Systemic HRT (Estrogen + Progesterone)

The most evidence-backed treatment available for menopause symptoms.

30-second summary

Systemic HRT replaces declining estrogen and progesterone throughout the body. It is the most effective treatment for vasomotor symptoms, sleep disruption, mood changes, and joint pain — and also protects bone density and, when started within 10 years of menopause, cardiovascular health. Despite its reputation, modern HRT is far safer than the 2002 WHI study suggested.

What it is

Systemic HRT delivers estrogen — and for women with a uterus, progesterone — throughout the body. It comes in patches, gels, sprays, and tablets. Transdermal (through the skin) forms are generally preferred because they bypass the liver and carry a lower clot risk than oral forms.

What the evidence shows

Strong evidence for: hot flash reduction (85-90% of women notice significant improvement), night sweat reduction, sleep improvement, mood stabilisation, joint pain reduction, bone density protection, and cardiovascular protection when started within the critical window. Growing evidence for cognitive protection and dementia risk reduction when started in perimenopause.

Honest about risks and side effects

The 2002 WHI study created widespread fear about breast cancer risk that has since been significantly revised. The absolute risk increase from combined HRT is approximately 1 additional case per 1,000 women per year of use — comparable to drinking 1-2 glasses of wine daily or being overweight. For women using estrogen-only HRT (after hysterectomy) there is no increased breast cancer risk and possibly a reduced risk. The type of progesterone matters — micronised progesterone (Utrogestan) appears safer than synthetic progestogens. Transdermal estrogen does not increase clot risk the way oral estrogen does.

What we do not know

The optimal duration of HRT use has not been established. Whether all forms and routes carry identical risk profiles has not been fully determined. The precise timing window for maximum cardiovascular protection is still being studied.

Who it is best for

Women within 10 years of menopause or under 60 with moderate to severe symptoms. Women with significant vasomotor symptoms, sleep disruption, mood changes, or joint pain. Women concerned about bone density or cardiovascular risk.

Who should be cautious

Women with a personal history of breast cancer, blood clots, stroke, or uncontrolled blood pressure need specialist guidance — not automatic exclusion. Many can still use HRT with appropriate monitoring. Discuss your individual history thoroughly.

How to access this

Requires a prescription. GP or gynaecologist. Telehealth menopause clinics provide faster, more menopause-literate access — search for menopause telehealth clinics in your country. Ask specifically for a Menopause Society certified practitioner.

Questions to ask your doctor

• Can you explain my personal risk-benefit balance for HRT given my history?

• What type and route of HRT would you recommend for me and why?

• Should I use micronised progesterone (Utrogestan) rather than synthetic progestogens?

• Can we discuss transdermal estrogen specifically?

• What monitoring will I need while taking HRT?

Rose honest take

"If your doctor has not discussed HRT with you, ask directly. If they dismiss it without a thorough conversation about your individual risk profile, ask again or find a different doctor. You deserve this conversation."