Menopause: Is Hormone Replacement Therapy (HRT) safe?

Updated January 2023 | 5 min read
Expert contributor Professor Susan Davis, consultant endocrinologist and Director of the Women’s Health Research Program at Monash University; Dr Roisin Worsley, endocrinologist at Jean Hailes for Women’s Health
Words by Karen Burge

There’s a lot of confusion around the safety of hormone replacement therapy. We weigh up the evidence.

Menopause can mark the start of a complicated relationship with your body. After experiencing somewhere between 400 and 500 periods in your lifetime, hormone levels shift, which can bring on a host of symptoms like hot flushes and night sweats. Hormone replacement therapy (HRT), more recently referred to as menopausal hormone therapy (MHT), can help you manage these symptoms. But just how effective and safe is it?

Common symptoms of menopause

Most women reach menopause between the ages of 45 and 55 years, and the average age in Australia is 51. While some have only mild menopause symptoms, for some women, menopause may affect their everyday lives.

When you’re no longer able to release an egg from your ovaries, your periods stop and you experience a shift in three important hormones: oestrogen, progesterone and testosterone.

Consultant endocrinologist and Director of the Women’s Health Research Program at Monash University, Professor Susan Davis, says it’s the dramatic fall in oestrogen that brings on most symptoms. Common symptoms of menopause include:

• hot flushes
• night sweats
• sleep disturbance
• joint pain
• anxiety
• mood changes
• vaginal dryness
• bladder discomfort
• mild urinary incontinence
• reduced sex drive.

Prof Davis says many women’s symptoms last for around five to 10 years, although the duration and severity vary.

“We know that about 50% of women in their early 60s are still having hot flushes, and for about 10% of these women, they’re quite severe.”

What is HRT?

HRT, the medical replacement of oestrogen, progesterone and sometimes testosterone, is known to be the most effective therapy for troubling menopause symptoms.

Most women take a combined HRT with oestrogen and progesterone, or a synthetic form called ‘progestin’. While oestrogen is the main hormone, alone it can overstimulate the cells lining the uterus which can increase the risk of endometrial cancer – the addition of progesterone helps to neutralise this risk. Oestrogen-only HRT is usually only recommended for women who’ve had a hysterectomy.

Some women also benefit from a low-dose testosterone replacement to help with loss of libido, lack of energy and fatigue, according to women’s health organisation, Jean Hailes for Women’s Health.

Is HRT safe?

While HRT can bring much-needed relief for many menopausal women, there has been a lot of confusion about its safety, risks and benefits among patients and even doctors.

Current guidelines recommend that if you take HRT for menopausal symptoms, you should take the lowest effective dose for the shortest time to alleviate symptoms. If you stay on HRT for up to five years, this is called ‘short-term HRT’. If you take it for more than five years, it’s called 'long-term HRT'. Your doctor should reassess and review your case every six months.

Pros and cons of HRT

It’s important that you know the risks and benefits of using HRT and discuss any concerns with your doctor as the risks vary from one woman to another and depend on many factors.

On the plus side, using HRT brings relief from hot flushes and night sweats, which can be inconvenient and uncomfortable, and so severe you need to change your clothes or sheets.

“Most women who go on HRT because they have severe menopausal symptoms feel much better physically, with better sleep, more energy and less aching,” says Dr Roisin Worsley, an endocrinologist at Jean Hailes for Women’s Health. Some experience a better mood and less anxiety, too.

HRT can also reduce the risk of some chronic conditions that may affect older women, including:

• osteoporosis and bone fractures
• type 2 diabetes
• bowel (colon) cancer
• endometrial cancer
• heart disease
• cataracts.

Like all medications though, there can be side effects. “Common ones are nausea, breast tenderness, headache and menstrual bleeding. More serious risks include blood clots in the legs and lungs, an increased risk of gallbladder problems and an increased risk of some cancers,” Dr Worsley says.

Some types of breast cancers rely on oestrogen to develop and grow, so women who take HRT for long periods of time (over five years) have a 0.3-fold increased risk of developing cancer. Women who take HRT for shorter periods (two years) have the same risk of developing breast cancer as women who have not used HRT.

The evidence around HRT and cancer is where the message can get confusing. Many studies on HRT have been published over the past 15 years that highlight differing results. If you’re considering taking HRT it’s important to discuss the risks and benefits with your doctor.

If you have early menopause (before you’re 45), the advice is to take HRT until the average age of menopause (around 51) to protect your bones and heart.

“In these women, HRT has a completely different risk profile and actually increases life expectancy,” Dr Worsley says.

When to steer clear of HRT

If you’ve had a blood clot in your legs or lungs, or breast cancer, HRT for menopause isn’t advised, explains Dr Worsley. Your doctor will talk through your medical history and discuss what's appropriate for you.

Alternatives to HRT

If HRT isn’t suitable or if you’ve chosen not to take it, Dr Worsley says there are other prescription medications which have been shown to reduce hot flushes, although none of them are as effective as HRT.

She says common options include low-dose antidepressants and blood pressure medication. Psychological approaches, like cognitive behavioural therapy, can also be helpful, even though hot flushes are a 'biological' problem.

Some women can manage mild menopausal symptoms with a healthy lifestyle, including regular exercise and eating well. Or you might need to try a few different treatments to find one that works for you.

No matter how complicated it all seems, if menopause symptoms are causing you concern, get medical advice.

“We have a lot more research now than before so we have more accurate information available for women,” says Dr Worsley.

Menopause Matters Podcast

Join host Alison Brahe-Daddo as she chats with leading experts to unpack the experience of perimenopause and menopause, including ways to manage your symptoms, how to navigate your career, mental health and relationships during this time, as well as the joys of life post-menopause.

Listen to our podcast here. 

A GP at your fingertips

If you’re struggling with menopausal symptoms, speak to your GP. If you prefer an online video GP service, our partnership with GP2U makes it easier for you to access telehealth services and get the advice you need.

All HCF members with health cover can access a standard GP2U consultation (up to 10 minutes) for a fee of $50. To register and make an appointment, contact GP2U.