for most people. However, like any medication, HRT comes with certain risks which need to be carefully weighed up for everyone who takes it.

In some cases, HRT can cause an increase in breast cancer risk and this needs to be weighed up carefully in each individual case. For example, if you have a strong family history of breast cancer, you may choose to avoid HRT. It’s worth bearing in mind that the increased risk caused by HRT is less significant than the increase caused by having a BMI over 30, or drinking two alcoholic drinks per day.

Oral oestrogens are associated with an increased risk of VTE and stroke. Transdermal oestrogens are not associated with this increased risk.

Regardless of which type of HRT you take, breast cancer and VTE (including PE and DVT) are still quite common. If you have any breast changes or symptoms suggestive of VTE (like chest pain, breathlessness, leg swelling, tenderness or redness), seek urgent medical help.