Hormone replacement therapy – Royal Osteoporosis Society

How does menopause affect the bones?What is the menopause?

Menopause is the time in a womans life when the ovaries stop producing enough hormones for pregnancy. Around the menopause, the level of oestrogen can vary for a time and then eventually decreases. This often causes symptoms such as hot flushes and sweats.

You've completed your menopause (or are post-menopausal) when you havent had a period for at least one year. The average age for this to happen is 51 years.

Some women have an early menopause, before the age of 45. This can happen naturally, or after surgery to remove your ovaries. Early menopause can also be triggered by chemotherapy or radiotherapy, as these treatments can cause a sudden drop in hormones.

The inside of our bones is constantly being broken down and rebuilt by specialist bone cells. This process, called bone remodelling, helps to keep bones healthy and strong.

During the menopause, the drop in oestrogen causes this process to become out of balance. More bone is broken down than formed, leading to bone loss.

Bone loss happens more quickly for a few years around the menopause. You then continue to lose bone at a slower rate as you get older. Over time, you may develop osteoporosis and a higher risk of breaking bones in later life. This is particularly likely if you have an early menopause.

HRT is medication that mimics oestrogen and progesterone.

HRT usually combines both hormones. This is because oestrogen taken on its own could make your womb lining too thick and increase your risk of womb cancer. But if youve had surgery to remove your womb (a hysterectomy), youll only need to take oestrogen.

There are more than 50 different HRT products available for prescription in the UK, including tablets, patches that you stick on your skin, small implants that are placed under the skin, and gels you rub on your skin. Progestogen is also available via a contraceptive device called a coil.

There are also rings, creams and pessaries (small removable devices) that can be placed inside the vagina to treat symptoms such as vaginal dryness. But these aren't used to treat osteoporosis, as they only contain very low levels of oestrogen.

HRT comes in the following three forms. Your healthcare professional should explain which form is most suitable for you and why.

Sequential combined therapyYou take oestrogen every day and progestogen for around 12 days per month. The progestogen causes you to have a bleed like a menstrual period.

Continuous combined therapyYou have both oestrogen and progestogen every day, so you wont have periods. The progestogen stops your womb lining from getting too thick. You need to be at least a year past your last period before having continuous combined therapy, or it may cause irregular bleeding.

Oestrogen-only HRTThis doesnt contain any progestogen. You can have oestrogen-only HRT if youve had an operation to remove your womb (a hysterectomy). You wont have any periods.

Tibolone (Livial)This is taken as a tablet once a day. Its similar to taking combined HRT, but contains the ingredient tibolone, rather than oestrogen and progestogen. Tibolone mimics oestrogen, progesterone, and the hormone testosterone inside the body. It can be used if you completed your menopause over a year ago. It may be helpful for libido (desire for sex) and bone strength.

Regulated bio-identical hormonesThese medications are designed to be more similar to the hormones we produce naturally. They include:

Some clinicians prescribe these with oestrogen, instead of standard progestogen, as they are less likely to cause side effects or increase risks of blood clots and stroke. They may also be less likely to increase the risk of breast cancer. There isnt as much research about these newer products, which is why most doctors still prescribe standard progestogen.

Natural bio-identical hormonesThese unregulated products are different to the regulated bio-identical hormones mentioned above. They havent been tested in the same way to prove they work and are safe. Its important to remember that just because a product says it is natural, this doesnt automatically mean it is safe or effective.

Visit the Womens Health Concern website for more information about all of these treatments.

HRT causes your oestrogen levels to increase. This can help to prevent bone loss and reduce your risk of developing osteoporosis and of breaking bones.

If you already have osteoporosis or a high risk of breaking bones, HRT can help to strengthen your bones and make fractures less likely.

Is it as effective as other osteoporosis drugs?

There havent been many studies comparing HRT with other osteoporosis drug treatments. But its thought that HRT probably reduces the risk of breaking a bone by a similar amount to other osteoporosis medications, including bisphosphonates.

