Coming Off HRT
Various approaches can help to manage menopause symptoms, including lifestyle changes, non-hormonal pharmacological or non-pharmacological therapies, and hormone replacement therapy (HRT). Every woman should be allowed to make an informed choice about the best option for her, after receiving factual evidence-based information about the pros and cons of each approach.
This article was included in issue 105 (Summer 2025) of The Menopause Exchange newsletter.
Currently, HRT remains the most effective medical treatment for menopause symptoms, improving quality of life. It’s strongly recommended for women with an early or premature menopause until the age of the natural menopause, after which it’s their choice whether or not they continue with HRT, depending on the benefits versus risks in their unique situation.
For women going through the menopause after 45, HRT also provides bone and cardiovascular protection (if it’s started within 10 years of experiencing the menopause) alongside symptom suppression. All these benefits need to be balanced against side-effects, such as breast pain, irregular bleeding or headaches and the slightly increased long-term risks of blood clotting and ovarian, uterine and breast cancers depending on the type of HRT.
For most women under 60 with menopause symptoms and within 10 years of their menopause onset, the benefits of HRT outweigh the risks. Transdermal HRT and body-identical oestradiol combined with progestogens such as micronised progesterone and dydrogesterone are the preferred formulations in women over 60 or those with medical risk factors.
Stopping HRT
The decision to come off HRT depends on a woman’s choice, nature of her symptoms and medical background. Ongoing benefits for symptom control and bone and cardiovascular health, and potential future risks, should be part of this discussion, which should take place annually with your healthcare team. You may decide to stop HRT once you reach a certain age or your menopausal symptoms start to ease. In some situations, you may have to stop HRT abruptly, such as following the diagnosis of hormone-dependent cancer such as breast cancer.
Reducing HRT
There’s currently no medical consensus about the best approach to discontinue HRT. You need to work with your healthcare team to ensure you’re doing this safely and monitor any symptoms that may recur. If you decide to stop HRT, you’ll be advised to reduce the dosage gradually over three to six months. Stopping abruptly will likely cause some menopause symptoms to return, such as hot flushes, night sweats, joint pains and sleep disruption. This happens in around 40 to 50% of women.
If your symptoms return and persist for more than two to three months, you may choose to go back on a low dose of HRT to manage your symptoms or consider lifestyle or non-hormonal therapies. Women in their 60s often need smaller doses of oestrogen than younger women, so use lower-dose preparations.
Various approaches are recommended when it comes to decreasing oestrogen gradually. These include using lower strength tablets, patches or fewer pumps/sprays every day, cutting patches or tablets to use very low doses, and using HRT preparations on alternate days. No one size fits all so it’s important that you discuss the pros and cons of each approach with your healthcare professional before choosing the one that best fits your situation.
It typically takes a few days to a couple of weeks for hormones to be cleared from your body and their effects to disappear. This may depend on the HRT preparation, how long you were taking it, and individual factors such as metabolism. Oral HRT is generally cleared more quickly than HRT injections or patches. When coming off cyclical HRT, it’s ideal to finish the monthly course of oestrogen and progesterone and have the withdrawal bleed before stopping. When coming off continuous combined HRT, you can stop the preparation at any time. Some women have a withdrawal bleed after their last dose.
Symptom return
If you notice that symptoms such as hot flushes, night sweats, mood swings or vaginal dryness return after stopping HRT, these may be due to oestrogen withdrawal. This is a strong indicator that HRT was effectively suppressing your symptoms. Some women stop HRT and don’t get systemic symptoms such as flushes or sweats but still continue to experience vaginal and bladder symptoms. Vaginal oestrogen pessaries, creams or ring can be used safely without any risks for as long as you need to, even when systemic oestrogen may not be required.
Since stopping HRT also includes coming off progesterone, some women may experience symptoms such as mood fluctuations, anxiety and insomnia. These symptoms will usually subside over a few days to a few weeks. If they persist, you may need to consider going back on HRT.
Mirena coil removal
If the Mirena coil is used as the progestogen part of HRT, it should be removed or replaced after five years. It may need to be replaced earlier if you have persistent breakthrough bleeding before five years. If the Mirena is solely used for contraception, it’s now licensed for eight years. Mirena coil removal is typically performed in an outpatient setting using a speculum to visualise the cervix and then forceps to gently grasp the threads of the coil and pull it out. This procedure is generally well tolerated, but some women have cramping or bleeding for a few days afterwards. If the threads of the coil aren’t visible or the coil has been displaced or embedded in the uterine muscle, you’ll need a hysteroscopy procedure to remove the coil.
About the author
Dr Vikram Talaulikar is associate specialist in reproductive medicine at University College London Hospital (UCLH) and a BMS-certified menopause specialist at two private clinics in London.
Created Summer 2025
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