Hormone Replacement Therapy

Hormone Replacement Therapy (HRT) is a treatment that adds hormones to the body when the body's own hormone levels have dropped too low to work properly.

Hormones are chemical messengers that control many body functions, from body temperature and mood to bone strength and reproductive health. When certain hormone levels fall — most commonly oestrogen and progesterone in women going through menopause (the natural end of monthly periods), or testosterone in men as they age — the body struggles to maintain these functions. HRT delivers those hormones from outside the body, usually through tablets, skin patches, gels, or injections, so that levels return closer to the range the body is used to.

Doctors recommend HRT when falling hormone levels are causing symptoms that affect daily life, or when low hormone levels are putting the patient at risk of longer-term health problems such as bone loss.

• Menopause symptoms: hot flushes (sudden waves of heat), night sweats, vaginal dryness, and sleep problems.
• Early menopause or premature ovarian insufficiency (POI) — when ovaries stop working before the age of 40.
• Surgical menopause — when ovaries are removed during an operation, causing an abrupt drop in hormones.
• Osteoporosis prevention — protecting bone density (the thickness and strength of bones) in women at high risk of fractures after menopause.
• Hypogonadism (a condition where the sex glands produce little or no hormones) in both men and women.
• Gender-affirming hormone therapy — supporting transgender individuals in aligning their hormone profile with their gender identity.
• Low testosterone in men causing fatigue, low mood, reduced muscle mass, or sexual difficulties.

HRT is generally not suitable for everyone. A doctor will carefully review the patient's full medical history before recommending it.

• A personal history of hormone-sensitive cancers, such as certain types of breast cancer or uterine cancer.
• A history of blood clots (deep vein thrombosis or pulmonary embolism) depending on the type of HRT considered.
• Uncontrolled high blood pressure or uncontrolled heart disease.
• Active or recent liver disease.
• Unexplained vaginal bleeding that has not yet been investigated.

HRT is generally well tolerated, but like any medical treatment it carries some risks; the level of risk depends on the type of hormones used, how they are taken, the dose, how long treatment continues, and the patient's personal health history.

• Breast tenderness or swelling, especially in the first few months of treatment.
• Irregular vaginal bleeding or spotting, particularly in the early weeks.
• Headaches or migraines in some patients.
• Nausea, bloating, or stomach discomfort.
• Mood changes or irritability, though HRT also often improves mood in those with hormone-related low mood.
• Fluid retention (mild swelling of the hands, feet, or ankles).
• Skin reactions at the site of a patch or gel application.
• A small increase in the risk of blood clots with certain forms of HRT taken as tablets — oral (swallowed) forms carry a higher clot risk than patches or gels applied to the skin.
• A small increase in the risk of stroke with certain types and doses, particularly in older patients.
• With long-term use of combined oestrogen and progestogen HRT (the type used when the uterus is still present), there may be a small change in breast cancer risk — doctors weigh this carefully against the benefits for each individual patient.
• In men receiving testosterone therapy: acne, increased red blood cell count, testicular shrinkage, or reduced fertility.

HRT does not usually require fasting or a hospital stay to start. However, the preparation phase is important because the doctor needs a clear picture of the patient's health before choosing the right type, form, and amount of hormone therapy.

Before the first prescription, the doctor will usually ask the patient to stop or adjust certain medications temporarily — for example, some drugs can interfere with how hormones are absorbed or broken down. Patients who smoke are usually counselled to reduce or quit, because smoking increases clot risk and can reduce the benefits of HRT. Alcohol intake is also reviewed, as heavy drinking affects hormone metabolism (the way the body processes hormones).

Tests commonly ordered before HRT begins include:

• Blood hormone tests — to measure current levels of oestrogen, progesterone, testosterone, FSH (follicle-stimulating hormone, a signal from the brain that tells the ovaries to work), and LH (luteinising hormone, another brain signal linked to ovulation).
• Blood pressure check.
• Liver function tests, especially if tablet forms of HRT are being considered.
• Blood count and clotting profile if there is a personal or family history of blood clots.
• Thyroid function tests, to rule out a thyroid problem mimicking hormone deficiency symptoms.
• Breast examination and, depending on age and history, a mammogram (an X-ray of the breast).
• Pelvic ultrasound (USG) or endometrial assessment (checking the lining of the uterus) in some women.
• Bone density scan (DEXA scan) if osteoporosis risk is high.

Once all results are reviewed, the doctor discusses the findings with the patient and agrees on a plan. Starting HRT itself typically follows these steps:

• 1. The doctor explains the chosen type of HRT (for example, oestrogen-only or combined oestrogen-progestogen), the delivery method (tablet, patch, gel, vaginal preparation, or injection), and the expected timeline for reviewing progress.
• 2. The patient is shown how to use the delivery method correctly — for instance, where and how to apply a skin patch or gel.
• 3. The first dose is given or the first prescription is dispensed.
• 4. A follow-up appointment is scheduled, usually within a few months, to check how the body is responding and whether any adjustments are needed.

Because HRT is an ongoing treatment rather than a one-time procedure, aftercare focuses on regular monitoring to keep the therapy safe and effective over time. Most patients are seen by their doctor every few months at first, then annually once the dose is stable.

• Regular hormone level checks through blood tests to confirm levels are in the right range and to guide any dose adjustments.
• Blood pressure monitoring at each follow-up visit, as HRT can affect blood pressure in some patients.
• Breast awareness and continued mammogram screening according to local guidelines, particularly for women on combined HRT.
• Reporting any unexpected bleeding promptly, especially if the uterus is still present, as this may need further investigation.
• Skin patch or gel users should rotate application sites and check for irritation or redness at each change.
• Bone density scans repeated periodically if osteoporosis was the main reason for starting therapy.
• Lifestyle support: regular weight-bearing exercise (such as walking or light strength training) helps protect bones; a balanced diet supports overall hormone health; quitting smoking reduces clot risk.
• The doctor will periodically review whether HRT should continue, be adjusted, or be gradually reduced — this decision depends on the original reason for treatment, age, and any new health developments.
• Patients are encouraged to tell all other treating doctors and pharmacists that they are on HRT, as it can interact with certain other medications.