Hormone replacement therapy for menopause?

Can hormone replacement therapy (HRT) really improve your quality of life during menopause – and what are the risks? DR SRIRAM NARAYANAN, Senior Consultant Vascular Surgeon at The Harley Street Heart and Vascular Centre, shares his views on the benefits of HRT as well as potential risks such as deep vein thrombosis.

The arrival of menopause is both a normal consequence of ageing and a time of great physical, emotional and mental health challenges for a woman. And it isn’t just about a few hot flushes. Fatigue, weight gain, loss of bone strength, a waning libido, depression and inability to focus on tasks severely affect many women who otherwise feel ready to live their lives to the full.

Hormone replacement therapy (HRT) with combinations of oestrogen and progesterone hormones can be life changing for these women. The use of hormone replacement therapy for menopause is rising rapidly, and enthusiasts promote it as the panacea to all the ills of being middle-aged. But while its benefits are undoubtedly great, HRT is not risk-free.

Hormone replacement therapy and clotting risk

In its earliest form, hormone replacement therapy had high doses of oestrogen that significantly increased the risk of blood clots – and clots often did form in the leg veins (deep vein thrombosis), which can travel to the lungs (pulmonary embolism, a potentially fatal condition) as well as in the veins in the brain (cerebral sinus thrombosis).

Historical data on hormone replacement therapy and deep vein thrombosis suggests a two-to-four-fold increased risk with older forms of HRT, especially if oestrogen and progesterone are combined. However, that risk has reduced significantly now, and with newer low-dose transdermal preparations of oestrogen and new non-norpregnane derived progesterone, the risk is almost negligible.

I say almost, as the risk is not zero.

Do all types of HRT carry the same risk of clotting?

The short answer is no. Here, one must understand that while most women have a low risk of deep vein thrombosis in general, a baseline increase in risk exists for those with increased weight (especially body mass index or BMI over 30), a predisposition to clotting (a condition known as thrombophilia), recent surgery, ongoing or treated cancer and a history of thrombosis in first degree relatives.

The issue is one of additional risk with hormone replacement therapy. Current research suggests that transdermal oestrogen, topical oestrogen creams for vaginal dryness and micronised progesterone preparations carry no additional risk of clotting. However, these may not be suitable or available to all women – so a clear assessment of the need for hormone replacement therapy, the baseline clotting risk for an individual and the type of hormone combination being recommended should all be considered when embarking on the hormone replacement therapy journey.

HRT undoubtedly helps many peri-menopausal women live happier and fuller lives. However, an informed choice can significantly reduce any clotting risks that go with it.

How to minimise clotting risk on hormone replacement therapy for menopause

Before starting hormone replacement therapy for menopause, some preliminary steps will help reduce your clotting risk to a minimum:

• Get a baseline DVT risk assessment for yourself
• Have a detailed discussion with your doctor on the lowest risk option for yourself
• Learn about blood thinners, long-haul flight risks and how they fit in with HRT

The Harley Street Heart and Vascular Centre (Gleneagles Hospital)
#02-38/41 Annexe Block, 6A Napier Road
6472 0503 | WhatsApp 8822 8164
circulation@harleystreet.sg | vascular.harleystreet.sg

This article about hormone replacement therapy for menopause and deep vein thrombosis first appeared in the August 2025 edition of Expat Living. You can purchase the latest issue or subscribe so you never miss a copy!

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