Hot flushes & night sweats
Systemic HRT works throughout the body and is the most effective treatment for these symptoms. Reducing sweats and disrupted nights can make everyday life more manageable.
PATIENT GUIDE
Menopausal hormone therapy (HRT)
Whether you are considering HRT or reviewing treatment you already use, the aim is to understand what is affecting your life, discuss the benefits and risks, and find a plan that suits your circumstances.
WHAT TREATMENT CAN OFFER
Relief shaped around your symptoms.
HRT, also called menopausal hormone therapy or MHT, usually uses oestrogen with a progestogen when needed. Treatment can begin during perimenopause; you do not have to wait until your periods stop.
Sleep & daily wellbeing
Sleep may improve, particularly when flushes are waking you. Some menopause-related mood symptoms may improve too. Persistent low mood, fatigue or concentration problems deserve assessment for other causes as well.
Bone health
HRT reduces bone loss and fracture risk while it is being used. The benefit diminishes after stopping. Your longer-term bone plan depends on your own risk, activity, nutrition and other treatment needs.
When menopause happens earlier
Premature ovarian insufficiency before 40, early menopause before 45 and removal of both ovaries need a distinct discussion. Hormone treatment may be recommended until the usual age of menopause for health protection as well as symptoms, unless contraindicated. Risk estimates for starting HRT in the 50s do not directly describe this situation.
MAKING SENSE OF THE HEADLINES
Why has the advice about HRT changed?
HRT began as a way to ease menopausal symptoms. Over the decades, hopes for wider health benefits and concerns about safety changed how it was prescribed. Following that story helps make sense of the different advice you may have heard.
Choose a date, or use Next to follow the story.
1940s–1970s · THE EARLY YEARS
It began with relief from symptoms.
Oestrogen medicines became more widely available in the 1940s. They offered relief from hot flushes and other menopausal symptoms, and their use grew through the 1960s.
1980s–1990s
Hopes grew beyond symptom relief.
Some studies suggested HRT might also protect the heart. However, women who chose HRT could differ in their health and lifestyle from women who did not. Larger trials were needed to test whether the hormones themselves explained the apparent benefit.
2002 · COMBINED HRT
The trial that changed the conversation.
One WHI trial tested oestrogen plus a progestogen. It stopped early because the overall balance of benefits and harms was unfavourable, including higher risks of breast cancer and problems such as blood clots and stroke.
2004 · OESTROGEN ALONE
A second trial told a different story.
The trial of oestrogen alone, for women who had had a hysterectomy, stopped because of an increased stroke risk. It did not show the same increase in breast cancer as the combined-treatment trial.
LATER RESEARCH
Age, timing and the preparation matter.
Many WHI participants were years past menopause. Later research supports a more favourable balance for many healthy women who start treatment closer to menopause to relieve troublesome symptoms.
TODAY
A decision based on your circumstances.
HRT remains an effective option for symptoms. The choice depends on your age, health, symptoms and treatment. It is not routinely prescribed to prevent heart disease or dementia.
A little more about the WHI trials
The trials included women aged 50–79. They tested oral conjugated equine oestrogens, with medroxyprogesterone acetate in the combined arm. They were designed to study longer-term health effects; symptom relief was already established.
Later analyses focused on younger participants, but fewer events made some estimates less certain. Studies can also follow women for different lengths of time or examine different medicines. This helps explain why two headlines can give different numbers. How to read the figures below ↓
Research context: IARC: early treatment history · NIH: what WHI follow-up tells us · FDA: February 2026 label changes.
UNDERSTANDING YOUR OPTIONS
Three decisions help shape the prescription.
Start with where treatment needs to work, then consider the route and whether your womb needs protection.
01 Where does treatment need to work?
VIA THE BLOODSTREAM · THROUGHOUT THE BODYSystemic HRT
For symptoms such as hot flushes and night sweats.
