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Side effects and risks of HRT

Checked: 09-12-2024 by Vicky Ryan Next Review: 08-12-2026

Unscheduled bleeding

Unscheduled bleeding within the first six months of initiating HRT or, within three months of a change in dose or preparation in those already established on HRT, is common.

In women with unscheduled bleeding outside of this, please see Unscheduled Bleeding. Women should be reviewed at 3 months following any change to their HRT.

Initial mild side-effects

Mild side effects on starting HRT such as bloating, breast tenderness and nausea usually settle in the first 6 – 12 weeks.

Oestrogen  

Side effects 

Management options  

Fluid retention  

Breast tenderness 

Bloating  

Nausea, Dyspepsia 

Headaches  

Leg cramps

Reduce dose – use lowest dose to manage menopause symptoms  

Change route (i.e. oral, transdermal)

Change preparation (i.e. patch, gel, spray, oral, brand)

Progestogen 

Side effects  

Management options 

Fluid retention  

Breast tenderness 

Headaches 

Mood swings 

PMT-like symptoms  

Change type (i.e. micronised progesterone, norethisterone, dydrogesterone, levonorgestrel etc.)

Change route (i.e. oral, transdermal, intrauterine, vaginal)

Consider LNG-IUD

Can switch to vaginal administration of micronized progesterone at same dose (use oral capsules, off-license)

Alter duration – must continue safe doses  

Consider reducing dose, if safe to do so.

For guidance on changing type/route/preparation of HRT and equivalent doses please see Hormone Replacement Therapy – Dose Section.

Women with side effects or persistent side effects may choose to stop their HRT, if required they could be managed with alternatives to HRT.

Women with persistent side effects despite adjustments can be considered for referral to the complex menopause clinic. See referral section.

Risks

See NICE Guidance: Recommendations | Menopause: diagnosis and management | Guidance | NICE

Endometrial cancer

Risk is increased if estrogen-only HRT is used when uterus present (or insufficient progestogen)

Risk is reduced by addition of appropriate progestogen.

Continuous progestogen provides better long-term protection than cyclical/sequential.

VTE: see HRT and VTE

CHD: see HRT and Cardiovascular disease

Stroke: see HRT and Cardiovascular disease

Breast cancer: see Breast conditions and HRT

Dementia: Women who start HRT >10 years after their menopause have a higher risk of dementia

See BMS Guidance: 02-BMS-ConsensusStatement-BMS-WHC-2020-Recommendations-on-HRT-in-menopausal-women-SEPT2023-A.pdf (thebms.org.uk)

Testosterone

See Testosterone page

Resources

Patient Resources

11-WHC-FACTSHEET-HRT-BenefitsRisks-NOV2022-B.pdf (womens-health-concern.org)

References

02-BMS-ConsensusStatement-BMS-WHC-2020-Recommendations-on-HRT-in-menopausal-women-SEPT2023-A.pdf (thebms.org.uk)

04-BMS-TfC-HRT-Guide-NOV2022-A.pdf (thebms.org.uk)

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