As with all medications, HRT has both benefits and risks.

The levels of risk vary from one person to another and depend on things such as your age, weight, medical and family history. As you reach your 60s, the overall risks of HRT may outweigh the benefits. This is because your risk of the health problems mentioned above increases naturally with age, and taking HRT could add to this risk.

Its important to discuss your own benefits and risks with your doctor, so you can decide whats right for you. A regular review of treatment choices is also useful.

Worried by stories you've seen in the news?

You may have seen news stories about HRT, and be feeling worried and confused about its safety. But it's important to remember that news stories arent always accurate or balanced.

Experts regularly review the safety and use of treatments. If official guidance on HRT changes, well update our information on this website. You can also find reliable, up-to-date information on the NHS website, or on other websites such as Womens Health Concern and Menopause Matters.

As with any drug, HRT can cause side effects. But most people dont get any side effects and they dont usually last for long. Possible side effects include:

The patient information leaflet that comes with your treatment will have more information on possible side effects of HRT.

If you do get side effects that don't go away, speak to your doctor or pharmacist.

Its very important to consider taking HRT if you reach menopause early. This is because you will start losing bone at an earlier age than the average woman, increasing your risk of osteoporosis and broken bones. If youve had an early menopause, talk to your healthcare professional about taking HRT, at least until you are about 50.

Many women take HRT to treat symptoms caused by the menopause. Even if this is your main reason for taking HRT, you can be reassured that youll also be helping your bones.

HRT is also an option after the menopause as an osteoporosis drug treatment. Its particularly helpful for women needing a bone-strengthening medication who also have menopausal symptoms.

The decision about which osteoporosis treatment to use will depend on lots of things, including your own level of fracture risk, whether youve already broken a number of bones, your age, and your own needs and preferences. Youll need to speak with your healthcare professional about the most suitable treatment for you.

Like any osteoporosis medication, HRT wont reduce the pain caused by broken bones. But dont worry there are other medications and treatments for pain that can help.

Make sure it's the right treatment for youGet all the information you need and discuss any questions or concerns with your doctor. For many women, HRT will be a useful option. But it may not be right for you if youve previously had a blood clot, breast, ovarian or womb cancer, heart disease, untreated high blood pressure, or liver disease.

Its important to read the information in the patient information leaflet that comes with your treatment. You can also read more detailed information in our fact sheet, 'Hormone replacement therapy (HRT) and bone health'.

Ourspecialist nurse Helplineis here for you, if you have any questions or concerns. Call free on 0808 800 0035.

Make sure you understand your dose, monitoring regime, and what happens nextHRT as a tablet, patch or gel will usually help with bone strength, even if youre having a low dose such as 1mg oestradiol. But you may need a higher dose, such as 2mg, if your menopausal symptoms are severe or arent improving.

You wont need regular blood tests to check your oestrogen levels while youre taking HRT. You probably wont need regular bone density scans either, even if youre taking HRT to help strengthen your bones. However, your healthcare professional may recommend regular scans if you have a high risk of breaking bones.

You should have a medication review about once a year, to make sure HRT is still the right choice for you. Make sure you mention any side effects youre getting. Its important to understand the possible side effects and ways to reduce them.

You can keep taking HRT as long as the benefits outweigh any risks. Some women stay on HRT for several years. How long you take it for will depend on your own situation talk to your doctor about this.

When you stop taking HRT, the beneficial effect on your bones will begin to decrease straight away. If you still have an increased risk of breaking a bone, your doctor will probably recommend you start a different type of osteoporosis drug treatment. Or they may suggest you have a bone density scan or other tests.

Lead a healthy lifestyleIt's important to follow the usual guidance on healthy living while you're on HRT, and aim for a calcium intake of around 1,000mg a day. Your doctor may prescribe calcium and vitamin D supplementsif you cant get enough from your diet.

Content reviewed: February 2022

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Hormone replacement therapy - Royal Osteoporosis Society