If you have any questions about this information, you can contact the Drugs in Breastmilk team through their Facebook page or on druginformation@breastfeedingnetwork.org.uk.
There is limited information on the use of HRT while breastfeeding.
You can continue to breastfeed whilst taking HRT.
You can use local vaginal estrogen while breastfeeding.
The estrogen component of HRT may reduce your milk supply.
In this factsheet
Introduction
What is Menopause?
The menopause is when your menstrual periods stop permanently. Menopause can be diagnosed when you are over 45 years old, have not had a period for 12 months and you are not using hormonal contraception (NICE). It is a “retrospective” diagnosis, meaning you are diagnosed as having completed the menopause after it’s happened.
The years leading up to the menopause are known as the perimenopause.
Perimenopause Symptoms
You may have no symptoms at all, or you could experience several symptoms including:
- vasomotor symptoms (hot flushes and sweats)
- genitourinary symptoms (for example, vaginal dryness or pain when urinating or having sex, or recurrent urine infections)
- effects on mood (for example, low mood, anxiety, mood swings)
- musculoskeletal symptoms (for example, joint and muscle pain)
- sexual difficulties (for example, low sexual desire)
- brain fog, changes in memory or experiencing worsening symptoms of neurodivergent or long-term conditions
- changes in menstrual cycle including changes in regularity/frequency/heaviness of your periods
During perimenopause, your hormones, estrogen in particular, fluctuate irregularly as levels slowly decline. After menopause, your estrogen and progesterone levels will remain consistently lower.
Sometimes, perimenopausal symptoms overlap with other conditions, so your healthcare professional may do a blood test to check for other conditions such as anaemia, thyroid function and vitamin B12 levels. As hormone levels change a lot during the perimenopausal period, blood tests are not used to diagnose menopause if you are over 45 years of age.
Perimenopause and Mood
Typically, if your anxiety or mood changes are new and associated with perimenopause, the first line of treatment is hormone replacement therapy (HRT). Sometimes antidepressants are offered for anxiety or depression associated with the menopause, but this is not the usual choice recommended by guidelines when perimenopause is the cause, unless HRT is not suitable for you. You can use other strategies that help with anxiety at the same time though. You can find more information on these in our anxiety and breastfeeding factsheet.
Early Menopause
Premature, or early, menopause is when you finish your menopause between the ages of 40-45 years. You can be diagnosed when you have not had a period for 12 months. Early menopause affects your fertility as you will stop ovulating once you have completed the menopause.
Early Menopause and Contraception
It is very unlikely you will become pregnant if you have been diagnosed with early menopause. After 12 months with no periods your menopause is considered complete. However, guidelines recommend that if you are under 50, you continue to use contraception if you wish to prevent pregnancy, or if you take regular medication which isn’t safe during pregnancy, until you have had no periods for two years (CoSRH). See below for information on contraception if you have not been diagnosed with early menopause.
Primary Ovarian Insufficiency (POI)
Primary ovarian insufficiency (POI, also known as premature ovarian failure) is when the your ovarian function reduces or your ovaries stop working before 40 years of age.
POI differs from early menopause as you may have intermittent ovarian function. POI may lead on to early menopause.
A diagnosis of POI is made based on menopause-associated symptoms, including no or infrequent periods (taking into account whether you have had a hysterectomy) and elevated follicle stimulating hormone (FSH) levels on 2 blood samples taken 4 to 6 weeks apart. It cannot be diagnosed based on one blood test alone. (NICE)
While POI and early menopause both result in an early end of ovarian function, leading to infertility, POI is associated with intermittent ovarian function. This means you may have a small chance of becoming pregnant without fertility treatment with POI.
Treatment for POI
If you have POI, you will be offered hormone replacement with HRT or Combined Hormonal Contraception (CHC), which contains an estrogen and progestogen, unless these are not suitable for you (for example if you have a hormone sensitive cancer). You can take these until at least the age of expected menopause for symptom control and to protect your bones and heart.
If you have a history of high blood pressure, you may be offered HRT (usually transdermal- through the skin) over CHC as transdermal HRT may help control your blood pressure.
You may be offered the CHC as hormone replacement rather than usual HRT as it has the added convenience of providing contraceptive cover. You may also be offered CHC in place of HRT if you are taking medication that is not compatible with pregnancy for both hormone replacement and contraception purposes. HRT doesn’t provide contraceptive cover alone (except in combinations including the Mirena® coil, or Slynd® discussed below).
You can find out more about POI in this Guideline on premature ovarian insufficiency.
Further information sources
Women’s Health Concern has been the patient arm of the British Menopause Society (BMS) since 2012. The BMS was established earlier, in 1972. You can find out more about menopause, and perimenopause on the Women’s Health Concern Factsheets webpage.
