For uncomfortable and sometimes debilitating physical and emotional menopause symptoms, hormone replacement therapy (HRT) is the go-to relief for many women. However, no one really talks about what happens when you don't want to take it anymore.
You may be on it - or thinking about taking HRT - and wondering how long you can take it for and what'll happen after you stop. Will menopause symptoms come back?
Coming off HRT can be a complex decision, says Dr Aarthi Sinha, GP and menopause expert, and the effects may not be the same for everyone. "I always review patients regularly in practice to assess if they still need the HRT and how they feel about continuing it. Women can certainly try coming off HRT, but I find that it is important to have a detailed conversation first so that they be adequately supported in doing so."
What happens when you come off HRT?
1. Symptoms may come back
The main side effect of coming off HRT is a return of the symptoms that have many women being prescribed hormone replacement therapy in the first place, says Dr Sinha. "Common symptoms include hot flushes and night sweats. These are caused by the lack of oestrogen in the perimenopause and post-menopause phase," she explains. "HRT contains oestrogen, which replenishes the body’s levels, resulting in improved symptoms. However, once the HRT and therefore oestrogen is stopped, these symptoms can often recur."
For this reason, fellow menopause specialist Dr Susanna Unsworth recommends coming off HRT slowly if you do decide to come off it. "I recommend gradually reducing the oestrogen element (if taking progesterone, keep this the same). If symptoms remain controlled, HRT can be stopped (including progesterone)," she says.
2. You might get new symptoms
Many women choose to take HRT earlier rather than later in perimenopause, meaning some breeze through the transition with few symptoms. However, as the doctors have noted, if you stop the therapy then symptoms may appear for the first time.
"Staying on HRT doesn't delay menopause symptoms," explains Dr Unsworth. "They resolve in the background with the therapy bridging the time it takes for your body to adjust."
3. Your mood might change
Equally, some women find they struggle with mood swings and low mood after coming off HRT, says Dr Sinha. "This can significantly affect quality of life, and again, it's the lack of oestrogen in the body once HRT is stopped that's causing this," she explains.
4. You might experience body aches
Oestrogen and progesterone stimulate bone formation, slow bone resorption, and help maintain bone density, so when the body stops receiving these hormones, many women experience some generalised aches and pains with fatigue and low energy when they stop HRT, Dr Sinha says.
"These levels are replaced with HRT and stopping it means that often these symptoms can recur as the levels drop again," she says.
Similarly, these hormones help protect against conditions like osteoporosis - a condition that causes the bones to become fragile and increases the risk of fractures. Stopping HRT raises this risk again.
5. Lifestyle changes may be needed
Often when we discuss HRT, it's an 'all or nothing' approach, when actually, many doctors advocate for a double or even triple-thronged approach to dealing with menopause symptoms. So, whether you choose to stay on HRT or come off the medication, you may need to make lifestyle changes.
For example, you might decide to use one of the alternatives to HRT alongside lifestyle changes like exercise and drinking less alcohol, all of which have been found to ease symptoms.
6. You might want to consider alternatives
If you decide to come off HRT, you may want to think about other options, given that there's no guarantee symptoms will disappear if you do. Along with lifestyle changes, there's evidence that cognitive behavioural therapy (CBT) in menopause can make a big difference, for example. This can help ease symptoms like low mood, night sweats, insomnia in menopause, and calm hot flushes.
"There are also other medications that can be used to treat hot flushes – such as selective serotonin reuptake inhibitors (SSRIs) and oxybutynin, along with a new medication called fezolinetant. These don’t have all the benefits of HRT, but could help if someone has to stop sooner than planned," says Dr Unsworth.
Whatever you decide, speak to your doctor first.
Do you have to stop HRT at some point?
While most people find their menopause symptoms improve with age, it's a myth that all women have to stop HRT after a fixed number of years. If you continue to experience menopause symptoms, are under 60 years old, and are not at high risk of breast cancer or blood clots, NHS advice is that the benefits of it are likely to outweigh any risks.
"There’s no limit on the duration of taking HRT, but no ideal length of treatment either – it’s individual," says Dr Unsworth. "Bone health, cardiovascular health and potentially cognitive function may be improved with longer-term use."
