Hormone replacement therapy (HRT) is one of the most discussed topics in perimenopause. For years, many women were afraid of it. Today, it is sometimes presented as a solution for almost everything. The reality sits somewhere in between.

Much of what you read online about HRT in perimenopause comes from the UK and the US. Dutch advice draws on the same research, but its recommendations can differ. This article explains how perimenopause is recognised, why views on HRT differ, how treatment works and what other options exist if HRT isn't right for you.

Perimenopause has no single test

Perimenopause is usually identified from your age, changes in your cycle and your symptoms. A blood test is generally not needed, as hormone levels can change sharply during perimenopause, sometimes from one day to the next [2]. A blood test shows one moment. It can't capture the pattern over time.

The UK's National Institute for Health and Care Excellence (NICE) recommends identifying perimenopause in otherwise healthy women aged 45 and over from symptoms and cycle changes rather than blood tests. For women aged 40 to 45, an FSH (follicle-stimulating hormone) test may sometimes be considered [1].

If your doctor can't confirm perimenopause with a blood test, it doesn't mean your symptoms aren't real. One test simply can't tell the whole story. The same applies to commercial hormone tests that promise a clear answer.

Some women first notice cycle changes, such as periods coming closer together or becoming less predictable. Others notice disrupted sleep, mood changes, anxiety, brain fog, hot flushes or night sweats. Symptoms vary and appear in different combinations.

If several of these sound familiar, make an appointment with your GP. In the Netherlands, your GP (huisarts) is your first point of contact and can refer you to a gynaecologist or another specialist if needed.

Why views on HRT differ

Advice about HRT has changed over the years, and it still differs between countries. Knowing why helps you make sense of what you read.

Much of the concern started with a major study published in 2002: the Women's Health Initiative (WHI). It tested one specific hormone combination, conjugated equine oestrogen with medroxyprogesterone acetate, and found higher rates of breast cancer, heart disease, stroke and blood clots in women taking it. The participants were 63 years old on average, generally more than ten years past the typical age of menopause [3].

That detail was lost in the headlines. The message became that hormones cause cancer. Prescriptions fell, and many women went through menopause without considering treatment that might have helped.

Since then, the evidence has been read more carefully. In February 2026, the US Food and Drug Administration (FDA) removed statements about cardiovascular disease, breast cancer and probable dementia from the boxed warnings of a first group of six hormone therapy products. The warning about endometrial cancer remains for oestrogen-only products [4]. These changes apply to the US. In the Netherlands, medicine information follows European and Dutch regulations, which have not changed in the same way.

Why do guidelines still differ? They look at much of the same research but weigh benefits and risks differently.

The US-based Menopause Society states that for healthy women under 60, or within ten years of menopause, with bothersome symptoms and no medical reasons to avoid treatment, the benefits of HRT generally outweigh the risks [5].

The Dutch guideline for GPs, the NHG-Standaard De overgang, also recognises HRT as an effective treatment for menopausal symptoms, but takes a more cautious approach. It considers the risks acceptable mainly for women with severe hot flushes, for up to five years, and discourages longer use. It estimates that after three years of treatment, HRT causes around two extra cases of breast cancer and two extra blood clots per thousand women. It no longer recommends stopping after six months, as symptoms often continue for several years [6].

Neither approach is wrong. This difference may explain why your GP sounds more cautious than British or American articles. Ask how the Dutch guideline applies to your situation. For more specialised advice, you can ask for a referral to a gynaecologist or a menopause clinic (overgangspoli).

HRT is primarily a treatment for menopausal symptoms. The US Preventive Services Task Force advises against using it solely to prevent long-term conditions such as heart disease or fractures [7]. It is also not an anti-ageing treatment, as the next section explains.

What HRT is, and what it isn't

HRT replaces some of the hormones your body makes in lower or less predictable amounts during the menopause transition. That makes it different from the contraceptive pill.

HRT and the pill have different purposes. Most combined contraceptive pills contain ethinylestradiol, a synthetic oestrogen, with a progestogen, and they prevent ovulation. HRT usually contains oestradiol, the same oestrogen your ovaries make, at doses designed to replace declining levels.

For some women, the pill may still be the better choice during perimenopause, for example with endometriosis, where hormonal changes can affect symptoms. Hormonal treatments, including the combined pill, are among the recommended options for endometriosis pain [8].

What matters is understanding why a treatment is recommended, how long you may need it and what the alternatives are. You deserve clear answers before you decide.

Choosing HRT involves three decisions.

