Menopause hormone therapy (MHT), often called HRT, is one of the most misunderstood treatments in women's health. For two decades after the Women's Health Initiative study in 2002, MHT was widely feared, widely under-prescribed, and often withheld from women who would have benefited. The picture has changed considerably since then, with newer analyses, updated guidelines, and better understanding of how type, dose, timing, and route of administration affect the risk-benefit balance. Here is where the evidence sits today.
What MHT Is
MHT replaces the hormones that decline through menopause. For women with a uterus, that means oestrogen combined with a progestogen (either progesterone or a synthetic version), because oestrogen alone would over-stimulate the uterine lining and increase the risk of endometrial cancer. For women without a uterus, oestrogen alone is used.
Testosterone is a separate consideration and is sometimes prescribed for low sexual desire that causes distress, once other causes have been assessed.
What MHT Is Used For
MHT is the most effective treatment available for hot flushes, night sweats, and other vasomotor symptoms. It also helps with sleep disruption, mood symptoms linked to the transition, joint pain, and the range of genitourinary changes such as vaginal dryness and painful sex. It protects against bone loss and reduces fracture risk, which is why current European Society of Endocrinology guidance (updated in 2025) includes MHT as an option for bone protection in women with early or natural-timed menopause.
What MHT is not used for is cardiovascular prevention. It should not be prescribed simply to lower heart disease risk in women without symptoms.
Timing Makes a Difference
One of the most important developments in the evidence is what is known as the timing hypothesis. When MHT is started within ten years of menopause or before the age of 60, the benefits generally outweigh the risks for most women. Starting MHT more than ten to twenty years after menopause, or after the age of 60, changes the picture because absolute risks of cardiovascular events, stroke, and dementia are higher in older women overall.
This is not a strict cut-off. It is a framework for individual decision-making with a clinician who understands your health history.
Route and Type Also Make a Difference
Not all MHT is the same. Transdermal oestrogen (patches, gels, sprays) is preferred by most current guidelines over oral oestrogen because it bypasses the liver and does not increase the risk of blood clots to the same degree. This is particularly relevant for women with higher baseline cardiovascular or clotting risk, migraine with aura, obesity, or a family history of clots.
The type of progestogen also affects risk. Body-identical progesterone (micronised progesterone) is generally preferred, with a more favourable profile for breast tissue and cardiovascular risk than older synthetic progestogens.
What About Breast Cancer Risk
This is the concern most women want addressed honestly. Combined MHT does carry a small increase in breast cancer risk, which appears mainly with longer-term use and depends on the type of progestogen. The absolute risk for most women remains low, and needs to be weighed against symptom relief, quality of life, and other benefits including bone protection. Oestrogen-only MHT (for women without a uterus) does not appear to increase breast cancer risk in the same way.
This is a conversation to have with a clinician who can look at your individual risk factors, not a decision to make from a headline.
The Bottom Line
MHT is not a one-size-fits-all decision, but for the right woman, at the right time, in the right formulation, it remains the most effective treatment for menopausal symptoms and one of the few interventions that also protects long-term bone health. If you have been told you cannot take it without a proper individual assessment, it is worth seeking a second opinion from a menopause specialist.