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HRT: Side effects

Side effects of HRT.

Many women experience side effects in the first few months of taking HRT. If problems persist after 3 months of therapy, a change of therapy should be considered.


HRT taken in the early stages of ovarian decline (the perimenopause), is usually in the form of daily estrogen with cyclical progestogen (sequential therapy) which induces a monthly bleed in about 85% of women. Heavy or irregular bleeding in the first few months of treatment is quite common and usually settles. If not, the HRT can be changed and consideration given to investigation. For women who have had at least 1 year without periods, or who are aged 54 or over, period free (continuous combined) HRT can be used, consisting of daily estrogen and daily progestogen. With period free HRT the endometrium (lining of the womb) should remain thin and although some bleeding within the first 6 months is quite common, bleeding should then cease. Investigation is recommended if bleeding persists beyond 6 months, or if bleeding occurs at a later stage.

Fluid retention

Fluid retention is very closely related to weight gain but can be aggravated by HRT. Fluid retention can cause bloating (particularly at night), ankle swelling, facial swelling, headaches, leg discomfort and breast tenderness. If possible, losing weight can help, but sometimes the dose or type of HRT may be changed if the problem persists beyond the first few months of treatment. Breast tenderness may be helped by oil of evening primrose.

Weight gain

This is often greatly feared but in fact weight gain around the time of the menopause is very common and HRT does not generally cause significant further weight gain.

Premenstrual syndrome

PMS type symptoms can occur with HRT when the progestogen is taken cyclically (sequential therapy). These symptoms can often be helped by changing the preparation to one using a different type or route of progestogen. PMS often worsens in the few years before the menopause due to the increasingly fluctuating hormone levels and some types of HRT may reduce the symptoms. For more information about PMS visit


Nausea associated with HRT can be reduced by taking tablet HRT at night with food instead of morning or by changing from tablet to another route.

Side effect management table




Breast tenderness, enlargement
Leg cramps
Headache »

For breast symptoms »




Evening Primrose oil, starflower oil or reduce dose of estrogen



For gastrointestinal symptoms » Take with food or change route
Other side effects » Change type or route




PMS type symptoms
Breast tenderness
Lower abdominal pain
Depressed mood
Acne/greasy skin
Headache »

Change progestogen. »

Testosterone derived:
Norethisterone, Norgestrol, Levonorgestrel.
Progesterone derived:
Medroxyprogesterone, Dydrogesterone, Drospirenone.

Change route. » Progestogen by Mirena or vaginal gel avoids side effects.
If postmenopausal, change to continuous combined or tibolone. »
Avoids symptoms of progestogen fluctuation.

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