1. Which hormones?

Oestrogen is the main hormone in HRT. It can reduce hot flushes and night sweats, relieve vaginal symptoms and help protect against bone loss [1, 5].

If you still have your uterus, oestrogen is usually combined with a progestogen. Oestrogen alone can thicken the uterine lining and raise the risk of endometrial cancer, and the progestogen protects against this.

After a hysterectomy (removal of the uterus), oestrogen-only HRT is usually an option [1]. If you have a history of endometriosis, combined HRT may still be advised. Discuss this with your specialist [8].

You may also hear the terms "body-identical" and "bioidentical". They describe hormones with the same molecular structure as your body's own, such as oestradiol and micronised progesterone. They are not the same as custom-compounded hormones. A 2020 report by the US National Academies found insufficient evidence to support custom-compounded bioidentical hormone therapy and raised concerns about incorrect dosing when products aren't made to standard specifications [9]. Approved body-identical products are widely available.

2. How is it taken?

Oestrogen comes as a tablet, or as a patch, gel or spray absorbed through the skin. Tablets pass through the liver before reaching the bloodstream. Skin-based forms bypass this first pass.

A large study in The BMJ found that oral HRT was linked to a higher risk of blood clots, while oestrogen through the skin was not [10]. Since its 2022 update, the Dutch guideline makes skin-based oestrogen an option for all women. In the Netherlands, the progestogen is usually a tablet, so if you still have your uterus and use a patch or gel, you'll typically take a progestogen tablet alongside it [6]. If your doctor suggests one form over another, ask why.

3. What schedule?

If you still have periods, you'll usually take oestrogen every day and add a progestogen for part of each month. This sequential or cyclical HRT usually brings a regular withdrawal bleed. After menopause, many women switch to continuous combined HRT, taking both hormones every day to avoid regular bleeding [1].

What HRT doesn't do

HRT is not a weight-loss treatment. Midlife often brings changes in body composition, including more fat around the abdomen. HRT doesn't replace the habits that support your health at this stage: regular movement, strength training, nutritious food and enough sleep.

It won't remove wrinkles or reverse sun damage either. A four-year randomised trial found no significant difference in facial wrinkles between women on HRT and those on a placebo [11]. Oestrogen can also worsen pigmentation in women prone to melasma [12]. If this concerns you, mention it to your doctor or dermatologist.

When HRT is not an option

Systemic HRT isn't suitable for everyone. If it isn't recommended for you, other options exist.

Reasons to avoid systemic HRT can include certain hormone-sensitive cancers, a history of blood clots, stroke or some types of heart disease, and unexplained vaginal bleeding. Whether HRT suits you depends on your medical history and is a decision for you and your GP or specialist.

A risk factor doesn't automatically rule out every form of hormone treatment. Women with a BRCA1 or BRCA2 gene variant, for example, may have their ovaries removed to lower their risk of ovarian cancer, which brings on early menopause. A meta-analysis of three studies found no significant increase in breast cancer risk from HRT after this surgery in women without a previous breast cancer [13]. The decision should always be made individually with a specialist.

The Dutch guideline also notes that stress-reduction approaches may help some women with hot flushes [6].

Hormone-free prescription options

Some prescription medicines help with hot flushes and night sweats without hormones. Fezolinetant and elinzanetant act on brain pathways involved in regulating body temperature, which become more sensitive as oestrogen falls. Both are approved in the EU and reduced the frequency and severity of hot flushes in clinical trials [14, 15].

Elinzanetant is also approved in the EU for hot flushes caused by hormone-blocking treatment for breast cancer [15]. Fezolinetant requires liver function tests before and during treatment, because of a risk of liver injury [16]. Insurance coverage for these medicines can vary, so check with your insurer.

Options for vaginal symptoms

Low-dose vaginal oestrogen is an option for vaginal dryness, discomfort during sex and some urinary symptoms. It works locally, so far less oestrogen enters the bloodstream than with systemic HRT [17]. The Dutch guideline also mentions vaginal moisturisers and creams with hyaluronic acid [6]. If you've had breast cancer, discuss vaginal oestrogen with your oncologist first [17].

Preparing for your appointment

These questions can help you prepare for a conversation with your GP:

• Do my symptoms and cycle changes fit perimenopause? Why, or why not?
• Is HRT suitable for me, given my medical history?
• If so, which hormones, dose and form would suit me, and for how long?
• If not, what other options do I have?
• Would a referral to a gynaecologist or menopause clinic help?

You deserve clear answers about your health. If your concerns aren't being addressed, asking for a second opinion is reasonable.

