Hormone replacement therapy (HRT)

Hormone replacement therapy (HRT) is a medicine taken to help manage symptoms of menopause and to strengthen bones. It can help to prevent osteoporosis in the years around menopause, especially if you have an early menopause. It can also be a good choice if you need treatment for both osteoporosis and menopausal symptoms.

HRT is very effective when it is prescribed in the right way. Its benefits usually outweigh the risks. HRT is usually started before the age of 60. As you get older than this, the risks may start to outweigh the benefits. It’s important to discuss the benefits, risks, and the best length of treatment for you, with a healthcare professional. This can help you decide what’s right for you.

This information may be helpful if you (or someone close to you):

• have osteoporosis or a high risk of broken bones (fractures), and want to know how HRT can help
• are going through menopause or have menopausal or perimenopausal symptoms and are looking for ways to protect your bone health
• want to understand the benefits and risks of HRT, including the possible side effects.

What is hormone replacement therapy (HRT)?

HRT is a treatment that replaces the hormones called oestrogen and progesterone. Some people are also given testosterone. It is often prescribed to relieve menopausal and perimenopausal symptoms, and to either prevent or treat osteoporosis.

 

What is menopause?

Menopause is when your periods stop due to low levels of the hormones oestrogen, progesterone and testosterone. This usually happens between the ages of 45 and 55. Menopause can also be caused by surgery to remove your ovaries or womb, some cancer treatments like chemotherapy, and your genetics.  

Perimenopause is when you have symptoms of menopause, but your periods haven’t stopped. This is due to changes in your hormones. You may have irregular periods during this time. When you have not had a period for one year, it is menopause.

Menopause and perimenopause can cause symptoms like anxiety, low mood, brain fog, hot flushes, night sweats, poor sleep and vaginal dryness. These symptoms can start before your periods stop and then continue for years after your last period.

The fall in oestrogen can also increase your chance of osteoporosis and broken bones.

 

How does menopause affect the bones?

The inside of our bones is constantly being broken down and rebuilt by specialist bone cells. This process helps to keep bones healthy and strong.

As we get older more bone is broken down than rebuilt and your bone strength slowly lowers.

Oestrogen is important for bone strength. During menopause, the decrease in your level of oestrogen causes the process of breaking down bone to speed up. More bone is broken down than rebuilt. This can increase your chance of osteoporosis and broken bones. This is why osteoporosis is more common in women than in men. Not everyone who goes through the menopause will develop osteoporosis. But if you have an early or premature menopause you are more likely to develop it.

There are things you can do to reduce your chance of osteoporosis and broken bones. This includes eating a healthy, balanced diet and exercise.

 

How does HRT work?

HRT replaces your oestrogen and progesterone. The increase in oestrogen can help to reduce your chance of developing osteoporosis and broken bones.

If you already have osteoporosis or a high chance of breaking bones, HRT can help to strengthen your bones and make broken bones less likely while you are taking it.

 

Is HRT as effective as other osteoporosis medicines?

Yes - HRT appears to be as effective as other osteoporosis medicines at lowering the chance of broken bones in postmenopausal women. It is a recommended treatment for osteoporosis.

Some people who have broken multiple bones or had spinal fractures may need to try a different medicine.

 

Other benefits of HRT

HRT also helps with perimenopausal and menopausal symptoms. This includes

• hot flushes
• night sweats
• sleep problems caused by menopause
• anxiety and low mood caused by menopause
• vaginal dryness. 

It can take a few weeks or months for these symptoms to improve.

HRT alongside exercise can also help your muscle strength. Strong muscles help to keep your bones strong. Explore our muscle strengthening exercises.

HRT may also decrease the risk of heart disease in women who start treatment around the age of menopause. But more research is needed.

You may also be wondering if HRT can reduce the chance of dementia. It is not known yet if HRT reduces dementia risk. More research is needed.

 

Who can have HRT?

HRT may be suitable if you:

• have symptoms of menopause or perimenopause
• have an early menopause (before the age of 45)
• are a postmenopausal woman under the age of 60 who has a high chance of breaking a bone. A healthcare professional will be able to assess your chance of breaking a bone.

