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Plainly Her Guide · Treatment · 12 minutes

HRT, Explained Plainly

The most consequential and most misunderstood decision in this whole area. This guide separates what the 2002 study found from what was reported, explains why route and timing matter more than the yes or no, and gives you the questions that make a ten-minute appointment useful.

Free, and not gated. You do not have to give us an address to read it.

A woman at a laptop in her home office during a video consultation, writing questions in a notebook.
Medically reviewed by Dr Ana Reyes
MD, MSCP, Menopause Society Certified Practitioner
Reviewed 24 August 2026
Updated 29 August 2026
In this guide
  • What hormone therapy actually is, in its parts
  • 2002, and what the reporting got wrong
  • What the November 2025 labelling change did and did not do
  • Route, timing and dose, the three variables that matter
  • Who it is not straightforward for
  • What to ask, and what to bring
If you read nothing else
  • Timing is the biggest single variable in the risk picture.
  • Transdermal oestrogen is not associated with the clot risk seen with oral.
  • Vaginal oestrogen is a very low dose and is considered separately from systemic therapy.
  • Hormone therapy is not contraception.

What it is, in parts

Hormone therapy is usually two things rather than one.

Oestrogen does the symptomatic work: hot flushes, night sweats, sleep, vaginal and urinary symptoms, and bone protection. It can be delivered orally as a tablet, through the skin as a patch, gel or spray, or locally to the vagina as a cream, tablet or ring.

A progestogen is added for anyone who still has a uterus, and its job is specific: it protects the endometrium from the thickening that unopposed oestrogen causes. It is not there for symptoms. This is why the endometrial cancer warning remained on oestrogen-alone products after the other warnings were removed.

Local vaginal oestrogen sits in a category of its own. The dose is very small, systemic absorption is negligible, and it is generally considered separately from systemic hormone therapy in both risk and prescribing.

2002, and what actually happened

The Women’s Health Initiative published early findings in 2002 that were communicated as showing increased breast cancer and cardiovascular risk with hormone therapy. Prescribing fell off a cliff worldwide within eighteen months.

Two things about the study got flattened in the reporting. The average participant was sixty-three, more than a decade past her final period, which is not the woman a clinician typically considers hormone therapy for. And the results in women in their fifties, close to their final period, looked substantially different from the headline.

The consequence was a generation of women who went through menopause untreated, and a generation of doctors who trained without learning to prescribe it. That is the backdrop to every conversation you will have about this.

November 2025

The FDA removed the broad boxed warnings on cardiovascular risk, breast cancer and dementia from menopausal hormone therapy labelling, including from low-dose vaginal products where systemic absorption is minimal. The endometrial cancer warning on oestrogen-alone preparations remained.

It is worth being precise about what a labelling change is. It corrected how the evidence was being communicated. It did not announce new evidence, and no regulator said hormone therapy is right for everybody. What it changed is the starting point of the conversation: from a black box that ended the discussion, to a discussion.

The three variables

Timing. The risk and benefit picture for a fifty-two year old starting two years after her final period is materially different from that of a sixty-five year old starting fifteen years after. This is the single largest variable and it is the one the 2002 reporting obscured.

Route. Oral oestrogen passes through the liver first and is associated with an increased risk of venous thromboembolism. Transdermal oestrogen is not, at standard doses. Where there is any vascular concern, migraine with aura, raised BMI or a family history of clots, transdermal is generally preferred, and this is the single most useful thing to know before you walk into the appointment.

Dose. The usual principle is the lowest dose that controls the symptoms, reviewed rather than set and forgotten.

Who it is not straightforward for

A personal history of breast cancer, of oestrogen-sensitive cancer, of blood clots or stroke, of liver disease, or undiagnosed vaginal bleeding. None of these are automatically absolute barriers in every case, and all of them mean the decision belongs with a specialist rather than with a general consultation or with a website.

Any bleeding after twelve months without a period is investigated first, before anything else is considered. That is not negotiable and it is the one symptom that should never be assumed to be hormonal.

What to bring

Write down, before you go:

  • Your symptoms, how often, and specifically what they are stopping you doing. “I have hot flushes” is weaker than “I have twelve flushes a day and I have stopped chairing meetings.”
  • Your cycle history for the last six months.
  • Your personal history: clots, cancers, liver disease, migraine with aura, blood pressure.
  • Your family history in first-degree relatives.

And ask about route and dose rather than about hormone therapy as a single question. It is not one decision, it is three, and the second and third are where most of the useful conversation is.

One more thing, because it is missed constantly: hormone therapy is not contraception.

Short answers on this

Is HRT safe? Read the answer → Can you still get pregnant during perimenopause? Read the answer →
Sources

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