The Menopause – NHS webpage discusses the menopause, but you may find blogs with lived experience useful.
Treatment for Perimenopause and Menopause Symptoms
Introduction to Treatment Options
Natural Remedies
There is some limited evidence that natural remedies, including isoflavones, black cohosh and St John’s Wort, may relieve some symptoms associated with menopause. However, the long-term safety of these products is uncertain. There is a lot of variation in dosage and effect with little quality control, as they are considered supplements, rather than regulated medicines. These supplements can have serious interactions with other medicines including hormonal contraceptives (which may become less effective), blood thinners and epilepsy medication. Although these remedies are available to buy without a prescription, you should not use them without consulting with a healthcare professional, especially if you are taking any other prescribed or purchased medicines.
St Johns Wort has a recognised and significant effect on other medications- it reduces effectiveness of contraception, leading to unplanned pregnancies.
These natural remedies should usually be avoided when breastfeeding, as we do not have any data on any side effects they may have. Supplements are classed as food supplements rather than medication and are not subject to the same rigorous regulations as licensed medications. There can be large variations between brands or batches and the quantity of ingredients can vary compared to that stated on the packaging. For more information on food supplements in general, see the SPS page Using food supplements.
Contraception
Fertility declines over time. If you want to avoid pregnancy, then you should use contraception until you are 55 years old or menopause is confirmed. Contraception is recommended for 2 years after your last period if you’re under 50 years of age, or 12 months after your last period if you’re over 50 years of age (CoSRH).
Although you cannot become pregnant after your menopause is complete, you can still contract sexually transmitted infections (STIs), so it is important to continue practising safer sex and using condoms if you are not aware of your partner’s sexual health status.
You may need contraception while taking HRT. If so, there are various options that may be suitable for you. For some people, particularly if you have POI, Combined Hormonal Contraception (CHC), which contains estrogen and a progestogen, may be used to provide you with contraceptive cover and increase your hormone levels as a form of HRT.
The UKMEC guidance on the safety of contraceptives advises that the CHC pill can be used from 6 weeks postnatally, whilst breastfeeding, as a risk level 2: “A condition where the advantages of using the method generally outweigh the theoretical or proven risks.” One systematic review reports that the impact of CHC on breastfeeding duration and success is inconsistent. There are anecdotal reports of milk supply reducing with estrogen, even after 6 weeks.
The amount of estrogen in CHC is higher than in HRT, so if you do experience a drop in your supply while taking CHC, you could switch to HRT and use an alternative contraceptive. The effect on your milk supply is reversible. A reduction in your supply could be significant if your baby is under one year old and their sole or main source of nutrition is breastmilk. If they are over one year old, a reduced supply is less of a concern, especially as feeds naturally decrease as your child gets older.
You can read more about contraception while breastfeeding on our Contraception and Breastfeeding – The Breastfeeding Network factsheet.
Hormone Replacement Therapy (HRT)
Various HRT treatments are available to support with symptoms of the menopause as well as to reduce the risk of health issues that you may experience after the menopause. HRT has been available in the UK since 1965. Treatment options and understanding of the menopause have come far since then.
Prescribing for perimenopause and breastfeeding: Off-label use
HRT and local estrogen are not currently licensed for use while breastfeeding. This means the manufacturers haven’t applied for their patient information leaflets to list that breastfeeding is ok while using them. Using these treatment options whilst breastfeeding is therefore classed as “off-label”. Sometimes the patient information leaflets may even say it should not be used whilst breastfeeding. This does not necessarily mean that these medicines aren’t compatible with breastfeeding (see below for individual medicine information).
Some of the products discussed in this factsheet are also used “off-label” for HRT. Again, this means that whilst we know they work as part of HRT treatment, it isn’t listed as a use on the patient information leaflet. We talk more about what this means in our Patient information leaflets – what do they mean? factsheet.
Estrogen
Estrogen is the main component of HRT treatment. HRT raises your estrogen back to more usual levels in your system. However, as estrogen levels in your blood may vary greatly during the perimenopause, estrogen blood levels are not routinely tested (BMS).
If you are taking estrogen systemically (through your skin by patch, gel or spray, or orally by tablet) and you still have your uterus, you will also need to take a progestogen (either progesterone, which is also known as body similar progesterone, or a progestin, which is synthetic progesterone) alongside estrogen. This protects the lining of your uterus, preventing thickening which could lead to endometrial hyperplasia and increase your risk of endometrial cancer. A progestogen is usually not recommended as part of HRT if you have had a full hysterectomy, unless you have risk factors such as endometriosis.
There is limited data on taking HRT while breastfeeding, but there are many studies looking at hormonal contraceptives, including Combined Hormonal Contraception (CHC) which is a mixture of estrogen and a progestogen, usually in higher levels than those used in HRT. The estrogen used in CHC is a synthetic form known as ethinylestradiol which is more potent compared to body identical estradiol used in HRT. CHC is considered acceptable while breastfeeding from 6 weeks after birth.