Even if your main reason for taking HRT is to relieve menopause or perimenopause symptoms you will also be helping your bones.

Like any osteoporosis drug, HRT won’t reduce the pain caused by broken bones. But there are other treatments that can help with pain.

Always talk to a healthcare professional about your treatment options and if HRT is the right osteoporosis medicine for you.

 

When is HRT not suitable?

HRT may not be suitable if you:

• have a history of breast, ovarian or womb cancer
• have a history of blood clots
• have a condition that increases your chance of blood clots
• have liver problems
• have had a recent heart attack
• have vaginal bleeding and do not know the cause
• are pregnant.

There are other health conditions that may mean you can’t have HRT.

Always tell a healthcare professional about any medical conditions you have. This can help them assess if you can take HRT. There are many types of HRT. You may be able to take one type, but not others.

Types of HRT

There are many different HRT medicines available. HRT can:

• be taken in different ways
• contain different hormones
• contain different amounts of hormones.

 

How do I take HRT?

There are different forms of HRT that can be used to treat and prevent osteoporosis. The main types are:

• tablets
• patches that you stick on your skin
• spray that you put on your inner arm or inner thigh
• gels you rub on your skin.

There are also rings, creams and pessaries that can be placed inside the vagina to treat symptoms such as vaginal dryness. But these won’t strengthen your bones, as only small amounts of oestrogen travel to the rest of the body.  

If the type of HRT you are taking is not working for you, it’s okay to talk to your doctor about other options. Sometimes it can take time to find the treatment that works for you.

 

What hormones can you have with HRT?

Oestrogen-only HRT

Oestrogen-only HRT does not contain any progestogen. You can have oestrogen-only HRT if you’ve had an operation to remove your womb (a hysterectomy).

Combined HRT

Combined HRT contains both oestrogen and progesterone. Progesterone is important because it protects the lining of your womb. If you have a womb and take oestrogen without a progestogen this may cause the womb lining to grow abnormally.  

Combined HRT comes in two forms:

• Sequential combined therapy - Sequential means you will not always take both oestrogen and progesterone. It is usually recommended if you have menopausal symptoms and have had a period in the last 12 months. The exact regime depends on what HRT you are taking.
• Continuous combined therapy - Continuous means you will usually have both oestrogen and progestogen every day. The exact regime depends on what HRT you are taking. This is usually recommended when you have not had a period for a whole year.

Testosterone

Testosterone can be used to help with low sex drive (loss of libido). It may also help with other menopausal symptoms. In the UK testosterone is not currently licensed for use in menopause. But a specialist doctor can prescribe it.

More research is needed to understand if taking testosterone for menopause can help with osteoporosis.

 

Other types of HRT

Body-identical hormones

These medicines, are designed to be identical to the hormones you produce naturally. Examples are micronised progesterone or 17 beta oestradiol. Some healthcare professionals prescribe these, instead of standard HRT, as it may reduce the chance of side effects. They may also help with sleep.

These hormones are regulated. This means they have been tested in research and shown to be safe and effective. They are available on NHS prescription from your GP.

Unregulated bio-identical hormones

These are different to the regulated medicines mentioned above. Although they claim to be more natural, they haven’t been tested in the same way as regulated products to prove they work and are safe. They aren’t recommended in treatment guidelines and they aren’t available on the NHS. It’s important to remember that just because a product says it is ‘natural’, this doesn’t automatically mean it is safe or effective.

If you are unsure if your HRT is regulated, contact your GP surgery or pharmacist.

Tibolone (Livial®)

Tibolone is a tablet that you take once a day. It’s similar to taking combined HRT, but contains the ingredient tibolone, rather than oestrogen and progestogen. Tibolone mimics oestrogen, progesterone, and testosterone inside the body. It can be used if you completed your menopause over a year ago.

 

What dose of HRT do I need for my bones?

HRT can be given in different amounts (doses). As long as you are taking HRT, you are helping your bones. The dose does not matter.

If you are using HRT to control menopausal symptoms, the dose you need may change depending on your menopausal symptoms. Your doctor will recommend the best dose for you.

