Uses of HRT: Here is When, Why and How HRT Can Help Women

Thank you for joining us Prof. Brincat. Hormone Replacement Therapy is still widely associated almost exclusively with menopause. From a clinical perspective, can you explain the broader uses of HRT and why it is sometimes essential for women well before the natural age of menopause?

Hormone Replacement Therapy has been recommended as primary treatment for short term symptoms of menopause, such as hot flushes, anxiety, palpitations, brain fog, and aches and pains in joints. Going beyond that however, HRT is also useful in a number of other situations. It is of course used in cases of premature menopause, premature ovarian insufficiency, and in other gynaecological and endocrinology abnormalities. Hormone Replacement Therapy, when used appropriately, is also of use in recharging osteoporosis, cardiovascular disease, heart attacks and strokes, and there is a strong suggestion for Alzeihmer’s in women. Similarly, there is also a suggestion that the immune response in women is improved with HRT, which becomes worse after menopause.

For younger women diagnosed with conditions such as premature ovarian insufficiency, early menopause or those who have undergone ovarian surgery or cancer treatment, why is HRT often recommended, and what risks can arise if hormonal loss is left untreated?

As mentioned earlier it is crucial to give HRT in younger women who have conditions of premature ovarian insufficiency, including those who have undergone surgery involving the removal of their ovaries for benign conditions when it comes to cancer related causes. This is a specialist and a multidisciplinary area, and demands careful consideration.

There is no doubt that delaying such treatment can lead to premature ageing, osteoporosis, skin changes including dryness and vulva vaginal dryness and pain, leading to not only pain in intercourse, but recurrent urinary tract infections, or inflammation, and a general deterioration in vaginal health.

The emphasis in both situations above is to emphasise the importance of carefully tailored treatment to individuals. Not all situations and conditions are the same, so HRT, which comes with a number of preparations, needs to be tailored to individual needs. Nowadays, as before, incidentally we tend to emphasise on regulated body or bioidentical natural hormone replacement therapy.

Much of the fear surrounding HRT stems from concerns about long-term risks. How does the safety profile of HRT differ for younger women compared to women who start treatment later in life, and how should these risks be understood today?

The largest trial study ever carried out was in the so called Women’s Health Initiative where there were women on oestrogen treatment alone and women on oestrogen and progesterone, i.e. those with a uterus when the two hormones need to be given. To cut an enormously long story short, after 18 to 20 years of fellowship in women who had been on treatment for at least 5 to 8 years, improvement in death rates was seen in many of the variable conditions.

However there seemed to be bigger improvements, and this included in breast cancer, in women who had been on treatment in the 50 to 60 year age bracket.

Another big study referred to by the Federal Drugs Authority (FDA) report recently indicated that HRT started in women in their 40’s also improved well being and improved longevity in a number of cases.

The overall message therefore is that at the time when most women start HRT, namely in their mid 40’s to mid 50’s, HRT is not only safe but is beneficial to the overall health of the women not only in the initiative period i.e. when they have symptoms such as hot flushes and so on, but even in the long term several years later.

You have long emphasised that hormone therapy is not a one-size-fits-all solution. How do factors such as age, medical history and the cause of hormone deficiency influence decisions about the type, dose and duration of HRT?

I have long emphasized together with my International Colleagues in the field that we cannot talk of a one size fits all HRT. The major components of HRT are oestrogen, progesterone or a synthetic progesterone referred to as progestogen, and testosterone. Contrary to popular belief, testosterone is also a female hormone and oestrogen is also a male hormone. Progesterone is a natural hormone, but presents in large amounts after ovulation, or during pregnancy.

As a rule, the older one is, the lower the dose of HRT needed but this is not necessarily so since oestopaenia (low bone mass) or oestoporosis need a higher dose. If a patient is obese then we might opt for HRT in gel or patch form since the risk of thrombosis is less than normal.

There is no medical treatment that is entirely free from potential side effects. However, HRT as such, particularly when using regulated body identical hormones, is amongst the safest of therapies. If for no other reason, it is replacing that which the woman has lost.

Indeed there might come a time when even men might require their own HRT, but the protocols have not yet been established for men, although there is no doubt that Testosterone levels do decrease with age. In women where treatment has been available for at least for some 70 years, we are on well trodden ground. Of course a lot of progress has occurred and new formulations are continuously coming on the market which make the treatment even safer. Different formulations should be used depending on the woman’s complaints and on her medical well being.

Despite growing evidence, many women remain hesitant about HRT. Based on your decades of experience, what would you say to women who have been advised to consider HRT but feel afraid or uncertain about starting treatment?

There is no one size fits all. Some studies have been going on for over 20 years and have looked at different formulations and women of all ages. Indeed this is probably one of the most studied areas in medicine. My advice is if you need it and can take it, take HRT. Otherwise, alternatives are available, even though these are not completely risk free. The main worry which was deemed to be the possibility of a small increase in Breast Cancer has now been shown to not be a realistic contra-indication. Caution and care in screening for breast cancer needs to be taken as routine. In some paricular types of HRT, breast cancer incidence is in fact reduced.

The FDA in November 2025 decided that the number of potential cautions interpreted as risks by most people had been exagerated, and following a presentation of experts, decided to remove them, save one. Namely, the original one, which is if one has a uterus then she needs approved therapy i.e. Oestrogen and Progesterone/ Progestagen, but this has been known for decades. At the end of the day HRT used properly is a very useful medical tool in the management of a woman’s health.

If an obese woman has a uterus, that, as in all cases of a woman with a uterus, the addition of a progesterone/progestogen is a must to stop the endometrium in the uterus from developing abnormally, and within regular periods are necessary on a foundation that does not require period, such as continuous progestogen, given daily on a medicated progestogen containing initiative contraceptive devices (eg Mirena) can be used.

The bottom line is, depending on the case, one needs to use the HRT dose that works.

And finally, what key message would you like women to take away about the uses of HRT and its role in supporting both short- and long-term health?

My final message is that women should not be afraid of HRT. The treatment is very safe when prescribed in proper hands, and having been tailored for an individual needs, very significant health benefits, be the physical, psychological and endocrine, are achieved. There is no doubt that a woman’s well being is highly improved when a woman who needs HRT is placed on it and it would be a shame if this natural way of replacing what a body needs is denied to many women as it has been in all these years.

Finally I want to say that the UK did not wait for the US FDA to come out with its pronouncement. Ever since 2017/2018 a number of GPs and journalists listening to the scientists have embarked in a campaign of education. The results are that prior the US pronouncements, there were twice as many women on HRT as there were before the WHI paper was released – a paper that was circulated and interpreted. Today the situation has normalised, but care needs to be taken just like in any other therapy, that HRT is given in a controlled and appropriate factor. In this way its full potential to women’s health can be realised.