How do I know which (and how much) HRT is for me?

When your ovaries are removed, the loss of hormones is instant and absolute. This sudden change can trigger severe menopausal symptoms and carry long-term risks to bone, heart, and brain health if untreated.

Hormone replacement therapy (HRT) is usually recommended for all eligible women who enter surgical menopause before the average natural menopause age (around 51). But HRT isn’t one-size-fits-all, and understanding the types, doses, and delivery routes can help you have more informed conversations with your clinician or GP, and make sure your treatment is working effectively.

A quick note before we start: MHT (menopausal hormone therapy) is becoming more frequently used in the menopause space. However, we specifically use HRT (hormone replacement therapy) as it adequately acknowledges the need for therapeutic replacement due to the hormonal deprivation experienced by women in surgical menopause.

Oestrogen: the foundation of HRT

Oestrogen (specifically 17β-estradiol) is the most important hormone to replace after surgery. It alleviates vasomotor symptoms such as hot flushes and night sweats, improves sleep, protects bone density, and supports cardiovascular and cognitive health. For women who’ve had their uterus removed, oestrogen can be used alone; those who still have a womb, or have retained the cervix with some endometrial tissue, need to take progesterone too for endometrial protection. Women who have a history of endometriosis and choose HRT will be offered combined therapy too.

Transdermal oestrogen – through patches, gels or sprays – is generally preferred because it bypasses the liver and carries a lower risk of blood clots and stroke than oral tablets. However, as shown by Glynne et al. (2025), absorption varies dramatically between individuals: around one in four women using licensed doses of transdermal oestrogen had blood estradiol levels below 200 pmol/L, which is considered sub-therapeutic. That means some women simply don’t absorb enough through the skin to reach symptom-relieving or bone-protective levels.

If you still feel unwell despite using the “standard” patch or gel, you may need your estradiol levels checked. Poor absorption can be managed by adjusting the dose, changing formulation (for example, switching from patch to gel or spray), or applying in a different area of the body. The right dose is the one that relieves your symptoms and brings your blood oestrogen into the physiological range—typically between 220 and 550 pmol/L.

Progesterone: essential protection and more

If you still have a uterus, part of the cervix with residual endometrial tissue, or a history of endometriosis, progesterone must be included to prevent the lining thickening and reduce cancer risk. Natural micronised progesterone (Utrogestan in the UK) is usually better tolerated than synthetic progestogens, with fewer mood-related side effects. It can also support sleep and calm the nervous system.

Progesterone can be taken orally, vaginally, or via a Mirena coil (which releases levonorgestrel directly into the uterus). For women using higher or off-label doses of oestrogen due to poor absorption, the balance between oestrogen and progesterone should be reviewed, but higher progesterone isn’t always necessary if blood estradiol levels are still within a normal range. It’s important to discuss this with your clinician or specialist.

Testosterone: restoring strength, mood, and libido

Testosterone is often overlooked, yet it plays a vital role in energy, mood, cognitive clarity, muscle maintenance, and sexual function although it’s important to note that in the UK, testosterone is not licensed for women. Women produce around three times more testosterone than oestrogen before menopause, and its loss after oophorectomy can be profound.

Evidence for testosterone therapy in women is growing. Clinical research supports its use for improving sexual desire and satisfaction, and many women report additional benefits to mood, energy, and quality of life. However, large-scale studies are still limited, and more research is needed to fully understand its wider effects. Women report that supplementing testosterone can significantly improve quality of life, particularly for women struggling with fatigue, brain fog, or loss of sexual desire despite adequate oestrogen.

Until recently, women in the UK could only access testosterone prescribed off-licence through products designed for men, such as Testogel or Tostran, which require careful dose splitting. In 2025, the MHRA approved AndroFeme – the first testosterone cream specifically formulated and licensed for use by women in the UK. The product is expected to become available in 2026, offering a body-identical, easy-to-apply option that should improve consistency and safety in prescribing.).

Blood levels should be monitored to stay within the premenopausal female range. It can take several months to feel the full benefit, but many women report marked improvement once it’s added to their regimen.

Getting the balance right

Hormone therapy after surgical menopause should aim to replicate what your body would have produced naturally, at least until the average menopause age. Evidence from Faubion et al. (2015) and Sarrel et al. (2016) shows that replacing these hormones reduces long-term risks of heart disease, osteoporosis, and cognitive decline. Yet the Cashell et al. (2024) audit found that only 4.8% of eligible premenopausal women received HRT after ovary removal in UK hospitals – an alarming gap in care.

If you’re already on HRT but still feel unwell, it doesn’t necessarily mean the therapy isn’t right for you – it might just not be the right dose for you. Request a review of your dosage, check absorption, and discuss whether testosterone could be beneficial.

Monitoring and follow-up

Once you start HRT, you should be reviewed after 3 months and then at least annually. Blood tests can help tailor treatment, especially if symptoms persist or your absorption pattern is unclear. Your clinician should also monitor your cardiovascular risk factors, bone density, and mental wellbeing as part of your long-term care plan.

It can be helpful to express your desire at being proactive with your HRT plan and that you intend to follow-up with a future appointment to review, and that’s exactly what we would recommend. You deserve to feel well, and in control of your health.