Transdermal HRT
You may have risk factors that mean an oral hormonal replacement is not the best option for you. The alternative is transdermal HRT (including patches, gel or spray used on the skin). Some transdermal HRT patches contain only estrogen. These will be offered with a separate progestogen. Some transdermal HRT patches contain estrogen and a progestogen; these are known as combined HRT patches.
Transdermal HRT treatments also include estrogen-only gels and sprays. These could be transferred to your child through direct contact if the application area is not fully covered, or if the product hasn’t fully dried, so if transdermal HRT is suggested for you, you may prefer to use patches.
Milk supply with HRT
The aim of giving estrogen in HRT is to replace what has been lost, in theory bringing your estrogen back up to usual levels. Therefore, we would not expect HRT estrogen to impact your milk supply in the same way that CHC with a higher dose of estrogen might if you’re not perimenopausal or menopausal. However, it is still possible that it could affect your supply. If your supply reduces, it should return to usual if you stop taking the HRT.
A reduction in your supply could be significant if your baby is under one year old and their sole or main source of nutrition is breastmilk. If you continue taking the HRT you may need to consider supplementing breastfeeds with stored expressed breastmilk or first infant formula.
If your child is over one year of age, a reduction in your supply is less of a concern in relation to growth and nutrition, as they will be eating more complementary foods and breastfeeds naturally decrease as your child gets older. Children over one year can drink whole cows milk, as well as breastmilk, as a main drink. Infant formula is not necessary after one year.
Cyclical vs continuous HRT
You can take HRT either cyclically (also called sequentially) or continuously. If your HRT is cyclical, you take a daily dose of estrogen but only take progestogen for part of the month (often two weeks), after which you have a monthly bleed. If your HRT is continuous, you take both estrogen and progestogen daily, with no break and no expected monthly withdrawal bleed.
Usually, cyclical HRT is offered to you if you’re perimenopausal, or if you’ve only been through the menopause in the last couple of years, though sometimes continuous HRT is offered earlier. You can find out more about this on the Women’s Health Concern – HRT factsheet. If you are using a contraceptive that stops your periods you will be offered continuous combined HRT.
You can find out more about evidence-based treatments on the Women’s Health Concern website factsheets.
When discussing treatment options with your healthcare professional, they will usually use resources from national guidelines including the NICE Discussion Aid for GPs and Patients, or the Genitourinary (GU) symptoms associated with menopause visual summary. However, these are menopause specific and won’t include information on breastfeeding.
Information below will signpost you to the limited information available to us on HRT while breastfeeding.
HRT options containing estrogen
Estrogen is available in various forms.
Estrogen is considered compatible with breastfeeding from 6 weeks postnatally in CHC, regardless of the sex of your breastfed child. Amounts of estrogen in HRT are usually lower than in CHC.
Estrogen may reduce your milk supply. This could be significant if your child is under one year of age.
Estradiol (E2), is the predominant circulating estrogen in the body and is usually found in HRT, but also in some CHC preparations.
Estradiol only HRT available as:
- Estradiol (body identical hormone) Transdermal (as Oestrogel®, Evorel® patches and Estradot® patches)
- Estradiol valerate Oral (as Progynova® tablets)
- Estradiol hemihydrate-
- Transdermal (as Estraderm® patches, Estradot® patches, FemSeven® patches, Progynova® TS patches, Lenzetto® spray and Sandrena® gel)
- Oral (as Zumenon®, Elleste® Solo)
Estradiol HRT is also available in combination with various progestogens as oral tablets and transdermal patches.
Oral Combined HRT containing estradiol:
- Estradiol 1mg with progesterone 100mg (body identical hormones) oral HRT as Bijuve®
- Bijuve® is a low dose estrogen, continuous HRT.
- It does not provide contraception.
Combined Hormonal Contraceptives containing estradiol:
- Estradiol (as Estradiol hemihydrate) 1.5 mg with nomegestrol acetate 2.5 mg oral tablets as Zoely®
- Zoely® contains low to medium dose estrogen.
- Zoely® offers contraceptive cover.
- Estradiol (as Estradiol valerate) 1mg, 2mg and 3mg with dienogest 2mg and 3mg oral tablets as Qlaira®.
- Qlaira® is taken over a 28-day cycle, with different levels of hormones at different times in the cycle.
- It contains low, medium and high dose estrogen.
- Qlaira® offers contraceptive cover.
Ethinylestradiol is a potent synthetic estrogen available in combination with various progestogens in different Combined Hormonal Contraceptives (CHCs).
