HRT, Hormones and the Great Internet Argument
There are three little letters capable of starting an argument among menopausal women faster than somebody suggesting we should all try yoga.
HRT.
Hormone Replacement Therapy.
Mention it in a group of women and you’ll probably hear several completely different opinions.
“It’s changed my life!”
“I wouldn’t touch it.”
“My doctor recommended it.”
“My doctor wouldn’t prescribe it.”
“My friend says it causes cancer.”
“My friend says everyone should be taking it.”
And somewhere in the middle of all that noise is a woman who hasn’t slept properly for six months, can’t remember where she’s put her glasses and would quite like somebody to explain what on earth she’s supposed to believe.
That woman was me.
Because I was already taking HRT.
And while I knew that some things seemed to have improved, other things definitely hadn’t.
So I realised I didn’t fully understand the bigger picture.
What exactly was I replacing?
Why were there so many different types?
Why did the dose seem to matter?
Why did some women think HRT was wonderful while others were terrified of it?
And, most importantly:
What did the actual evidence say?
Not Facebook.
Not somebody selling a menopause miracle.
Not a headline designed to frighten women into clicking.
The evidence.
So I went looking.
First, what exactly is HRT?
This is where I discovered that something I’d thought was terribly complicated was actually quite straightforward at its most basic level.
During perimenopause, hormone levels fluctuate.
As menopause approaches and periods eventually stop, oestrogen levels generally fall.
These hormonal changes can contribute to many of the symptoms we’ve spent the last nine chapters discussing.
Hot flushes.
Night sweats.
Sleep disruption.
Vaginal dryness.
Mood changes.
And various other delights.
HRT provides hormones to help manage symptoms associated with these changes.
The main hormone used is oestrogen.
Depending on your circumstances, another hormone called a progestogen may also be needed.
And that’s where the first important distinction comes in.
Apparently having a womb makes a difference
If you still have your womb and take systemic oestrogen, you generally also need a progestogen.
Why?
Because oestrogen can stimulate the lining of the womb.
Without adequate progestogen protection, that lining can become too thick, increasing the risk of endometrial cancer.
The progestogen helps protect it.
Women who have had a hysterectomy can usually take oestrogen without a progestogen, although individual circumstances can mean treatment needs to be tailored.
That was useful information.
Because until I started researching, I’d thought HRT was simply HRT.
One treatment.
One decision.
Apparently not.
There were combinations.
Different doses.
Different ways of taking it.
And different arrangements depending on whether you were still having periods and whether you had a womb.
Honestly, choosing a mobile phone contract seemed simpler.
Tablets, patches, gels and sprays
Another revelation.
HRT doesn’t necessarily mean taking a tablet.
Oestrogen can be supplied through tablets, patches, gels or sprays.
And the way it’s taken can make a difference.
This isn’t just about whether you prefer swallowing tablets or remembering to change a patch.
It can affect the risks associated with treatment.
For example, oral HRT is associated with an increased risk of blood clots.
Oestrogen absorbed through the skin—known as transdermal oestrogen—doesn’t carry the same increased risk of venous blood clots as oral HRT.
That doesn’t mean patches and gels are automatically the right choice for everyone.
But it does mean that saying:
“HRT increases the risk of blood clots.”
without explaining which type we’re talking about isn’t particularly helpful.
It’s a bit like saying:
“Cars are dangerous.”
Well, yes.
But there are several things I’d quite like to know before deciding whether to get into one.
My own HRT experience wasn’t an overnight transformation
This is where my own experience became interesting.
Because HRT didn’t arrive in my life like some kind of hormonal fairy godmother.
I didn’t put on my first patch, wake up the following morning and think:
She’s back!
It was much more gradual than that.
I started on a 50 patch.
And I can’t say there was a dramatic moment when everything suddenly improved.
It wasn’t until my patches were increased from 50 to 75 that I began to notice a couple of real differences.
The first was my hot flushes.
They seemed to improve.
And then there was something else.
The rage.
Now, when I say rage, I’m not talking about being mildly irritated because somebody has left an empty toilet roll on the holder.
I’m talking about those completely disproportionate flashes of anger where something relatively minor produces a reaction inside you that feels enormous.
Somewhere between:
That’s slightly annoying
and:
I MAY HAVE TO LEAVE THE COUNTRY BEFORE I SAY SOMETHING I REGRET.
Those feelings seemed to settle after my HRT dose was increased.
And I was grateful.
I’m fairly sure everybody around me was too.
But this is the important part.
HRT didn’t fix everything.
My memory didn’t suddenly come back
This is something I want to correct because it’s very easy to look back and attribute every improvement to one treatment.
My forgetfulness didn’t really improve with HRT.
I still forgot words.
I still lost track of what I was doing.