In short

Perimenopause is usually recognised from your age, cycle changes and symptoms, not from a blood test. HRT in perimenopause replaces hormones your body makes in lower or less predictable amounts, and it works differently from the contraceptive pill. Early fears about HRT were shaped largely by a study of older women using one specific hormone combination. Today, UK, US and Dutch guidelines all recognise HRT as an effective treatment for menopausal symptoms, but they weigh the risks differently. The Dutch guideline is more cautious, focusing on severe hot flushes and use for up to five years. If HRT isn't suitable, hormone-free prescription medicines and low-dose vaginal oestrogen may be alternatives. Your GP is the place to start.

FAQ

Can a blood test tell me if I'm in perimenopause? Usually not if you're over 45. Hormone levels change throughout perimenopause, so one test can't show the full picture. UK guidance recommends identifying perimenopause in this age group from symptoms and cycle changes instead [1].

Why does my GP seem more cautious than what I read online? Much online information follows UK or US guidance. The Dutch guideline also recognises HRT as effective, but considers the risks acceptable mainly for women with severe hot flushes and for up to five years [6]. Ask your GP how this applies to you, or whether a referral would help.

Is HRT safe? It depends on your age, medical history, symptoms and the type of HRT. The Dutch guideline estimates around two extra cases of breast cancer and two extra blood clots per thousand women after three years of use [6]. The US Menopause Society considers the benefits greater than the risks for most healthy women under 60 with bothersome symptoms [5]. Your GP can help you weigh this for yourself.

Are patches safer than tablets? For blood clots, research suggests they may be. A large study found a higher risk with oral HRT but not with oestrogen through the skin [10]. The Dutch guideline now makes skin-based oestrogen an option for all women [6].

What can I do if I can't take HRT? Fezolinetant and elinzanetant are hormone-free prescription medicines approved in the EU for hot flushes and night sweats [14, 15]. Low-dose vaginal oestrogen and vaginal moisturisers can help with vaginal symptoms [6, 17]. Discuss which options suit you with your GP.

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This article is for informational purposes only and is not medical advice.

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Sources

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• [2] Santoro N, Roeca C, Peters BA, Neal-Perry G. The menopause transition: signs, symptoms, and management options. Journal of Clinical Endocrinology and Metabolism. 2021.

• [3] Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA. 2002.

• [4] US Food and Drug Administration. FDA approves labeling changes to menopausal hormone therapy products. 2026.

• [5] The North American Menopause Society. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022.

• [6] Nederlands Huisartsen Genootschap (NHG). NHG-Standaard De overgang. 2022.

• [7] US Preventive Services Task Force. Hormone therapy for the primary prevention of chronic conditions in postmenopausal persons: US Preventive Services Task Force recommendation statement. JAMA. 2022.

• [8] Becker CM, Bokor A, Heikinheimo O, et al. ESHRE guideline: endometriosis. Human Reproduction Open. 2022.

• [9] National Academies of Sciences, Engineering, and Medicine. The clinical utility of compounded bioidentical hormone therapy: a review of safety, effectiveness, and use. The National Academies Press. 2020.

• [10] Vinogradova Y, Coupland C, Hippisley-Cox J. Use of hormone replacement therapy and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases. The BMJ. 2019.

• [11] Owen CM, Pal L, Mumford SL, et al. Effects of hormones on skin wrinkles and rigidity vary by race/ethnicity: four-year follow-up from the ancillary skin study of the Kronos Early Estrogen Prevention Study. Fertility and Sterility. 2016.

• [12] Ogbechie-Godec OA, Elbuluk N. Melasma: an up-to-date comprehensive review. Dermatology and Therapy. 2017.

• [13] Marchetti C, De Felice F, Boccia S, et al. Hormone replacement therapy after prophylactic risk-reducing salpingo-oophorectomy and breast cancer risk in BRCA1 and BRCA2 mutation carriers: a meta-analysis. Critical Reviews in Oncology/Hematology. 2018.

• [14] Lederman S, Ottery FD, Cano A, et al. Fezolinetant for treatment of moderate-to-severe vasomotor symptoms associated with menopause (SKYLIGHT 1): a phase 3 randomised controlled study. The Lancet. 2023.

• [15] European Medicines Agency. Lynkuet (elinzanetant): EPAR medicine overview. 2025.

• [16] European Medicines Agency. Veoza (fezolinetant): direct healthcare professional communication on the risk of drug-induced liver injury. 2025.

• [17] The North American Menopause Society. The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause. 2020.