Treatments and alternatives

Why this conversation got so confused

In 2002 a single piece of research suggested HRT increased the risk of breast cancer. The story was reported badly. Doctors stopped prescribing it. A generation of women went without treatment that, for most of them, would have been safe.

The research has since been revisited. The risks were significantly overstated. Modern HRT, used properly, is safe for the vast majority of women, and for most has more benefits than risks.

If your GP or your mother or a friend tells you HRT is dangerous, they may be working from the 2002 story. The story has changed. So has the medicine.

The HRT scare of 2002 cost a generation of women treatment they could have had. The science has moved on. The conversation should too.

HRT, in plain English

Most modern HRT looks like this:

• Oestrogen as a patch, gel, or spray applied to the skin. Goes through the skin into the bloodstream. Much safer than the older oral forms.
• Progesterone, separately, if you still have a womb. Usually a tablet you take at night, often Utrogestan (body-identical micronised progesterone).
• Sometimes testosterone, as a gel, if libido and energy haven’t responded to oestrogen alone. Licensed for women in the UK. Should be available on the NHS. Often isn’t, without a specialist.
• Vaginal oestrogen, separately, as a cream or pessary, for vaginal dryness and pain. Different thing, almost no systemic absorption, safe for almost everyone.

What HRT helps with

• Hot flushes and night sweats, often within weeks.
• Sleep, often within a few weeks.
• Brain fog and mood, often within 2 to 3 months.
• Joint aches.
• Libido (especially with testosterone).
• Long-term bone density.
• Cardiovascular protection if started early enough.
• Possibly long-term brain health (research is emerging).

What HRT doesn’t fix

Grief. Marriage stress. A demanding job. Caring for ageing parents. The fact that your teenager hates you this week. HRT works on the hormonal layer of midlife. It doesn’t work on the rest of your life.

If your suffering is partly grief or burnout or anxiety, you may need HRT and something else. Talking therapy, time off, a different job, support. HRT is not a one-stop fix.

Risks, honestly

The risks of modern HRT are real but small. They depend on which type you take, how you take it, and your own health background. For most women under 60, the benefits outweigh the risks.

Breast cancer risk: very small increase with combined HRT, mostly after 5 years of use. Lifestyle factors (alcohol, weight) often carry larger risks than HRT.

Blood clots: only relevant with oral oestrogen. Transdermal (patch/gel) doesn’t carry this risk.

Some women genuinely cannot take HRT, usually because of specific cancers or blood clot history. Speak to a menopause specialist if you are uncertain. “You shouldn’t have it” from a GP who isn’t specialist-trained isn’t always the final word.

If HRT isn’t for you

Some women can’t take it. Some don’t want to. Both are valid choices. Real alternatives:

• CBT for menopause. Specifically designed cognitive behavioural therapy works for hot flushes and sleep. Genuinely evidence-based. Available on the NHS in some areas.
• Certain antidepressants (SSRIs and SNRIs) can reduce hot flushes for some women. Not a small or trivial decision, but a real option.
• Gabapentin can help severe hot flushes when nothing else works.
• Vaginal oestrogen on its own, without systemic HRT, helps a lot of the urogenital symptoms safely.
• Lifestyle changes, properly applied, can move the needle. Sleep, strength training, protein, reducing alcohol. See Lifestyle and self care.

Things with real evidence behind them, alongside or instead of HRT

• Strength training, 2 to 3 times a week. Bones, mood, sleep, strength.
• 30 minutes of daylight, preferably before 11am, every day. Real impact on sleep and mood.
• Protein at every meal. Fibre, 30 different plants a week if you can.
• CBT-I (cognitive behavioural therapy for insomnia) for sleep specifically.
• Reducing alcohol, especially in the evenings.

Things we are sceptical of

Anything sold by a website with a checkout button and a money-back guarantee.

Anything that promises to “balance your hormones” in seven days.

Most herbal supplements marketed for menopause. They might do something, often they don’t, occasionally they interact with real medication.

Bioidentical hormones from compounding pharmacies (not the same as body-identical HRT). Not regulated. Not recommended by the British Menopause Society.

Anything that costs more than your weekly food shop and isn’t prescribed.

If the thing is real, the NHS will prescribe it. If you have to pay £400 a month for it, ask yourself why.

How to get started

• Read this page. Read Symptoms and solutions. Make a list of yours.
• Book a GP appointment. If yours isn’t menopause-confident, ask for one who is.
• If you can afford it, one private menopause consultation often unlocks the right NHS treatment. British Menopause Society has a specialist finder.
• Bring a written list of symptoms and how long each has been going on.
• Ask, specifically, about transdermal HRT, vaginal oestrogen, and (if relevant) testosterone.
• Don’t leave the appointment with antidepressants alone unless that is genuinely what you want.