I still put my glasses, phone and keys in places I wouldn’t previously have left them.
And I could still walk into a room and have absolutely no idea why I’d gone there.
So although brain fog and difficulties with memory and concentration can occur around menopause, I can’t personally say:
HRT fixed my brain fog.
It didn’t.
Perhaps other women have a different experience.
Mine was much less dramatic.
The hot flushes improved.
The rage feelings improved.
The forgetfulness?
Not really.
And that’s precisely why I think personal stories about HRT need a bit of nuance.
It helped some things.
It didn’t help everything.
My joints didn’t get the memo either
I might also have liked HRT to wave its magic hormonal wand over my aching joints.
Sadly, my joints declined the invitation.
The aches and pains I’d been experiencing didn’t noticeably disappear after starting HRT or after increasing my patches.
That doesn’t mean hormones have nothing to do with musculoskeletal symptoms around menopause.
We’ve already established that joint and muscle aches are recognised menopause symptoms.
But in my case, HRT wasn’t the answer to them.
Which brought me straight back to all the things I’d discovered earlier.
Strength.
Movement.
Hypermobility.
Muscle support.
Recovery.
And paying attention when pain needs investigating.
Apparently Hercules couldn’t outsource the entire job to a patch.
She was still going to have to exercise.
Rude.
And no, my weight didn’t magically return to normal either
This was another interesting one.
Because there’s so much discussion around HRT and weight.
Would it make me gain weight?
Would it stop menopausal weight gain?
Would my body return to how it used to be?
In my own case, my weight continued to creep up a little even while I was using HRT.
That doesn’t prove HRT caused it.
And it doesn’t mean HRT failed because it didn’t prevent it.
Midlife body composition and weight are influenced by a whole collection of things.
Ageing.
Activity levels.
Muscle mass.
Sleep.
Diet.
Genetics.
Hormonal changes.
Life.
Probably biscuits.
Although I refuse to blame biscuits for everything.
The NHS doesn’t consider weight gain a proven general side effect of most types of HRT, and weight changes commonly happen around menopause whether women take HRT or not.
So I’m not going to blame the patch.
But I’m also not going to pretend it somehow froze my body at its pre-menopause setting.
It didn’t.
My body continued to change.
HRT helped certain symptoms.
It wasn’t an undo menopause button.
And actually, understanding that made me much more realistic about what I wanted treatment to achieve.
The dose seemed to matter for me
The fact that I noticed more benefit after moving from the 50 patch to the 75 taught me something else.
HRT treatment isn’t necessarily:
Take this exact thing and that’s menopause sorted.
Sometimes treatment needs reviewing.
Different women may need different preparations or doses, and symptoms and side effects can change over time.
That doesn’t mean we should adjust HRT ourselves.
Increasing a dose isn’t something to experiment with because somebody on the internet said 75 worked better than 50.
My experience isn’t a dosing recommendation.
It’s simply what happened to me.
But if you’ve started HRT and feel it’s doing very little, that doesn’t necessarily mean the entire idea has failed.
It’s worth discussing your symptoms and treatment with the healthcare professional managing it.
The type, dose or way it’s being delivered may need reviewing.
For me, 50 to 75 was when I began noticing benefits.
Not everywhere.
Not magically.
But enough to matter.
So why did HRT become so controversial?
This was the question that fascinated me.
Because HRT hasn’t always been discussed with quite so much fear.
Then, in the early 2000s, major research findings raised concerns about risks associated with hormone therapy, particularly breast cancer and cardiovascular problems.
The headlines were enormous.
Women stopped taking HRT.
Some doctors became more reluctant to prescribe it.
And an entire generation of women heard that hormone treatment was something to be frightened of.
But as the evidence continued to be examined, the picture became more nuanced than many of those headlines suggested.
Age mattered.
The type of hormone treatment mattered.
The route of administration mattered.
How long treatment was used mattered.
And a woman’s individual health risks mattered.
That doesn’t mean the original concerns were imaginary.
It means risk isn’t adequately explained by a headline.
Which is precisely why I don’t particularly enjoy medical advice delivered in capital letters on social media.
The breast cancer question
Let’s address the elephant in the room.
Because this is often the first thing women mention when HRT comes up.
Does HRT increase breast cancer risk?
The answer depends partly on the type of HRT and how long it’s used.
Combined HRT—containing oestrogen and a progestogen—is associated with an increased risk of breast cancer, and that risk generally rises with duration of use.
Oestrogen-only HRT has a different risk profile.
But simply saying:
HRT causes breast cancer
doesn’t accurately explain the evidence.
Neither does saying:
HRT is completely safe.
Medicines have benefits and risks.
And individual risk matters.
Age.
Personal medical history.
Family history.
The type of HRT.
Duration of use.
Other health factors.
