I’m menopausal, when should I consider HRT?

menopause article 1200400

The majority of women will go through menopause in their lifetime, a period which can be challenging for some. The menopause means when you stop your periods for good and is diagnosed retrospectively, when you haven’t menstruated for 12 consecutive months. It is not an abrupt stop, but rather a gradual process which takes place over several months, or even years. This transition period, known as perimenopause, is a period where you are likely to undergo a lot of changes, some physical and some emotional. While there are plenty of women who won’t even notice this transition, some will be very aware they are going through perimenopause, as they find their periods get irregular and they start experiencing side effects such as hot flushes and mood swings.

But what exactly is it that causes menopause and its related symptoms? With increasing age, the number of primordial follicles in the ovaries declines, and this drop becomes precipitous at the time of menopause.1 This leads to decreased production of oestrogen and progesterone by the ovaries in response to the pituitary hormones FSH and LH. Although the exact mechanism behind each menopausal symptom is not clearly understood, they are mainly related to this hormonal fluctuation, particularly the reduced circulating oestrogen levels. Eventually, as the follicles are depleted, release of eggs and production of oestrogen by the ovaries ceases completely, resulting in menopause.

What is the role of HRT?

HRT (hormone replacement therapy) provides relief from menopausal symptoms by replacing the oestrogen that the body starts lacking during menopause. HRT comes in two forms: oestrogen-only HRT and combined HRT, which contains both oestrogen and progestogen (a synthetic type of progesterone). Progestogen is added here because the action of oestrogen on the endometrium (inner wall of the womb) unopposed by progesterone is known to increase the risk of endometrial cancer.2 For this reason, oestrogen-only HRT is only recommended for women who have had a hysterectomy (surgical removal of the womb).3

HRT is available in many forms, such as oral tablets, transdermal patches or gel, intravaginal cream or pessaries, and subcutaneous implants. None of these has been proven to be any more effective than any of the others, so the type you use depends predominantly on your personal preference. However, factors like your age, weight, other medical conditions, and which symptoms need to be treated, need to be discussed with your GP to find out what may be the best option for you.

Oral tablets are the most commonly used and need to be taken once daily. They are available in both combined and oestrogen-only forms. Oestrogen is also available as a gel which needs to be applied to clean dry skin once a day. If taking HRT every day seems like a hassle for you, skin patches are a better option as they can simply be stuck to your skin and replaced once every 3-4 days.

Although it’s not commonly used, some people may find it more convenient to use subcutaneous implants, pellets containing oestrogen, which need to be inserted under your skin once every few months. These gradually release the hormone and maintain desirable amounts of oestrogen in the blood stream consistently. However, if you are using an oestrogen-only preparation such as gel or an implant, you need to take progesterone separately to reduce the risk of endometrial cancer unless you have undergone a hysterectomy.

Intravaginal preparations such as oestrogen cream or pessaries are used as topical therapy for relief of symptoms related to urogenital atrophy.

So when should you consider HRT?

Vasomotor symptoms

During perimenopause and the years which follow, it is not uncommon to feel sudden heat waves passing through your upper body, or have nights where you wake up drenched in sweat. Hot flushes and night sweats, collectively known as vasomotor symptoms, are considered the most common of menopausal symptoms and affect between 50% and 80% of middle-aged women.4 Some of these women may be so severely affected that their usual daily activities are often interrupted and sleep is disturbed, leading to poor quality of life. In such instances, HRT is the recommended treatment of choice.5 HRT is known to reduce the frequency of vasomotor symptoms by over 75%, and is usually used at the lowest dose for the shortest effective duration.6 However, the decision to start HRT must be made after discussing all the benefits and risks, and mild symptoms can sometimes be managed with simple lifestyle modifications.

Mood swings

Along with the fluctuating hormone levels, going through menopause can seem like an emotional rollercoaster at times. You may find yourself short-tempered and irritable, sad or anxious over the simplest things, or have mood swings for no reason at all. Apart from changes in hormone levels, other associated symptoms such as hot flushes and insomnia may further aggravate your lousy mood.

HRT needs to be considered in the treatment of low mood occurring because of menopause, and there is limited evidence to support the use of antidepressants in this case unless a diagnosis of depression is made.7 Cognitive behavioural therapy (CBT) may also provide relief for low mood and anxiety that come about because of menopause.8 However, for those with depression, antidepressants like SSRIs are the treatment of choice for major depression, and HRT alone may be adequate for mild cases.9

Urogenital atrophy

Despite being common, symptoms relating to urogenital atrophy are often kept silent as many women find it an embarrassing thing to discuss. Research suggests that up to 40% of postmenopausal women have symptoms of urogenital atrophy, but only 20-25% seek medical care.10

As circulating oestrogen levels decline with menopause, the urogenital tract, including the vulva, vagina, and urethra, undergo many changes, which can lead to some distressing symptoms. Vaginal dryness is common, with associating itching leading to discomfort or pain during sexual intercourse. Women also complain of urinary symptoms such as dysuria, frequency, urgency, and incontinence.

