Should I take HRT? Understanding hormone therapy for surgical menopause

Hormone replacement therapy (HRT) is the cornerstone of care for women who experience surgical menopause before the natural age of menopause. When both ovaries are removed, levels of oestrogen, progesterone and testosterone fall abruptly, triggering symptoms that can be physically and emotionally overwhelming. Beyond symptom control, HRT also helps to protect long-term health — safeguarding bones, heart and brain function — and should almost always be offered to you unless there is a clear medical reason not to.

Why HRT matters after surgical menopause

The evidence is clear: early or premature loss of ovarian hormones increases the risk of heart disease, osteoporosis, cognitive decline, depression and sexual dysfunction. In 2024, a UK audit found that only 4.8% of women received HRT after bilateral salpingo-oophorectomy (BSO) despite national guidance recommending it until the average age of natural menopause (around 51).

Replacing the hormones the ovaries would normally produce is therefore essential for health as well as quality of life. The goal is to restore hormone levels to those typical for a premenopausal woman — not the lower doses used in older post-menopausal women.

What do the guidelines say?

Both NICE (NG23, 2015) and the British Menopause Society recommend that women who enter menopause early through surgery should be offered systemic HRT unless contraindicated, and that treatment should continue until at least the age of 51. The Royal College of Obstetricians and Gynaecologists (RCOG, 2021) echoes this, stating that HRT after risk-reducing or benign BSO improves quality of life and mitigates bone and cardiovascular risk.

For those who have had hormone-sensitive cancers such as oestrogen-receptor-positive breast cancer, systemic HRT is usually avoided, but women with triple-negative or receptor-negative disease may be considered on a case-by-case basis with oncology input.

What options are there for HRT, and how do you know what to choose?

The type of HRT depends on whether your womb (uterus) has been removed:

• Oestrogen-only HRT – for women who have had a hysterectomy.

• Combined oestrogen and progesterone HRT – for women who retain their womb or cervix, as progesterone protects the uterine lining from thickening.

• Testosterone – can be added to improve energy, concentration and libido, especially after ovary removal.

HRT can be taken in several forms. Oestrogen is the main component, delivered either through the skin as a patch, gel or spray (transdermal HRT) or taken as a tablet. Transdermal options are preferred because they’re safer for most women, avoid the liver, and allow flexible dosing — important after surgical menopause when higher levels may be needed.

If you have retained your womb or cervix, or have a history of endometriosis, progesterone – usually body-identical Utrogestan, or a Mirena coil – must be added to protect the uterine lining. Some women who’ve had a hysterectomy also choose to take micronised progesterone for its calming and sleep-supportive effects, or for potential breast-protective benefits.

Testosterone may be added to restore energy, mood and libido, while local vaginal oestrogen (creams, pessaries or rings) can relieve dryness, irritation and urinary symptoms. It can be prescribed “off-label” by clinicians, but some GPs are still reluctant to offer it which leaves many women seeking specialist menopause care privately.

The right combination is individual and should be reviewed regularly to ensure both symptom control and long-term health protection.

How to understand dosage and the importance of absorption

Many women who go through surgical menopause require higher-than-licensed doses to achieve adequate symptom control and bone protection. A 2025 UK study measuring blood levels of estradiol in over 1,500 women found wide variation in absorption, with one in four women using the highest licensed transdermal dose still recording sub-therapeutic hormone levels.

This means that for some, “off-label” dosing is not overtreatment — it’s simply the amount needed to restore normal premenopausal levels. Blood tests can help identify poor absorption, guiding clinicians to tailor treatment rather than withdraw it.

What if HRT isn’t suitable for me?

For those of us with oestrogen-receptor-positive breast cancer, active liver disease or a history of certain thromboses, systemic HRT may not be safe. However, local vaginal oestrogen can still be used to ease dryness, pain and urinary symptoms, as it is understood to have negligible systemic absorption. Non-hormonal options such as SSRIs, gabapentin, and clonidine can also help vasomotor symptoms, though they are less effective than hormone replacement therapy.

What should I expect in terms of monitoring and follow-up?

Women who have surgical menopause should be reviewed within six to twelve weeks of surgery, and regularly thereafter to assess symptom control, mood, sexual function and bone health – although we know in many areas, this isn’t happening routinely.

Bone density scanning (DEXA) is recommended within the first two years if HRT isn’t used or symptoms suggest deficiency. Blood tests for estradiol can help check whether transdermal treatment is adequately absorbed.

Should I continue HRT after
I’m 51?

Once a woman reaches the natural menopause age, the decision to continue or taper HRT becomes personal. Some choose to continue long term for symptom relief and protective benefits, balancing potential risks such as clotting and breast cancer (which remain very low with transdermal oestrogen and micronised progesterone).

The importance of individualised care

Surgical menopause requires individualised, proactive care — not the “wait and see” approach too many women still experience. HRT is not just symptom relief; it’s essential replacement therapy for women who lose their ovaries early. The dose, formulation and duration should all be personalised, guided by how a woman feels, not by arbitrary limits on a label.

Every woman deserves informed discussion, evidence-based treatment and compassionate follow-up so that recovery from surgery also means recovery of health, strength and self.