 

How will my treatment be monitored?

You will normally have a review with a doctor or nurse three months after starting HRT. You will then have a yearly review. This is to check you’re taking your treatment properly and are not having any problems. Tell the doctor or nurse if you have any side effects. They may be able to suggest ways to help you manage them. You can always contact your GP surgery between appointments if you have any questions or concerns about your medicine.

If you break a bone while taking HRT, contact your GP surgery. Breaking a bone doesn’t necessarily mean your treatment isn’t working. But it may be a good idea to have a bone health assessment.

If you have an increased chance of breaking a bone, you may also have a fracture risk assessment every two to five years. A fracture risk assessment is a questionnaire used by healthcare professionals to understand your bone strength. This assessment may also include a bone density scan.   

After your review you may be advised to:

• continue taking your HRT
• stop HRT and start another osteoporosis medicine
• stop your HRT and do not move on to another medicine
• continue to take HRT for menopausal symptoms but take a different osteoporosis medicine for your bones – this is less common.

How long will I stay on HRT for?

You can keep taking HRT as long as the benefits outweigh any risks. Some women stay on HRT for many years. How long you take HRT for will depend on your own situation – talk to a doctor, nurse or pharmacist about this.

If you’ve had an early or premature menopause, you will normally have HRT, at least until you are about 50. You may then decide to continue your HRT depending on your bone strength and menopause symptoms.

You can stop HRT at any point. A healthcare professional will be able to advise you on the best way to do this. Some people stop immediately. Others may slowly reduce their dose as this may reduce the likelihood of menopausal symptoms returning.

If you stop taking HRT, your doctor may recommend another treatment to strengthen your bones. This is because when you stop taking HRT you will lose its positive effects on your bone strength.  

 

What are the possible side effects?

As with any medicine, HRT can sometimes cause side effects. It is important to remember that side effects are less common than people think. Most people on HRT don’t have any problems. Even if you do get side effects at first, they usually improve within a few weeks or months. There are also ways to manage them.

 If you do get any side effects that don’t go away, it may help to:

• make sure the problem isn’t caused by any other medicine you are taking
• talk to a healthcare professional, who may be able to help find out what is causing the problem
• ask a healthcare professional about other types of HRT.

Possible side effects	How common are they?	How can I manage these side effects?
Breast enlargement or pain	Less than 10 in 100 people. This means 90 in 100 people will not have this side effect.	Try eating a low fat and high carb diet. Talk with a healthcare professional about decreasing the dose of oestrogen or changing your type of HRT.
Bleeding that happens between periods (break through bleeding)	Less than 10 in 100 people. This means 90 in 100 people will not have this side effect.	If this occurs more than six months after starting HRT, speak to your healthcare professional. Further investigation or a change of HRT may be needed.
Bloating and feeling sick	Less than 10 in 100. This means 90 in 100 people will not have this side effect.	Talk to your healthcare professional. Changing the dose of oestrogen or the type of progestogen may help.
Mood changes	Around 1 in 100 people. This means 99 in 100 people will not have this side effect.	Try regular exercises and stretching.

Any progesterone can cause side effects, such as low mood and stomach cramps. The low mood and stomach cramps can be reduced by using a version of progesterone that’s more similar to natural progesterone, such as dydrogesterone or micronised progesterone. However, these are more likely to cause irregular bleeding.

It’s important to understand that many of the side effects listed on the leaflet that comes with your HRT may not actually be caused by the medicine. When a medicine is first tested, the people taking it have to report anything unusual to the researchers. The problems they report are often just as common in people who aren’t taking the medicine.

For a full list of possible side effects, look at the patient information leaflet that comes with your HRT. If you don’t have a copy, ask your doctor or pharmacist for one.

Do speak to your healthcare professional if you think you are having side effects caused by your HRT, particularly unscheduled bleeding including spotting in between monthly bleeding and bleeding after sex.

 

More serious side effects

As with all medicines, HRT has both benefits and risks. The benefits of HRT usually outweigh the risks. Current evidence says that the risks of serious side effects from HRT are very low. We describe some of the possible risks below.