This was where I realised I didn’t need somebody to tell me HRT was either good or bad.
I needed enough information to understand whether the balance of benefits and risks made sense for me.
That’s a much more useful conversation.
What about the benefits?
Because if we’re going to talk about risks, surely we should also talk about what HRT actually does well.
HRT is an effective treatment for menopausal hot flushes and night sweats.
That certainly fitted my experience once my dose had been adjusted.
It can help other menopause symptoms too, depending on the woman and the symptoms involved.
And it can help protect bone while it’s being taken.
That last one caught my attention.
Because we’d already established that my bones had quietly become an important part of this conversation.
Oestrogen plays a role in maintaining bone strength, and bone loss accelerates after menopause.
HRT can reduce that bone loss and lower the risk of fragility fractures while it’s being used.
That doesn’t mean HRT replaces resistance exercise, good nutrition or the other things we’ve already discussed.
But bone protection is a genuine benefit.
And it deserves to be part of the decision.
HRT isn’t a miracle treatment
I think my own experience actually demonstrates this rather well.
Once you start reading menopause discussions online, HRT can sometimes sound like the answer to absolutely everything.
Tired?
HRT.
Aching?
HRT.
Forgetful?
HRT.
Weight changing?
HRT.
Unhappy with your hair?
HRT.
Can’t find your car keys?
Possibly HRT.
At this rate, I was expecting somebody to suggest putting a patch on the washing machine.
But menopause symptoms don’t all have one cause.
And HRT doesn’t necessarily improve every symptom.
Some women experience enormous relief.
Others notice more modest improvements.
Some need their treatment adjusted.
Some experience side effects.
Some find that particular symptoms don’t change at all.
That was me.
Hot flushes: better.
Rage: better.
Forgetfulness: still there.
Joint pain: still there.
Weight: still crept upwards.
That’s not HRT succeeding or failing as a whole.
That’s a treatment helping some of the symptoms I was experiencing.
And I think that’s a much more realistic way of talking about it.
What about side effects?
Of course, medicines can have side effects.
HRT is no exception.
Some women experience things such as breast tenderness, headaches, nausea or bleeding, particularly when treatment is started or changed.
Some effects settle as the body adjusts.
Sometimes the dose or preparation needs changing.
And sometimes a particular treatment simply isn’t suitable.
This is why follow-up matters.
Starting HRT isn’t necessarily:
Here’s your prescription. See you in ten years.
It’s something that should be reviewed.
Adjusted when appropriate.
Reconsidered if circumstances change.
I rather like that approach.
Because menopause isn’t static.
Symptoms change.
Our health changes.
Our priorities change.
And what works at one point may need reviewing later.
A word about unexpected bleeding
You knew I wasn’t going to let this one pass.
Because of my own experience with postmenopausal bleeding, this subject is particularly important to me.
I’d gone a full year without a period.
Then I bled.
My GP referred me to hospital.
I had a scan and a uterine biopsy.
It wasn’t pleasant.
But my results were clear.
And I was extremely grateful that the NHS took it seriously.
HRT can cause bleeding, particularly when treatment is started or changed, and the expected bleeding pattern also depends on the HRT regimen being used.
But that doesn’t mean unexpected bleeding should automatically be dismissed as:
It’s probably just my HRT.
Persistent, heavy or unexpected bleeding needs appropriate medical advice, particularly if it occurs after a period of having no bleeding.
Current guidance considers things such as when HRT was started, whether the treatment has recently changed and an individual’s risk factors.
So please don’t diagnose it yourself.
I’ve said it before.
I’ll say it again.
Don’t ignore the comeback tour.
What if HRT isn’t right for you?
This is another reason I dislike the idea that every woman should follow exactly the same menopause plan.
HRT isn’t suitable for everyone in exactly the same way.
Certain medical histories may affect the options available, and some women need specialist advice.
Some women simply don’t want HRT.
That’s their decision too.
There are other treatments that can help particular symptoms.
Menopause-specific cognitive behavioural therapy can help some women with hot flushes, night sweats and associated sleep problems.
There are also non-hormonal medicines that may sometimes be considered.
For vaginal and urinary symptoms, we’ve already discussed vaginal moisturisers, lubricants and local vaginal oestrogen.
And all the lifestyle measures we’ve talked about throughout this book still matter.
Movement.
Nutrition.
Sleep.
Strength.
Social connection.
Medical care.
Not because these things are a substitute for hormones.
And not because HRT is a substitute for them.
They’re different pieces of the same health picture.
Natural doesn’t automatically mean safer
Inevitably, my research led me back to supplements.
Again.
Honestly, I should start charging them rent.
There are countless products marketed as natural alternatives to HRT.
Herbal menopause blends.
Hormone-balancing powders.
Botanical capsules.
Products promising to restore balance.
