Can You Take HRT During Perimenopause?

With changes occurring within your body and the onset of menopause symptoms, it can be difficult to know when to seek help and what that help might even look like.

Hormone replacement therapy (HRT) is an effective way to manage symptoms, and you don’t have to wait until your periods have stopped completely to begin taking it. Instead, you can usually start HRT as soon as you notice bothersome symptoms (1).

In this article, we explore HRT in perimenopause by explaining the different types and forms, outlining the risks and benefits and discussing starting and managing treatment. Being armed with this information should help you to make an informed, individualised choice about what’s right for you.

Understanding HRT during perimenopause: timing and types

The timing and type of HRT used during menopause can impact its effectiveness, suitability and risk. Generally, starting HRT earlier, ideally within 10 years of menopause, is considered better as it can provide more health benefits and potentially reduce health risks compared to beginning HRT later in life (2).

As hormone levels fluctuate in perimenopause and menstrual bleeding still occurs, the type of HRT recommended at this stage is typically different to the type prescribed after menopause.

Learn more about perimenopause in our guide.

Perimenopause

During perimenopause, hormone levels start to fluctuate, and you may begin having symptoms such as hot flushes, sleep disturbances and irregular periods. The average length of perimenopause is four years although it can last up to eight years or longer for some women (3) which is a long time to potentially deal with symptoms.

Starting HRT in perimenopause can help manage these symptoms. However, as perimenopausal women still produce some hormones, a sequential combined HRT approach is usually taken as oestrogen helps regulate fluctuations while progesterone prevents endometrial overgrowth (4).

Sequential (or cyclical) combined HRT:

Includes oestrogen every day and progesterone for part of the cycle (usually 10-14 days per month).
Mimics the natural cycle, likely leading to withdrawal bleeding (a monthly period-like bleed).
Is suitable for those who still have periods but are experiencing irregular cycles and menopause symptoms (4).

Menopause and postmenopause

If HRT is started within the first 10 years after menopause (or before the age of 60), the health benefits largely outweigh the risks and is associated with maximising the reduction of coronary heart disease and overall mortality while also minimising risks (5).

Later postmenopause

If it’s been more than 10 years since you went through menopause or you’re over the age of 60, starting HRT at this stage is more complex. Risks such as heart disease or increased risk of breast cancer may outweigh benefits, particularly in higher risk women, such as those with cardiovascular risk factors (6) or a strong family history of breast cancer.

HRT vs birth control: making the right choice

During perimenopause, both HRT and combined hormonal contraception can help manage symptoms, but they serve different purposes. Choosing the right option depends on factors like your age, symptom severity, contraceptive needs, and personal health history.

Birth control:

Provides reliable contraception, which is still necessary in perimenopause.
Can help regulate periods and reduce heavy or irregular bleeding.
Helps control symptoms like hot flushes, acne, and mood swings.
Contains higher doses of hormones than HRT, which may not be suitable for those with certain risk factors such as migraines with aura high blood pressure or those who are overweight.
Is usually recommended for younger perimenopausal individuals who want to prevent pregnancy.
Could possibly lead to long-term benefits like bone and heart health (6, 7, 8, 9).

Find out more about contraception in menopause.

HRT:

Is designed primarily to relieve menopause symptoms like hot flushes, night sweats, and vaginal dryness.
Contains lower hormone doses compared to birth control, making it a gentler option for long-term use.
Does not provide contraception meaning additional birth control is needed if pregnancy is still possible.
May offer additional long-term benefits like bone and heart health if started at the right time.
Is an option for women with risk factors that make birth control unsuitable.

Find out more about HRT.

Different forms of HRT explained: pills, patches, gels

During perimenopause, selecting the right form of HRT is important for effectively managing symptoms and aligning with your individual preferences. HRT is available in several different forms, each with its own benefits and considerations.

Patches

HRT patches are applied directly to the skin, typically on the lower abdomen or thigh, and deliver a steady dose of hormones transdermally. They are available as oestrogen-only or combined formulations and are changed every few days. Patches are a popular choice for those who may forget to take tablets daily and can avoid some of the side effects experienced with other forms of HRT (10).

Gel

Oestrogen gel is applied to the skin, usually on the arms or legs, and absorbed gradually into the body. It allows for flexible dosing and avoids the risks associated with oral HRT. Many prefer gel for its ease of use, but it does require a little patience as you must wait for it to dry fully before dressing (10).

Spray

Similar to gel, HRT spray delivers oestrogen through a fine mist applied to the skin. It offers a quick-drying and convenient alternative to gel with precise dosing. As with other transdermal options, it has a lower risk of blood clots than oral HRT, but it requires consistent daily use (10).

Pills

HRT pills are taken orally, usually once a day, and come in both oestrogen-only and combined (oestrogen and progestogen) options. They are a convenient and familiar choice for many, but they carry a slightly higher risk of blood clots compared to non-oral forms (10).