• Many types of HRT are linked with a small increase in breast cancer risk. The longer you use HRT the more the risk increases. To help understand this risk some people find it useful to know how this risk compares to other things. HRT has a lower risk of breast cancer than being obese or drinking over the recommended amount of alcohol. Research has also shown that oestrogen-only HRT has little or no effect on the risk of breast cancer.
• HRT tablets can increase the chance of developing blood clots, but this risk is low. Oestrogen given through the skin as a patch, gel or spray does not increase the risk of blood clots.
• Some HRT tablets are linked with a small increase in stroke risk. But this risk is low, especially if you start HRT before the age of 60. There is no evidence that HRT patches, gels and sprays increase your risk of stroke.

The risk of serious side effects is small, but does vary from one person to another.  It depends on things such as your age, weight, medical and family history. For example, as you reach your 60s, the overall risks of starting HRT may outweigh the benefits. This is because the risk of the health problems mentioned above increases naturally with age, and taking HRT could add to this risk.

It’s important to discuss your own personal benefits and risks with a healthcare professional. They help you decide if HRT is the right treatment for you, as well as which type to use, and how long to use it for. Regular reviews of your treatment choices are also important.

In general, HRT is safe and effective when used in the right way, by the people who need it.

 

HRT in the news

You may have seen news stories about HRT and feel confused about its safety. Remember that news stories aren’t always accurate or balanced. Experts regularly review the safety and use of treatments. You can also find reliable, up-to-date information on the NHS website, Women’s Health Concern and Menopause Matters.

 

Making a decision about treatment

Some people worry about starting a new medicine and find it hard to make a decision. You might be concerned about possible side effects or wonder if you really need treatment. Or you might not like taking medicine in general.

It’s important to learn all you can about your treatment options, so you can decide what’s right for you. Talk to your doctors so that you fully understand your situation. Make sure you read – and understand – any information they give you, as well as the leaflet that comes with the medicine.

No-one can make you have an osteoporosis medicine if you don’t want it. But do take the time to understand the benefits and possible risks – both of taking HRT, and of not taking HRT.

Take care when visiting online forums or chat groups on social media. Reading about other people’s experiences can be helpful. But you may not always see a balance of views online. People are more likely to seek support for bad experiences than good ones. This can make it seem that everyone has problems with osteoporosis medicines. In reality, most people have no side effects at all.

Think about the advantages and disadvantages

As with any treatment, there are advantages and disadvantages to HRT for bone health. You should think about these when deciding whether to take HRT, and about what’s important to you. Here are some of the main things to consider.

Advantages

• HRT can help to reduce your chance of broken bones.
• HRT is available in multiple different forms.
• HRT can also help with menopause symptoms.
• HRT can be prescribed at your GP surgery.

Disadvantages

• As with all medicines, some people get side effects.
• The benefits of the drug wear off if you stop having it.
• There are small risks associated with taking some types of HRT, including breast cancer and blood clots.

If you have any questions about the treatment you’ve been offered, speak to your doctor or nurse. They can explain why they’ve recommended HRT and tell you about any other medicines that might be suitable.

We have information and tips on talking with your doctor.

 

More information on HRT

If you have started HRT for your bone health and would like more information join BoneMed Online. BoneMed online gives people with osteoporosis tailored information about their medicine when they need it most.

Find out more.

 

You may also find the following organisations helpful:

British Menopause Society
thebms.org.uk

Menopause Matters
menopausematters.co.uk

NHS Menopause
nhs.uk/conditions/menopause/

Women’s Health Concern
womens-health-concern.org

 

 

 

Content reviewed: July 2025

Next review: July 2028

 

Watch our discussion on HRT: 

If you're thinking about taking HRT as a drug treatment for osteoporosis, you may be interested in watching a conversation between osteoporosis experts, Dr Nicola Peel and Professor David Armstrong, who discussed how HRT can be used to strengthen bones in January 2023 as part of our #BoneMatters series of events. 

Watch our #BoneMatters Extra discussion: 

We also discussed the practical issues of taking HRT with Menopause Specialist Nurse, Kathy Abernethy in January 2023 as part of our #BoneMatters series of events.