Oestrogen reaches the bloodstream through a patch, gel or tablet. If you have a uterus, you usually need a progestogen too.
Compare the routes ↓
APPLIED LOCALLY · MAINLY VAGINAL TISSUESLow-dose vaginal oestrogen
For dryness, irritation and painful sex, and some urinary symptoms.
Very little oestrogen reaches the bloodstream with low-dose vaginal treatment. It usually does not need added progestogen. It does not treat flushes or protect bones.
Vaginal comfort, sex & bladder symptoms →You may use both. Vaginal symptoms can need local treatment even when systemic HRT is helping your flushes.
02 Which route fits your health and routine?
Through the skin: patches or gel
Oestrogen absorbed through the skin avoids the first pass through the liver. This generally offers an advantage for blood-clot risk compared with tablets; lower-dose transdermal treatment may also have a more favourable stroke profile. Skin tolerance, patch adhesion and the daily gel routine matter.
By mouth: tablets
Some women prefer a tablet and find it simpler to use consistently. Oral oestrogen has a greater effect on liver proteins and increases venous clot risk. Your medical history helps determine whether it is a suitable choice. Route alone does not determine breast-cancer risk.
03 How do we protect the lining of the womb?
If you have a uterus
Oestrogen+Progestogen
Systemic oestrogen stimulates the uterine lining. An adequate progestogen protects against excessive thickening and endometrial cancer. “Progestogen” includes micronised progesterone and synthetic alternatives. The dose and number of days must match your oestrogen treatment.
After a total hysterectomy
Oestrogen aloneoften appropriate
Oestrogen alone is often appropriate after removal of the whole uterus. Previous endometriosis or a subtotal hysterectomy may alter the plan. Removing the womb does not necessarily cause immediate menopause if the ovaries remain. When progesterone may still be considered ↓
Two ways to schedule combined HRT
The difference is when you use the progestogen. These are simplified monthly patterns; follow your own prescription for the exact days.
Sequential or cyclical
Start of monthEnd of month
Oestrogen
Every day
Progestogen
Part of the month
Often used during perimenopause or soon after periods stop. A monthly withdrawal bleed is expected around the end of the progestogen course.
Continuous combined
Start of monthEnd of month
Oestrogen
Every day
Progestogen
Every day
Usually used once established after menopause. The aim is no bleeding, although spotting can occur initially. Choosing the right time to switch can help.
A hormonal IUS can have more than one role
A suitable 52 mg levonorgestrel intrauterine system, such as Mirena, can provide uterine protection with systemic oestrogen, help heavy bleeding and provide contraception. The South African Mirena information specifies five years of use. Check the device and insertion date; lower-dose systems are not interchangeable for HRT protection.
HRT itself does not prevent pregnancy. We consider contraception alongside symptoms and bleeding. Do not assume an existing contraceptive supplies adequate protection for the uterine lining when oestrogen is added.
BENEFITS, RISKS & YOUR CIRCUMSTANCES
Could HRT suit you?
For many healthy women with troublesome symptoms, starting before 60 or within ten years of menopause has a favourable benefit–risk balance. These are guides to a discussion, not automatic eligibility rules. Your symptoms, preferences, personal and family history, and the preparation all matter.
SYMPTOM RELIEF
Flushes, sweats & sleep
Systemic HRT is the most effective treatment for hot flushes and night sweats. Sleep and daily wellbeing may improve as symptoms settle.
BONE PROTECTION
Less bone loss & fewer fractures
Protection lasts while treatment is used and diminishes after stopping. Your starting fracture risk affects how much benefit you gain.
TYPE & DURATION MATTER
Breast cancer
Combined HRT increases risk, more so with longer use. Oestrogen alone has a different profile. A patch does not remove breast-cancer risk.
THE ROUTE MATTERS
Blood clots in veins
Oral oestrogen increases clot risk. Patches or gel generally have a more favourable profile. A previous clot needs individual assessment.
