The question of whether to take hormone replacement therapy (HRT) during perimenopause and menopause is one of the most significant health decisions many women will make. It has also been one of the most confused — shaped by a 2002 study that caused a generation of women to stop or avoid HRT out of fear, only for the evidence to be substantially reinterpreted in the years since.
This article sets out what current evidence — including updated NICE guidance — actually says about HRT and its alternatives, so that you can have an informed conversation with your doctor.
What Is Perimenopause?
Perimenopause is the transitional phase before menopause — typically lasting 4 to 8 years — during which oestrogen levels fluctuate and decline. It usually begins in the mid-to-late 40s. Symptoms can be significant:
Vasomotor
Hot flushes, night sweats, palpitations
Sleep
Insomnia, poor quality sleep
Psychological
Anxiety, low mood, brain fog, memory difficulties
Genitourinary
Vaginal dryness, painful sex, recurrent UTIs
Musculoskeletal
Joint aches, reduced muscle mass
Metabolic
Weight redistribution, cardiovascular risk increase
The Case for HRT
HRT — oestrogen alone (if you have had a hysterectomy) or combined oestrogen and progesterone — is the most effective treatment for perimenopausal symptoms. The evidence for benefit is robust:
- Hot flushes and night sweats: HRT reduces frequency and severity by up to 90% in most women — far more effective than any alternative.
- Sleep: Improves significantly, primarily through reduction of night sweats.
- Mood and cognitive function: Good evidence for improvement in mood, anxiety, and brain fog. Particularly beneficial when symptoms coincide with perimenopausal hormonal fluctuation.
- Genitourinary syndrome of menopause (GSM): Both systemic HRT and local vaginal oestrogen reduce vaginal dryness, discomfort, and recurrent lower urinary tract infections.
- Bone health: Oestrogen prevents bone loss and reduces fracture risk. For women with premature ovarian insufficiency (POI), HRT is recommended until at least age 51 for this reason.
- Cardiovascular: When started within 10 years of menopause or before age 60 (the "window of opportunity"), HRT is associated with a neutral or beneficial cardiovascular effect. This benefit does not apply to women starting well after menopause.
- All-cause mortality: Large observational studies suggest HRT started at the right time may reduce overall mortality.
The Risks — Reframed by the Evidence
The 2002 Women's Health Initiative (WHI) study caused widespread alarm about breast cancer and cardiovascular risk. Its findings have since been substantially reassessed — the participants were older (average age 63), overweight, and many already had cardiovascular disease; the HRT used was oral equine oestrogen plus a synthetic progestogen. These are not the conditions under which HRT is now prescribed.
| Risk | What the evidence shows |
|---|
| Breast cancer | Oestrogen-only HRT is not associated with increased breast cancer risk (may even reduce it in some studies). Combined HRT with synthetic progestogens carries a small increase in risk (similar to drinking 1–2 units of alcohol daily). Combined HRT with micronised progesterone has significantly lower risk than synthetic progestogens. |
| Blood clots (VTE) | Oral oestrogen increases VTE risk. Transdermal oestrogen (patches, gels, sprays) does NOT increase VTE risk — this is a critical distinction. |
| Stroke | Oral oestrogen at standard doses slightly increases stroke risk. Transdermal oestrogen does not increase stroke risk. |
| Endometrial cancer | Oestrogen alone increases risk — which is why progesterone is prescribed for women with a uterus. When combined properly, endometrial cancer risk is not increased. |
| Ovarian cancer | A small increase in risk has been associated with HRT use — approximately 1 extra case per 1,000 women using HRT for 5 years. |
The takeaway: For most healthy women under 60, or within 10 years of menopause, the benefits of HRT (particularly transdermal oestrogen with micronised progesterone) substantially outweigh the risks. This is the position of NICE, the British Menopause Society, and the International Menopause Society.
Who Should Not Take HRT?
HRT is not suitable for everyone. Absolute or strong relative contraindications include:
- Current or recent (past 2 years) breast cancer
- Oestrogen-sensitive endometrial cancer (some exceptions exist)
- Unexplained vaginal bleeding (until investigated)
- Active or recent VTE not fully anticoagulated
- Untreated endometrial hyperplasia
- Severe active liver disease
Many women in these categories can still benefit from local vaginal oestrogen for genitourinary symptoms, as systemic absorption is minimal.
If You Choose Not to Take HRT
Choosing not to take HRT is a valid, personal decision. Effective alternatives exist for specific symptoms:
- SSRIs and SNRIs (such as venlafaxine or paroxetine) reduce hot flush frequency by approximately 50–60% and are NICE-endorsed first-line non-hormonal options for vasomotor symptoms
- Cognitive Behavioural Therapy (CBT) is recommended by NICE for mood symptoms and hot flushes — it has good quality evidence and no systemic side effects
- Clonidine is modestly effective for night sweats in some women
- Local vaginal oestrogen (pessaries, rings, creams) is absorbed minimally and can be used by most women including many breast cancer survivors, to treat GSM symptoms independently of systemic HRT
- Lifestyle: reducing alcohol, caffeine, and refined carbohydrate; regular aerobic and resistance exercise; maintaining a healthy BMI all reduce symptom severity
Making the Decision
The right choice depends on your symptoms, your medical history, your risk factors, and your personal values. Some women are significantly debilitated by perimenopausal symptoms; others barely notice them. Some prioritise bone protection; others worry about cancer risk or dislike taking medication.
At Lambert Medical Practice, Dr Dela Dillon-Gbekor takes the time to explore your individual situation — your symptom profile, family history, lifestyle, and what matters most to you — before making any recommendation. She can also arrange blood tests if hormonal assessment is clinically appropriate.
Book a Private Perimenopause Consultation
Dr Dela Dillon-Gbekor MRCGP DFSRH · Surbiton · Same-week appointments · No referral needed
Frequently Asked Questions
For most healthy women under 60, or within 10 years of menopause, benefits outweigh risks. Transdermal oestrogen with micronised progesterone carries the most favourable risk profile. Your individual circumstances will determine what is right for you.
SSRIs/SNRIs for hot flushes, CBT for mood and flushes, clonidine for night sweats, and local vaginal oestrogen for genitourinary symptoms. Lifestyle changes (diet, exercise, alcohol reduction) also reduce symptom severity.
There is no maximum duration set by NICE. It should be reviewed annually. Many women take it for 5–10 years; some take it longer with appropriate monitoring.
Yes. Within 10 years of your last period and under 60, the benefit-to-risk ratio is generally favourable. Starting more than 10 years after menopause requires more careful individual assessment.
Book directly at Lambert Medical Practice in Surbiton — no GP referral needed. Book online, call 0208 133 5694, or WhatsApp 07882 677844. Dr Dela typically has same-week availability.