Hormone replacement therapy (HRT)

Hormone replacement therapy (HRT) is medication used to help manage symptoms of the menopause and to strengthen bones. It can help to prevent osteoporosis in the years around the 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 safe and effective when it’s prescribed in the right way for the women who need it. 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 your own benefits and risks, and the best length of treatment for you, with your doctor, so you can decide what’s right for you.

How does menopause affect the bones?

What is the menopause?

Menopause is the time in a woman’s life when the ovaries stop producing enough hormones for pregnancy. Around the menopause, the level of oestrogen can vary for a time and then eventually decreases. This often causes symptoms such as hot flushes and sweats.

You've completed your menopause (or are ‘post-menopausal’) when you haven’t had a period for at least one year. The average age for this to happen is 51 years.

Some women have an ‘early’ menopause, before the age of 45. This can happen naturally, or after surgery to remove your ovaries. Early menopause can also be triggered by chemotherapy or radiotherapy, as these treatments can cause a sudden drop in hormones.

What happens to the bones?

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

During the menopause, the drop in oestrogen causes this process to become out of balance. More bone is broken down than formed, leading to bone loss.

Bone loss happens more quickly for a few years around the menopause. You then continue to lose bone at a slower rate as you get older. Over time, you may develop osteoporosis and a higher risk of breaking bones in later life. This is particularly likely if you have an early menopause.

What is HRT?

HRT is medication that mimics oestrogen and progesterone.

• Oestrogen is often prescribed to relieve menopausal symptoms, and to either prevent or treat osteoporosis.
• Progestogen (a man-made version of progesterone) is given to protect the womb.

HRT usually combines both hormones. This is because oestrogen taken on its own could make your womb lining too thick and increase your risk of womb cancer. But if you’ve had surgery to remove your womb (a hysterectomy), you’ll only need to take oestrogen.

Types of HRT

There are more than 50 different HRT products available for prescription in the UK, including tablets, patches that you stick on your skin, small implants that are placed under the skin, and gels you rub on your skin. Progestogen is also available via a contraceptive device called a ‘coil’.

There are also rings, creams and pessaries (small removable devices) that can be placed inside the vagina to treat symptoms such as vaginal dryness. But these aren't used to treat osteoporosis, as they only contain very low levels of oestrogen.

HRT comes in the following three forms. Your healthcare professional should explain which form is most suitable for you and why.

Sequential combined therapy
You take oestrogen every day and progestogen for around 12 days per month. The progestogen causes you to have a bleed like a menstrual period.

Continuous combined therapy
You have both oestrogen and progestogen every day, so you won’t have periods. The progestogen stops your womb lining from getting too thick. You need to be at least a year past your last period before having continuous combined therapy, or it may cause irregular bleeding.

Oestrogen-only HRT
This doesn’t contain any progestogen. You can have oestrogen-only HRT if you’ve had an operation to remove your womb (a hysterectomy). You won’t have any periods.

Can HRT help prevent or treat osteoporosis?

HRT causes your oestrogen levels to increase. This can help to prevent bone loss and reduce your risk of developing osteoporosis and of breaking bones.

If you already have osteoporosis or a high risk of breaking bones, HRT can help to strengthen your bones and make fractures less likely.

Is it as effective as other osteoporosis drugs?

There haven’t been many studies comparing HRT with other osteoporosis drug treatments. But it’s thought that HRT probably reduces the risk of breaking a bone by a similar amount to other osteoporosis medications, including bisphosphonates.

What are the possible side effects of HRT?

As with any drug, HRT can cause side effects. But most people don’t get any side effects – and they don’t usually last for long. Possible side effects include:

• breast enlargement and tenderness
• breakthrough bleeding
• leg cramps
• stomach upset, feeling sick and bloating.

Man-made progestogen can cause side effects, such as low mood and stomach cramps. These can be reduced by using a version that's more similar to natural progesterone, such as dydrogesterone.

The patient information leaflet that comes with your treatment will have more information on possible side effects of HRT.

If you do get side effects that don't go away, speak to your doctor or pharmacist.

More serious side effects

As with all medications, 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. Research has shown that oestrogen-only HRT has little or no effect on the risk of breast cancer.
• Some 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.
• 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.
• Research has shown that HRT does not increase the risk of heart disease.

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 your doctor. 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 review of treatment choices is also important.

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

Worried by stories you've seen in the news?

You may have seen news stories about HRT, and be feeling worried and confused about its safety. But it's important to remember that news stories aren’t always accurate or balanced.

Experts regularly review the safety and use of treatments. If official guidance on HRT changes, we’ll update our information on this website. You can also find reliable, up-to-date information on the NHS website, or on other websites such as Women’s Health Concern and Menopause Matters.

Is HRT right for you?

It’s very important to consider taking HRT if you reach menopause early. This is because you will start losing bone at an earlier age than the average woman, increasing your risk of osteoporosis and broken bones. If you’ve had an early menopause, talk to your healthcare professional about taking HRT, at least until you are about 50.

Many women take HRT to treat symptoms caused by the menopause. Even if this is your main reason for taking HRT, you can be reassured that you’ll also be helping your bones.

HRT is also an option after the menopause as an osteoporosis drug treatment. It’s particularly helpful for women needing a bone-strengthening medication who also have menopausal symptoms.

The decision about which osteoporosis treatment to use will depend on lots of things, including your own level of fracture risk, whether you’ve already broken a number of bones, your age, and your own needs and preferences. You’ll need to speak with your healthcare professional about the most suitable treatment for you.

Like any osteoporosis medication, HRT won’t reduce the pain caused by broken bones. But don’t worry – there are other medications and treatments for pain that can help.

If you're prescribed HRT for osteoporosis

Make sure it's the right treatment for you

Get all the information you need and discuss any questions or concerns with your doctor. For many women, HRT will be a useful option. But it may not be right for you if you’ve previously had a blood clot, breast, ovarian or womb cancer, heart disease, untreated high blood pressure, or liver disease.

It’s important to read the information in the patient information leaflet that comes with your treatment. 

Our specialist nurse Helpline is here for you, if you have any questions or concerns. Call free on 0808 800 0035.

Make sure you understand your dose, monitoring regime, and what happens next

HRT as a tablet, patch or gel will usually help with bone strength, even if you’re having a low dose such as 1mg oestradiol. But you may need a higher dose, such as 2mg, if your menopausal symptoms are severe or aren’t improving.

You won’t need regular blood tests to check your oestrogen levels while you’re taking HRT. You probably won’t need regular bone density scans either, even if you’re taking HRT to help strengthen your bones. However, your healthcare professional may recommend regular scans if you have a high risk of breaking bones.

You should have a medication review about once a year, to make sure HRT is still the right choice for you. Make sure you mention any side effects you’re getting. It’s important to understand the possible side effects and ways to reduce them.

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

When you stop taking HRT, the beneficial effect on your bones will begin to decrease straight away. If you still have an increased risk of breaking a bone, your doctor will probably recommend you start a different type of osteoporosis drug treatment. Or they may suggest you have a bone density scan or other tests.

Lead a healthy lifestyle

It's important to follow the usual guidance on healthy living while you're on HRT, and aim for a calcium intake of around 1,000mg a day. Your doctor may prescribe calcium and vitamin D supplements if you can’t get enough from your diet.

Content reviewed: February 2022

(updated May 2022)

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.