AGE, DOSE & ROUTE MATTER
Stroke & heart health
Oral HRT can increase stroke risk; patches or gel appear more favourable. HRT is not routinely prescribed to prevent heart disease.
PROTECTION IS ESSENTIAL
The lining of the womb
If you have a uterus, systemic oestrogen on its own increases cancer risk in its lining. An adequate progestogen protects the lining.
This is an overview of systemic treatment. NICE guidance and The Menopause Society position statement explain how age, health, dose and preparation affect the balance. Low-dose vaginal treatment has a separate benefit–risk discussion.
ABSOLUTE NUMBERS · A FIVE-YEAR EXAMPLE
What might that mean for 1,000 women?
These NICE estimates illustrate outcomes over five years, ages 50–54, comparing no HRT with five years of HRT from age 50. The fracture estimate does not separate HRT regimens; the breast-cancer estimate is specifically for combined HRT. They come from different bodies of evidence.
Fragility fractures
Broken bones after a minor fall or injury
- Never use HRT
- 60in 1,000
- HRT
- 40in 1,000
20 fewer women with a fracture
Breast cancer diagnoses
Combined HRT: oestrogen plus progestogen
- Never use HRT
- 12in 1,000
- Combined HRT
- 21in 1,000
9 more women diagnosed with breast cancer
Estimates, not predictions. These use UK population risks and different bodies of evidence. The breast-cancer estimate draws on observational studies; NICE gives a range of 19–23 diagnoses around the estimate of 21. Results vary between studies and preparations. The fracture evidence does not distinguish combined from oestrogen-only HRT. The breast-cancer estimate must not be applied to oestrogen-only treatment. Neither example describes early menopause or predicts your personal risk.
These are two examples, not the whole decision. A fracture and a cancer diagnosis have different consequences, so subtracting one number from the other cannot give an overall score. Symptom relief and the other risks also matter.
Sources: NICE discussion aid, 2024, page 14 · NICE breast-cancer evidence review, 2024, table 14.
Why do different studies give different numbers?
First check who was studied, which treatment was used and how long outcomes were counted. Five years taking HRT is not the same as counting diagnoses for twenty years.
Randomised trials compare assigned treatments; observational studies follow treatment choices in everyday life, where other differences can influence results. The WHI tested particular oral medicines. Its oestrogen-only trial involved women after hysterectomy, so it was not a direct comparison with combined HRT in otherwise identical women.
Smaller age groups in trials give less precise estimates. A chart showing fewer events does not always establish a protective effect. Micronised progesterone may suit some patients better, but a lower breast-cancer risk than other progestogens has not been established with sufficient certainty.
Breast cancer over a longer period: the 20-year example
Here the treatment still starts at 50 and lasts five years, but diagnoses are counted over twenty years, ages 50–69. This includes years after HRT has stopped.
| Treatment history | Develop breast cancer | Additional diagnoses |
|---|---|---|
| Never use HRT | 59 in 1,000 | Reference group |
| Oestrogen-only HRT for 5 years | 69 in 1,000 | 10 in 1,000 |
| Combined HRT for 5 years | 79 in 1,000 | 20 in 1,000 |
UK population estimates drawing on observational evidence. They do not distinguish every preparation or describe premature ovarian insufficiency. Trials can give different estimates. NICE discussion aid, 2024, pages 7 and 19.
Your health history still matters
Age, smoking, blood pressure, weight, diabetes and previous vascular disease affect your starting risk. Unexplained bleeding should be assessed before treatment. Previous breast or other hormone-sensitive cancer, clots, stroke, coronary disease or active liver disease may make systemic HRT unsuitable or need specialist discussion. Family history or migraine does not automatically rule it out.
Other risks to discuss
HRT is also associated with a small increase in ovarian-cancer risk; oral treatment can increase gallbladder problems. Reliable progestogen use is essential when prescribed. Unexpected bleeding needs review. Vaginal treatment after breast cancer needs its own discussion, with oncology input where appropriate.
