HRT Explained

What is HRT?

Hormone replacement therapy (HRT) replaces the hormones your body produces less of during perimenopause and menopause. At its core, it provides oestrogen — the hormone responsible for most menopausal symptoms — and often progesterone (to protect the uterine lining if you have a uterus).

HRT is the most effective treatment available for vasomotor symptoms (hot flashes and night sweats) and has been shown to improve many other symptoms including brain fog, mood changes, joint pain, and sleep disruption.

Types of HRT

By hormone combination

Oestrogen-only HRT: For women who have had a hysterectomy.
Combined HRT (oestrogen + progesterone): For women with a uterus. The progesterone component protects against endometrial hyperplasia.

By delivery method

Transdermal (patches, gels, sprays): Applied to the skin. Generally considered the safest delivery method, with lower risk of blood clots compared to oral.
Oral (tablets): Taken by mouth. Convenient but passes through the liver first.
Vaginal (creams, pessaries, rings): Local treatment for vaginal dryness and urinary symptoms. Very low systemic absorption.

By dosing schedule

Cyclical (sequential): Oestrogen daily, progesterone for part of the cycle. Typically used in early perimenopause.
Continuous combined: Both hormones taken every day. No monthly bleed. Typically used later.

Benefits

The evidence for HRT’s benefits is strong and well-established:

Vasomotor symptoms: Reduces hot flashes and night sweats by 75% or more in most women.
Sleep: Improved sleep quality, partly from reducing night sweats.
Mood and cognition: Many women report improvements in brain fog, anxiety, and mood stability.
Bone health: The most effective treatment for preventing osteoporosis-related bone loss.
Cardiovascular health: When started within 10 years of menopause, associated with reduced cardiovascular risk.
Urogenital health: Helps with vaginal dryness, urinary frequency, and recurrent UTIs.

Risks in context

Breast cancer: Combined HRT is associated with a small increase in breast cancer risk after 5+ years. The risk is comparable to drinking 2 glasses of wine per day. Oestrogen-only HRT shows no increase. Micronised progesterone appears to carry lower risk than synthetic progestogens.
Blood clots: Oral oestrogen slightly increases clot risk. Transdermal oestrogen does not — this is why many guidelines now prefer transdermal delivery.
Heart disease: When started before age 60 or within 10 years of menopause, HRT is associated with reduced cardiovascular risk.

For most healthy women under 60, the benefits of HRT significantly outweigh the risks. This is the position of the British Menopause Society, the North American Menopause Society, and the International Menopause Society.

Body-identical vs bioidentical vs synthetic

Body-identical: Hormones with the same molecular structure as those your body produces. Available on prescription. Regulated and evidence-based.
Bioidentical (compounded): Custom-mixed hormones from compounding pharmacies. Same molecular structure but not standardised — doses can be inconsistent.
Synthetic: Hormones with a different molecular structure. Still effective but may carry different risk profiles.

Body-identical HRT prescribed through your doctor or specialist is generally considered the gold standard.

Questions to ask your doctor

Having a symptom record (like the one Sulu’s doctor export provides) makes this conversation much more productive. Here are some questions worth asking:

Based on my symptoms and history, am I a candidate for HRT?
Which type and delivery method would you recommend for me, and why?
What are the specific risks for my individual profile?
How long will it take to notice effects?
How will we monitor and adjust the dosage?
Are there alternatives if HRT isn’t suitable for me?

What Sulu does (and doesn’t do)

Sulu doesn’t recommend or prescribe HRT. What it does is give you a clear symptom record to bring to the conversation. If you start HRT, continued tracking helps you and your doctor see what’s improving, what isn’t, and whether dosage adjustments are needed.

A structured record turns “I think the hot flashes are a bit better” into “hot flash severity dropped from 2.8 to 1.4 over the last 6 weeks.” That’s the kind of data that helps your doctor make better decisions.