I understand the appeal.
If somebody is worried about taking hormones, something labelled natural can sound reassuring.
But natural doesn’t automatically mean safe.
And it certainly doesn’t automatically mean effective.
Some herbal products can interact with medicines.
Some have limited evidence behind the claims being made for them.
And product quality can vary.
Then there’s the phrase bioidentical hormones, which can make things even more confusing.
Regulated hormone preparations can contain hormones identical in molecular structure to those produced by the body.
That’s different from unregulated compounded preparations sometimes marketed as bioidentical HRT, which don’t have the same evidence, regulation and quality assurance as licensed treatments.
Yet another example of two things sounding almost identical while actually requiring a much longer explanation.
A scientific-sounding label isn’t evidence.
And a natural-sounding label isn’t a safety guarantee.
Interesting. Not magic.
There it is again.
Do I have to take HRT forever?
This was another question I wanted answered.
Because the internet appears to offer two completely opposite instructions.
Take it for the shortest possible time.
Or:
Never stop taking it.
Neither works particularly well as a rule for every woman.
There isn’t one fixed duration that’s right for everybody.
How long someone continues HRT depends on their symptoms, age, health, individual risks, preferences and how the balance of benefits and risks changes over time.
Some women use it for a relatively short period.
Others continue for much longer.
The important thing is that the decision is reviewed rather than made once and forgotten about.
And if HRT is stopped, some menopause symptoms may return.
Again:
Individual.
Not universal.
I was beginning to notice a theme.
I don’t want to be frightened into a decision
This was probably the biggest thing I took away from my research.
I didn’t want somebody telling me:
You must take HRT.
And I didn’t want somebody telling me:
You must never take HRT.
I wanted to understand what it could help.
What it probably wouldn’t help.
What the risks were.
How those risks applied to me.
What alternatives existed.
And what I could do if my treatment wasn’t working as well as I’d hoped.
Because informed choice isn’t about being persuaded to agree with somebody else’s opinion.
It’s about having enough reliable information to make a decision that fits your own circumstances.
And that decision may look completely different for different women.
One woman may feel HRT transformed her life.
Another may notice a couple of important improvements.
Another may decide it isn’t right for her.
Another may be unable to use a particular form of it.
None of those women needs a lecture from somebody on Facebook.
The great internet argument can carry on without me
I’ve decided the internet can argue about HRT as much as it likes.
I’m not joining in.
I know what happened to me.
My first dose didn’t produce a miraculous transformation.
After my patch increased from 50 to 75, my hot flushes improved and those horrible rage feelings settled.
But I remained forgetful.
My joints still hurt.
And my weight continued to creep upwards a little.
So if somebody asks me:
“Did HRT work?”
my answer isn’t simply yes or no.
It’s:
It helped with some things.
And perhaps that’s the kind of answer we need more often.
Not miracle stories.
Not horror stories.
Just women’s actual experiences alongside good evidence.
It’s not HRT versus lifestyle
This was another important realisation.
I kept seeing discussions that seemed to suggest women had to choose between medical treatment and looking after themselves.
As though taking HRT meant you didn’t need to exercise.
Or eating well meant you shouldn’t need HRT.
Why would those things be mutually exclusive?
HRT may help manage certain menopause symptoms.
Strength training supports muscles and bones.
Good nutrition supports overall health.
Movement benefits the heart.
Sleep matters.
Medical screening matters.
They’re different parts of the same picture.
Taking medication doesn’t mean you’ve failed to manage menopause naturally.
And choosing not to take medication doesn’t mean you’re ignoring your health.
The goal isn’t to win the menopause Olympics.
It’s to find an approach that works for you.
So where does that leave me?
At the beginning of this menopause journey, I felt as though my body had started changing without consulting me.
I was reacting to symptoms.
Trying things.
Reading things.
Worrying about things.
Occasionally buying things.
Actually, quite frequently buying things.
And wondering why nobody had given me an instruction manual.
But gradually, something changed.
I stopped looking for one perfect answer.
I started looking at the bigger picture.
My muscles needed attention.
My bones needed protecting.
My sleep mattered.
My forgetfulness deserved understanding.
My sexual health mattered.
My digestion deserved attention.
And HRT was one possible part of looking after myself.
Not the whole story.
Just one part.
Because I wasn’t simply trying to get through menopause anymore.
I was starting to think about what came afterwards.
The next ten years.
The next twenty.
Hopefully considerably longer.
And suddenly I found myself asking a completely different question.
What does Future Me need from me now?
Not the twenty-year-old version of me.
Not the woman I used to be.
The woman I’m going to become.
Because, as much as I hate to admit it, she’s relying on me to make some reasonably sensible decisions.
And given that I still can’t remember where I’ve put my glasses, she may have legitimate concerns.