What about brain fog and weight?
Relief of sweats and poor sleep may help you function better. HRT is not prescribed as a weight-loss or anti-ageing treatment, or to prevent dementia. Persistent cognitive or mood symptoms need their own assessment. Testosterone has a specific role in distressing low sexual desire; it is not a routine treatment for energy or concentration.
UNDERSTANDING THE TERMS
Body-identical does not have to mean compounded.
Regulated preparations
Estradiol and micronised progesterone can have the same molecular structure as hormones produced by the body. Regulated prescription products containing these hormones already exist. Their strength and quality are controlled; being body-identical does not make them free of side effects or risk.
Compounded preparations
Custom mixtures, creams or pellets may be promoted as more natural or individually balanced. Their dosing, quality controls and safety evidence can differ from regulated medicines. SAMS advises against their routine use when suitable regulated treatment is available. Saliva and urine hormone tests are not a reliable basis for adjusting HRT.
OTHER HORMONES & SLEEP
Other hormones, and help with sleep.
A change in sexual desire, persistent poor sleep or difficulty with your current prescription may need a different approach. We consider what is causing the problem, the evidence for each option and how we would judge whether it helps.
STARTING WITH A PLAN
Your consultation and first months of treatment.
Understand your priorities
We discuss the symptoms affecting your life, periods, contraception, medicines and supplements, previous treatment and relevant medical or family history. Tell me what helped, what did not and any side effects you experienced.
Choose useful checks
Blood pressure and relevant health risks guide the plan. Hormone panels are usually unnecessary to diagnose menopause in otherwise healthy people over 45. Younger presentations or other possible causes may need tests. Screening and bone-density checks depend on age and risk.
Agree treatment and follow-up
We choose a suitable route, dose and regimen, with an explanation of how to use it and what to report. Improvement may begin over several weeks; review at about three months helps assess the fuller response. Seek advice sooner if symptoms or side effects are troublesome.
Bring your medicine list or photographs of the packs and any relevant results if available. You do not need to arrange tests before booking. If examination would help, we discuss it first; you can pause or stop.
Back to contents ↑TESTING WITH A PURPOSE
Which blood tests are useful?
A test is useful when its result can change the plan. There is no single hormone number that explains every symptom or proves that an HRT prescription is right for you.
To help make a diagnosis
From age 45, typical symptoms and menstrual changes usually identify perimenopause or menopause without hormone tests. Levels fluctuate, so one normal result does not rule it out. Follicle-stimulating hormone (FSH) testing can help in selected women aged 40–45 or when menopause is suspected before 40. Hormonal contraception and HRT can complicate interpretation.
Thyroid tests, a blood count or iron studies may help when symptoms suggest another cause. Cholesterol or glucose testing depends on your health risks; a broad panel is not necessary for everyone.
To review treatment safely
Oestrogen dosing is usually guided by symptoms, side effects and review. An estradiol test may sometimes help investigate poor absorption from a patch or gel, but there is no universal target for routine HRT and a single result can mislead. A progesterone level does not replace the correct dose and schedule for womb protection.
Testosterone is an exception: blood monitoring is needed before and during treatment to avoid excessive levels. Results help assess safety; symptoms and clinical assessment guide the decision to treat and whether it is helping.
Tell us exactly which products you use and when you last used them. Follow the specific sampling instructions; do not stop or alter treatment for a test unless advised. Saliva and urine hormone panels do not reliably guide routine HRT dosing.
Guidance: NICE: identifying menopause · BMS: interpreting estradiol blood tests, 2025 · testosterone monitoring above ↑.
PRACTICAL GUIDANCE
Using your HRT day to day.
Keep your prescription and the leaflet for your exact product together. Different brands can have different schedules, application sites and missed-dose instructions.
Patches
Use clean, dry, intact skin at a site allowed in the leaflet. Avoid cream under the patch and rotate sites. Remove the old patch when changing it and use a calendar reminder for your change days. If it lifts or falls off, follow that brand’s replacement instructions or ask your pharmacist.
