The rise of HRT prescribing in the UK
Hormone replacement therapy (HRT) is the first-line treatment for menopausal vasomotor symptoms (VMS) such as hot flushes and night sweats in the absence of contraindications.1 Recently, there has been increasing interest in menopause in the UK, driven in part by the media and campaigners, resulting in more women seeking advice from healthcare professionals (HCPs) and large increases in HRT prescribing. In England the estimated number of women prescribed HRT has increased since 2015, with a steeper increase since 2020. The estimated number of identified patients prescribed HRT increased by 12%, from 2.3 million in 2022/2023 to 2.6 million in 2023/2024.2 Similar increases have been seen in transdermal HRT preparations in Wales.3 Interestingly other countries have not shown such rises in prescribing.4
The Women’s Health Strategy for England reported that only 9% of 100 000 responders to the ‘Women’s Health — Let’s talk about it’ survey said that they had sufficient information about menopause and its treatment.5 To improve this, we need to understand the complexities of decision making around HRT and develop individualised discussion and decision aids to help women and their HCPs navigate treatment decisions about starting and stopping HRT.1,6
When to stop — informed decision making about the duration of HRT use
The optimal duration of HRT use is unknown and may differ depending on age, reproductive stage (use in perimenopause or years since menopause), severity of symptoms, concomitant medical conditions (such as osteoporosis), and individual risk of developing future conditions. Although HRT is prescribed for the management of menopausal symptoms it does have benefits and risks for longer-term health. These include a reduction in risk of osteoporosis but an increased risk of breast and ovarian cancer, as highlighted in the National Institute for Health and Care Excellence’s (NICE) 2024 published discussion aid.1
NICE suggests that when starting, and at subsequent reviews, HCPs should discuss the duration of HRT treatment. They advise that it should be explained to women that symptoms may return when HRT is stopped and that treatment may be restarted if necessary.1 How best to individualise advice on duration of HRT, as well as the best way to discontinue it when a woman decides the time is right, remains unknown. This was highlighted by women and stakeholders as a key research priority in the recently published James Lind Alliance Menopause Priority Setting Partnership.7
Why women stop HRT
A study in Finland in 2002, around the time of the Women’s Health Initiative trial and the Million Women Study (2002), found that women’s decisions to discontinue were affected not only by reporting of the trials outcomes (which showed an increased risk of breast cancer in combined HRT users) but also a desire to stop medication due to side effects of HRT and fear of cancer.8 Reasons may differ depending on a woman’s age,9 and it is likely that the counselling women receive from their HCP influences their decision to continue or discontinue HRT, given that it also affects their decision to start it.10
Reasons for wanting to continue or discontinue HRT are seldom recorded. Recent research from Wales suggests that discontinuation is higher in transdermal than oral HRT preparations.3 In our 2025 systematic review (awaiting publication) we found that for women initiated on HRT the mean duration of HRT use was 5.4 ± 2.8 years.11 However, the evidence was not UK-specific. Given the rapid change in HRT uptake in England and Wales there is a need to understand current decision-making around how and why women discontinue HRT as well as commence and continue it.
How to stop — the problems with HRT discontinuation
It is common to consult a HCP when stopping medication and many medications are problematic to stop. Discontinuing HRT is commonly associated with resurgence of menopausal symptoms (>40% of women that stop), particularly VMS.12 Even women who start HRT without VMS may experience symptoms when stopping,13 suggesting that HRT withdrawal may be the trigger for VMS.
Resurgent symptoms can be problematic, affecting quality of life, ability to work, and relationships, and lead to over 25% of women who stop HRT restarting treatment.14 This can lead to a cycle of stopping/restarting and potentially increasing risks associated with longer duration of use. In addition, restarting HRT at an older age carries elevated risks of CVD, stroke,15 and dementia.1 Stopping and restarting HRT may require additional HCP appointments, requires further prescriptions, potentially impacting already strained HRT supplies, and has cost implications for the NHS and the patient.
Abrupt discontinuation or taper?
Except where there has been a new diagnosis that contraindicates continuing use of HRT (such as hormone-sensitive breast cancer), women discontinuing HRT can choose to discontinue either abruptly or gradually. Tapering is commonly advised to mitigate resurgent VMS but its effectiveness compared with abrupt discontinuation is unknown. While a tapering regimen necessitates taking HRT for longer (greater treatment cost short-term), it might reduce the severity of resurgent symptoms, overall healthcare costs, and result in better quality of life in the longer-term.
The NICE guideline on menopause (2015) asked: ‘what is the effectiveness of an abrupt HRT discontinuation strategy compared with a tapered strategy?’ They found four randomised control trials comparing abrupt discontinuation with tapered .16–19 Conducted in Brazil, Israel, Sweden, and Turkey, the studies ranged in size (60–91 participants) and produced inconsistent findings. Tapering regimes all involved oral HRT and varied widely. Instruments to measure outcomes ranged from manual diaries of VMS, the Blatt–Kupperman menopausal index,17 and the Greene Climacteric score.18 One study reported that VMS were decreased in the tapered versus the abrupt method,17 one found no difference,16 and one that VMS were significantly higher by the end of tapering compared with those who stopped abruptly 6 months prior.18 NICE concluded that the quality of evidence was low to very low with high risk of bias. Subsequently they were unable to give clinical guidance regarding the best way to discontinue.
The need for future research
None of the randomised control trials described above were pragmatic nor represented the reality of current practice, namely that women are taking either oral or increasingly transdermal oestrogen preparations with different progestogen types, and start discontinuation from different oestrogen doses. Transdermal oestrogen is first line for women with increased thromboembolism risk (BMI >30 kg/m2)1 and is reportedly easier to taper then oral preparations, as it is available in more varied doses, making reduction easier.
There is an evidence gap relating to the experiences of women discontinuing HRT in the UK, the decisions women and clinicians make when discontinuing and restarting HRT, and the best way to discontinue HRT to minimise resurgent VMS and the impact on health care. This uncertainty should be discussed when HRT is started and again when discussing a discontinuation strategy.
Only by addressing this uncertainty with pragmatic trials using contemporary HRT preparations will we be able to provide the evidence women need to reduce their risk of resurgent symptoms when stopping treatment, reduce the need to restart, and have better quality of life during the menopause transition.
Footnotes
Provenance Commissioned; not externally peer reviewed.
Competing interests Dr Sarah HIllman received sponsorship by the pharmaceutical company Besins Healthcare to attend the International Menopause Society Congress 2024. All other authors have declared no competing interests.
- © British Journal of General Practice 2025