Intrauterine system (Mirena coil)

The Mirena coil is a small, T-shaped device inserted into the uterus that releases progestogen. It is often used as part of HRT for individuals who need progesterone to protect the uterus while taking oestrogen separately. It also provides contraception, reduces heavy periods, and lasts up to five years for HRT (longer if just used for contraception), making it a convenient option for perimenopausal individuals (10).

Vaginal oestrogen

For those experiencing vaginal dryness, discomfort, or urinary symptoms in perimenopause, vaginal oestrogen is available as creams, pessaries, rings, or tablets. Unlike systemic HRT, vaginal oestrogen primarily targets local symptoms, meaning it won’t help with vasomotor or mood symptoms (10).

Benefits and risks of starting HRT early

Starting HRT during perimenopause, rather than waiting until after menopause, can offer significant benefits, particularly for symptom management and long-term health.

However, as with any treatment, there are potential risks that should be carefully considered. Understanding both can help you make an informed decision about when to begin HRT.

Risks

Migraines: Oral HRT can worsen headaches or migraines in some, however transdermal options can be used and often help hormonal headaches/migraines.
Cancer: There is a slightly increased risk of certain cancers, particularly breast cancer, with long-term use of combined HRT (oestrogen and progestogen) (12).
Blood clots: Oral HRT is associated with a slightly higher risk of blood clots. Transdermal HRT (patches, gels, or sprays) should not increase this risk and is often recommended for those with clotting concerns (13).
Stroke or cardiovascular disease: Starting HRT later in life (after age 60) may slightly increase the risk of stroke or heart disease, particularly with oral formulations (13). However, beginning HRT earlier, within 10 years of the menopause, is associated with a lower risk and may even offer some cardiovascular protection (14).

Benefits

Reduces menopause symptoms: HRT is the most effective treatment for common menopause symptoms such as hot flushes, night sweats, mood swings, and vaginal dryness. Starting early can help maintain stability as hormone levels fluctuate.
Improves quality of life: By easing both physical and emotional symptoms, HRT can significantly improve overall well-being, helping you maintain an active and fulfilling lifestyle.
Helps prevent osteoporosis and bone fractures: Oestrogen plays a crucial role in maintaining bone density. Starting HRT early helps protect against osteoporosis, reducing the risk of fractures later in life. It’s particularly important if your periods stop before the age of 45 (13).
Maintains muscle strength: Losing muscle strength as you reach menopause is common but HRT can improve this and help retain muscle strength (13).
Reduces risk of heart disease: When started during perimenopause or soon after menopause, HRT may help protect the cardiovascular system by maintaining healthy blood vessels and cholesterol levels, reducing the risk of heart disease. The benefits are most pronounced when HRT is initiated before the age of 60 or within 10 years of the menopause (14).
Improves cognitive function: Some research suggests that early HRT use may support brain health and reduce the risk of cognitive decline or dementia (15).

There’s more information in our guide to the risks and benefits of HRT.

Finding the right HRT for you

Choosing the right HRT involves working closely with a healthcare professional, whether through the NHS or a private specialist.

When prescribing HRT, the following factors are considered:

Menopause stage: whether you are in perimenopause, menopause, or postmenopause.
Symptoms and severity: to tailor the treatment to your individual needs.
Medical history: including any risk factors for conditions like blood clots, stroke, or cancer.
Preferred method of administration: such as tablets, patches, gel, or spray.
Need for progesterone: for those with a uterus, combined HRT (oestrogen and progestogen) is necessary.
Personal preference and lifestyle: to ensure the treatment is manageable and sustainable.

Monitoring and adjusting treatment over time

Regular follow-ups are essential to ensure HRT remains effective and well-tolerated. It can take time for your body to get used to the reintroduction of hormones, and it’s common for HRT to take up to three months to yield improvements in symptoms and for any side effects to settle.

It can be a bit of trial and error to find the best HRT regimen so if you don’t feel it’s working, speak to your doctor as you can work together to adjust the type or dose until you see optimal results.

At Menopause Care we offer an all-in-one doctor plan. For £89 per month, you'll get an initial appointment with a menopause doctor, with follow-up appointments with the same practitioner every 3 months so that you can review your HRT regimen and discuss any concerns. This plan also included prescribed medication (up to £90 every three months), unlimited menopause monitoring and a personal care coordinator. With this plan, you’ll have peace of mind that you can get individualised advice, regular monitoring and evidence-led adjustments to your HRT plan without the worry of lengthy wait times or hidden costs.

Alternatively, we offer individual appointments with a menopause doctor or nurse. To get started, take a look at our practitioner profiles or get matched with a doctor by completing our symptoms quiz.

DisclaimerAt Menopause Care, we ensure that everything you read in our blog is medically reviewed and approved. However, the information provided is not meant to replace professional medical advice, diagnosis, or treatment. It should not be relied upon for specific medical advice.

References