Gel
Measure only the prescribed amount and use the application sites specified for your product. Let it dry, wash your hands afterwards and follow the leaflet’s timing before washing or swimming. Avoid transfer to others, particularly children: follow its advice about skin contact and covering the treated area.
Tablets & progesterone
A regular routine helps. For sequential treatment, record the exact progestogen days. Oral micronised progesterone can cause drowsiness and is often taken in the evening; follow your own prescription and local leaflet, including food instructions. Do not drive if affected. Discuss troublesome effects before omitting the uterine-protection component.
Missed doses & supply changes
Check the leaflet or ask your pharmacist rather than doubling up. Tell us about repeated missed progestogen doses. Pumps, sachets, patches and tablets are not equivalent dose for dose. If your usual product is unavailable, arrange a suitable replacement with your prescriber or pharmacist.
Your treatment plan should answer these questions
- What is each medicine called, and what does it do?
- How much do I use, by which route, and on which days?
- What bleeding pattern should I expect?
- Which symptoms should prompt a call or urgent assessment?
- When will we review whether it is helping?
Brief notes on flushes, sleep, bleeding and side effects can help. Track what matters to you; a detailed diary is optional.
IF TREATMENT IS NOT GOING TO PLAN
Common problems and the next step.
A treatment that has only partly helped can often be reviewed. These starting points help you describe the problem; dose or regimen changes should be agreed with your prescriber.
“My flushes have barely improved.”
Note how long you have used this prescription and whether doses or patch changes have been missed. Check application instructions. At review we can consider dose, absorption, formulation and other causes. Do not keep increasing oestrogen on your own.
“I have breast tenderness, bloating or nausea.”
Mild early effects may settle, but you do not have to tolerate persistent or troublesome symptoms. Note whether they relate to particular days of treatment and contact the practice. A new breast lump or skin/nipple change needs assessment rather than being attributed to HRT.
“Progesterone days affect my mood or make me sleepy.”
Record the timing and effect on daily life. We can review the preparation, schedule and other options for uterine protection. Do not continue systemic oestrogen while repeatedly leaving out a prescribed progestogen. Marked mood deterioration needs prompt help.
“My patch will not stick, or my skin reacts.”
Check skin preparation, placement and the product’s replacement instructions. Avoid putting it on irritated skin. Repeated adhesion problems or a persistent local rash may call for a different brand or route. A widespread reaction or breathing difficulty needs urgent assessment.
“The flushes improved, but sex still hurts.”
Vaginal tissue symptoms can persist despite systemic HRT. Local vaginal treatment may help, but infection, skin conditions and pelvic-floor pain can coexist. Explore vaginal comfort and painful sex and arrange review if symptoms continue.
“I have started bleeding.”
Record dates, amount, clots, pain and any missed doses or treatment changes. Compare the pattern with the expected bleed in your plan. Contact the practice about unexpected bleeding; heavy bleeding or feeling unwell needs earlier help. See the bleeding guidance below.
“It worked before, but symptoms are back.”
Bring the current packs and note any new medicines, supplements or health changes. We review consistency of use, treatment suitability and whether another problem is contributing. A return of symptoms does not automatically mean you need a higher dose.
“I missed doses or cannot get my usual product.”
Ask your pharmacist or prescriber for a plan using the exact product names and strengths. Avoid borrowing someone else’s prescription or estimating a substitute dose. Tell us if bleeding follows missed doses; that history helps assessment but does not exclude other causes.
BLEEDING & WHEN TO SEEK HELP
Know what is expected for your regimen.
A planned bleed or early spotting
Sequential HRT usually produces a withdrawal bleed. Continuous combined HRT aims for no bleeding, but spotting may occur after starting or changing treatment. The next step depends on timing, severity, regimen and your risk factors. Some lower-risk patterns can be managed with supervised adjustments.