In mild cases of vaginal dryness, treatment may be attempted with vaginal moisturisers and lubricants alone. However, evidence suggests that hormonal therapy is the best treatment as it’s more effective than lubricants, and no herbal therapy is known to exert any significant symptom relief.11

Symptoms related to urogenital atrophy can be treated with local (intravaginal) as well as systemic oestrogen. Local therapy has advantages over systemic HRT, as this means symptoms can be relieved with a lower dose of oestrogen, and absorption into circulation is less, leading to fewer side effects. Sometimes, local therapy can even be used in women in whom systemic HRT is contraindicated.

However, if you are experiencing other symptoms, such as hot flushes and mood swings along with vaginal symptoms, HRT is the best option as local therapy would not have much effect on these other symptoms. However, when standard doses of HRT are inadequate to alleviate urogenital symptoms, coadministration of local oestrogen can be considered.

Sexual dysfunction

During menopause, sexual dysfunction is another common yet under-reported complaint of many women. Low sexual desire and/or problems with arousal or achieving orgasm are some common issues women face, and their causes are often multifactorial. Altered hormone levels, as well as low mood and physical discomfort due to atrophic vaginitis, may all play a role, and assessment of the likely causes for each different woman is important when it comes to treatment. HRT is known to improve the symptoms of sexual dysfunction, and if not, then testosterone therapy can also be considered as an adjunct.12

No matter how beneficial HRT may be for menopausal symptoms, its use must always be weighed up against the risks, and its suitability needs to be assessed individually in each woman. As it is associated with certain negative effects, such as increased risk of thrombosis (forming blood clots), stroke, and breast cancer and endometrial cancer in some, HRT is not recommended for those with a history of blood clots, liver disease, women who are pregnant, women with uncontrolled high blood pressure, or women with a history of breast, ovarian, or endometrial cancer.13

However, the risks of HRT are often exaggerated leading to unnecessary avoidance. Various herbal remedies and complementary therapies are also available, but evidence is lacking regarding their efficacy and safety. Simple lifestyle modifications including eating a healthy diet and taking regular exercise are known to be helpful in alleviating many menopausal symptoms.

About a third of the lifespan, if not more, is still ahead of you at menopause, so it is important that it doesn’t leave you frustrated and distressed — most symptoms have effective solutions, so go and seek help from your GP if your symptoms are having a negative effect on your day to day life.

Featured image is of a woman in her late forties. The frame is cropped so that only her face and shoulders are visible. She is looking to the left of the camera and smiling. The picture is greyscale

Last update September 2019
Next update due 2021


  1. Santoro, N., and Randolph, J.F., Reproductive hormones and the menopause transition, Obstetrics and Gynecology Clinics of North America, September 2011, vol 38, issue 3, pp 455-466
  2. Kim, J.J., and Chapman-Davis, E., Role of progesterone in endometrial cancer, Seminars in Reproductive Medicine, January 2010, vol 28, issue 1, pp 81-90
  3. NICE, ‘Menopause’, Clinical Knowledge Summary, National Institute for Health and Care Excellence, March 2017, [online], https://cks.nice.org.uk/menopause#!scenario (accessed 22 September 2019)
  4. Abdi, F., et al., ‘Hops for Menopausal Vasomotor Symptoms: Mechanisms of Action’, Journal of Menopausal Medicine, vol. 22, no. 2, 2016, pp. 62-64.
  6. Pachman, D.R., et al., ‘Management of menopause-associated vasomotor symptoms: Current treatment options, challenges and future directions’, International Journal of Women’s Health, 2010, vol. 2, pp. 123-135.
  8. Ibid.
  9. Parry, B.L., Optimal management of perimenopausal depression, International Journal of Women’s Health, 2010, vol 2, pp 143-151
  10. Bachmann, G.A., and Nevadunsky, N.S., ‘Diagnosis and Treatment of Atrophic Vaginitis’, American Family Physician, vol. 61, no. 10, 2000, pp. 3090-3096.
  11. Ballagh, S.A., ‘Vaginal Hormone Therapy for Urogenital and Menopausal Symptoms’, Seminars in Reproductive Medicine, 2005, vol. 23, no. 2.
  13. NHS, ‘Hormone replacement therapy’, NHS Choices, September 2019, [online], https://www.nhs.uk/conditions/hormone-replacement-therapy-hrt/#whoi, (accessed 22 September 2019) 

Dr. Shehara Ariyaratne MBBS


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