Medically reviewed guide · Last updated: 23 June 2026 · Reading time: approx. 13 min

Hormone replacement therapy: benefits and risks at a glance

Hardly any topic of women's health is so marked by uncertainty as the hormone replacement therapy in the menopause. For years it was above all associated with fear, triggered by a large study whose results are seen much more differentiatedly today. This guide places benefits and risks factually, explains what the much-cited WHI study really showed and presents the various forms of application. The aim is a fact-based foundation beyond panic, so that you can go well informed into the conversation with the gynaecological practice. Important beforehand: this guide does not replace medical advice and no individual weighing and recommends no particular therapy. Its aim is to prepare an often emotionally charged topic soberly and understandably, so that a decision can rest on facts instead of on fear.

What a hormone replacement therapy is and what it achieves

In the menopause, medically called the climacteric, the level of the female sex hormones sinks, first of all of oestrogen. This can lead to a series of burdening complaints, from hot flushes and night sweats over sleep disorders to mood swings and vaginal dryness. How strongly these complaints turn out is very different from woman to woman: some hardly notice the menopause, others are clearly restricted in their everyday life over a longer time. A hormone replacement therapy, HRT for short, balances out this hormone deficiency in a targeted way and can thereby clearly relieve the complaints. The best-documented and most important benefit is the reduction of burdening hot flushes and the disturbed sleep often associated with them, which can noticeably improve the quality of life. For many women, precisely these complaints are so incisive that they clearly impair everyday life, work and well-being over months or years.

Beyond the pure symptom relief, the HRT has a further well-documented benefit: the protection of the bones. Since the oestrogen deficiency accelerates the bone loss, a hormone therapy can counteract this and lower the risk of osteoporosis and bone fractures. This protection is relevant precisely in the years after the menopause, in which the bone density often decreases especially rapidly without countermeasures. With women with a uterus, the oestrogen is combined with a progestogen that protects the lining of the uterus. This protection is important, because a sole oestrogen administration with an existing uterus can stimulate the growth of the lining and thereby increase the risk of changes. Important is the placement: the HRT is in the first place a treatment of burdening complaints and not a general rejuvenation cure. Whether it is sensible always depends on the individual situation and a careful weighing. It should therefore not be started out of pure anti-ageing promises but when concrete complaints impair the quality of life.

The WHI study and why the old fear is outdated

The strong uncertainty around the HRT goes essentially back to a large US-American study, the WHI study from the early 2000s. It showed an increased risk under a certain hormone combination and led worldwide to many women and doctors avoiding the HRT. The headlines of that time burned themselves deeply into the collective memory and have an after-effect to this day, although the science has moved on by now. Today it is known that this result strongly depended on the design of the study and is not transferable in a blanket way to every form of HRT. Examined was a combination usual in the USA of mare oestrogens and a synthetic progestogen, frequently with women who were clearly older and whose menopause lay long in the past. Exactly this constellation, a late therapy start with certain preparations, is today recognised as unfavourable and does not correspond to the way an HRT is usually used by now.

Later analyses of the same data over more than twenty years as well as newer investigations have put the original figures into perspective and drawn a more differentiated picture. What appeared then as a uniform risk turns out today to be strongly dependent on the respective circumstances. Decisive are accordingly the timing of the therapy start, the age, the chosen form of application and the personal risk profile. According to today's understanding, the benefit-risk ratio turns out especially favourable when the therapy is started early, that is within about ten years after the last menstruation or before the age of 60. The blanket fear of HRT, which kept many women from an effective treatment for years, is considered outdated today. Professional societies now emphasise that a too blanket rejection of the hormone therapy has harmed many women, because they unnecessarily did without an effective relief of their complaints.

Placing the risks correctly

Like every effective therapy, the HRT too has possible risks that must be named honestly but also placed correctly. Important here is to distinguish between a relative and an absolute risk, because a percentually increased probability often means, with an anyway rare event, only a few additional cases. In the foreground are an increased risk of blood clots and stroke as well as, with a long-term combination of oestrogen and progestogen, a slightly increased breast cancer risk. These risks are real but in their size often smaller than the public perception suggests. With breast cancer for example, with the combination therapy it is statistically a small number of additional cases, and under a pure oestrogen therapy without progestogen the risk is according to today's assessment not or only very slightly increased. By way of comparison: other, widely accepted living habits too influence the breast cancer risk, which shows that the magnitude should be placed factually.

A central point is the form of application. The risk of blood clots depends strongly on how the oestrogen gets into the body. If it is swallowed as a tablet, it first passes the liver, which can influence the blood clotting and increase the thrombosis risk. If it is, on the other hand, taken up through the skin, it largely bypasses this liver route. According to today's knowledge, estradiol taken up through the skin does not increase the risk of blood clots and stroke to the same extent. This difference between oral and transdermal application is one of the most important advances of the modern hormone therapy, because thereby a central risk can be reduced in a targeted way. Also with the choice of the progestogen there are differences, whereby micronised progesterone appears more favourable in observational data than older synthetic progestogens. From this results today's basic idea of putting the therapy together in such a way that the benefit is preserved but the risks are kept as low as possible through form and choice of active ingredient.

The forms of application at a glance

The HRT is available in various forms that differ in effect, handling and risk profile. Which form fits is decided individually. The following overview shows the common routes in comparison but does not replace medical advice.

The transdermal application of estradiol via patch, gel or spray is today considered by many professional societies the preferred standard option, above all because it bypasses the liver and does not increase the thrombosis risk. A practical advantage is moreover the flexible dosage, since the supplied amount can often be finely adjusted to the need. The oral intake is simple and can be suitable for women under 60 years with low risk. For women who anyway already take several tablets, it is often familiar and uncomplicated but should be critically checked with an increased thrombosis risk. With women with a uterus, additionally a progestogen is needed to protect the lining of the uterus, frequently in the form of progesterone. For purely local complaints such as vaginal dryness, a vaginal application that is hardly taken up into the whole body often suffices. It is therefore considered especially well tolerated and often comes into question also for women for whom a systemic hormone therapy is not suitable. Which combination is the best in the individual case is clarified by the medical practice. Factors such as the age, the time since the menopause, existing complaints, pre-existing conditions and personal preferences flow into the decision, so that in the end an as tailored as possible therapy stands.

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In sum, the hormone replacement therapy is neither a miracle cure nor the risk factor it was long considered. For many women with burdening complaints in the menopause it can clearly improve the quality of life and at the same time protect against osteoporosis, when timing, form and dose are right. The risks are real but mostly smaller than feared and can be further lowered through the choice of the form of application, for example transdermal estradiol. Decisive is the individual, fact-based weighing together with the gynaecological practice, far from blanket fear and exaggerated promises of salvation. This way an emotionally charged topic becomes a sober, personal decision that fits one's own life situation and one's own priorities.