Changes to report promptly
Contact the practice for heavy or prolonged bleeding, bleeding after a settled pattern, or recurrent bleeding. New bleeding beginning more than six months after starting, or more than three months after changing HRT, warrants assessment. These timeframes are not instructions to wait: earlier bleeding may also need investigation.
Assessment may include reviewing the prescription and how it is used, an examination, ultrasound and sometimes a sample of the uterine lining or hysteroscopy. Regimen adjustment does not replace investigation when indicated. Bleeding after menopause without an expected HRT withdrawal pattern deserves assessment, even if light or only once.
KEEPING THE PLAN USEFUL
Keep your treatment under review.
Review is usually around three months after starting treatment and at least annually thereafter, with earlier review for problems. Bring your current prescription and tell me what has changed.
Is it helping enough?
We compare your original priorities with how you feel now: flushes, sleep, daily functioning and any symptoms still needing attention. We also discuss whether taking the treatment fits your routine.
Is the plan still suitable?
We review side effects, bleeding, blood pressure, new health problems and medicines, contraception and uterine protection. Appropriate breast and cervical screening remain part of your wider care.
What should happen next?
We may continue, adjust or change treatment, add local care, discuss non-hormonal options or investigate another cause. Unexpected bleeding receives its own assessment. We agree the next review and what should prompt an earlier call.
DURATION & STOPPING
There is no single stop date for everyone.
Continuing treatment
Some women need treatment for a few years; others have persistent symptoms and benefit for longer. There is no automatic requirement to stop at 60 or 65. Continuing successful treatment and starting HRT for the first time much later are different decisions. Benefits, dose, route and changing risks should be revisited regularly.
Reducing or stopping
You can discuss stopping in one step or reducing gradually. Neither approach reliably prevents symptoms returning in the longer term. Plan how to manage a recurrence and consider bone health when systemic treatment stops. Local vaginal treatment may still be useful even when systemic HRT is no longer needed.
OTHER QUESTIONS
You may be wondering.
Can I use HRT while I still have periods?
Yes, it can be considered during perimenopause. The regimen needs to fit your cycle and contraception needs, and unusual bleeding may need assessment first. The contraceptive pill and HRT have different roles; discuss how any change between them should work.
Do I need repeated blood tests to get the dose right?
Routine dosing is usually guided by symptom response, side effects and clinical review, rather than aiming for a particular hormone number. Selected tests can answer specific questions; testosterone treatment does require blood monitoring. Read which tests help and when. Saliva and urine tests do not reliably “balance” HRT.
What if I do not want HRT, or it is unsuitable?
Your preferences matter. Menopause-specific cognitive behavioural therapy and selected non-hormonal medicines can help with flushes or their impact. Sleep, physical activity and other health measures also have a role. Read about non-hormonal options. Availability and monitoring requirements depend on the medicine.
Can I discuss a prescription started elsewhere?
Yes. Bring the names and strengths, how you take each medicine, when you started and any previous results if available. We can discuss what has helped, what has been difficult and whether the plan still suits you. Complete records are helpful but are not a condition of booking.
YOUR NEXT STEP
Discuss starting or reviewing treatment.
You can bring questions, uncertainty or an existing prescription. Consultations are in Claremont, with additional appointments in Simon’s Town on selected Mondays. Reception will confirm your date, time and venue.
General information to support your consultation. Your prescription and treatment plan are individual. Page updated: .
Sources & further reading: NICE NG23, updated April 2026 · The Menopause Society: hormone therapy, 2022 · Hormone therapy claims, 2024 · BMS: unscheduled bleeding guidance, reviewed 2026 · AUA/SUFU/AUGS: vaginal & urinary symptoms, 2025 · International POI guideline.
Practical medicine information: Using oestrogen preparations · Common side effects · South African oral Utrogestan leaflet, 2024. Follow the South African leaflet supplied with your own medicine.