For more information, see NHS- Combined Oral Contraception and Ethinylestradiol- e-lactancia
If you are experiencing vaginal or genitourinary symptoms including vaginal dryness, uncomfortable or painful sex, urinary urgency or repeated urinary infections, you may benefit from local vaginal estrogen. Local estrogen will be offered to you if you have genitourinary symptoms of the menopause (GSM), even if you’re also taking HRT or contraception.
You may be offered local estrogen if you’re perimenopausal or postmenopausal. Sometimes it is used for genitourinary symptoms or to help with healing postnatally when you are not peri/postmenopausal. Whilst there doesn’t seem to be any harm linked to this use, there is also only limited evidence that it is beneficial (Smith et al). Local vaginal estrogen is also used before menopause when you have genitourinary symptoms associated with low estrogen levels.
Local estrogen can be administered by a pessary or cream applied in the vagina. If you have estrogen cream, sometimes you may be advised to apply this to your vulva as well as in your vagina, depending on your symptoms. The dose of estrogen in these preparations is very small. It is such a low dose that if you only use local estrogen, you don’t need endometrial protection from progesterone or a progestogen.
Local estrogen can be used alongside HRT or alone. Very little is absorbed into the rest of your body once the estrogen has improved the quality of the skin lining of your vagina, bladder and pelvic floor muscles.
Local estrogen is considered compatible with breastfeeding. Use while breastfeeding is off-label.
You can read more about genitourinary symptoms on the Women’s Health Concern – Vaginal Dryness and Women’s Health Concern – Urogenital Problems pages.
Local vaginal estrogen is available in two forms, which are both body-identical. Some contain estriol (E3), the least potent estrogen. It plays an important role in pregnancy, prepares the vagina for birth and is most commonly used in local estrogen preparations for Genitourinary Symptoms of the Menopause (GSM). Levels of estriol in the body are very low. Others contain estradiol (E2), the predominant circulating estrogen in the body, which is also found in systemic HRT treatments.
- Estriol; available as
- Own brand cream.
- Own brand or Imvaggis® pessaries
- Blissel® gel
- For more information, see Estriol (topical use) and breastfeeding – e-lactancia
- Estradiol; available as
- Own brand, Vagirux® and Vagifem®pessaries
- Estring® vaginal ring- (a flexible intravaginal ring that lasts 90 days.)
- For more information, see Estradiol and breastfeeding – e-lactancia
Progesterone
Progesterone is a hormone made in the body. It is important in hormonal balance, particularly with estrogen, for bone metabolism and for your immune system. It is important for the functioning of your brain and nerves. Progesterone levels rise in response to stress. It is involved in the stress response and production of the stress hormone cortisol in the body.
If you are taking systemic estrogen for HRT or contraception, you will be offered a progestogen to protect the lining of your uterus. (The term progestogen includes natural and synthetic hormones that work on the body’s progesterone receptors). Progestogens may also be used alongside estrogen if you have had a subtotal hysterectomy or if you have a history of endometriosis.
Progestogens are available in two forms:
- Progestins are synthetic progesterone; these are usually used in contraceptives but may also be used in HRT.
- Progesterone, or micronised progesterone, also known as “body similar” or “body identical” progesterone, is the natural steroid hormone produced in your body. For HRT, you usually take it as an oral capsule.
- Micronised progesterone is also available as a vaginal pessary and micronised progesterone oral capsules have sometimes been used vaginally. You may be offered these options if you don’t get on with oral progesterone. However, if used for HRT, these are off-label uses which are not approved in most areas in the UK and evidence is limited for them (BMS).
Progestogens are considered compatible with breastfeeding.
Progestins may increase your risk of blood clots, while micronised progesterone does not increase this risk (BMS). Progesterone may also be used if you experience migraines (BMS).
Progestogens used in HRT
The progestogen Levonorgestrel (LNG-IUD 52mg delivering 20microgrammes per 24 hours, as Mirena®) is the most effective choice for reducing the risk of your uterus lining thickening. It is the choice least likely to cause unexplained or unscheduled bleeding while on HRT.
Mirena® is the progestogen of choice if you also need contraceptive cover under the age of 55 years.
Levosert® and Benilexa® are also effective for endometrial protection in HRT and contraceptive cover recommended by national guidelines, but are currently not licenced for use by their manufacturers for endometrial protection in HRT so use of these brands for HRT is currently off-label.
Mirena® and other LNG-IUD 52mg devices are compatible with breastfeeding.
For more information, see Who can get an IUS (intrauterine system) or hormonal coil – NHS
Drospirenone 4mg tablets (as Slynd®) is a newer progestogen-only oral contraceptive pill, although it has been available in CHC (as Yasmin) for many years.
Currently, Slynd® isn’t licenced for use during HRT for endometrial protection.
National guidelines from the BMS now suggest this “off-label” use is an option if needed, taking it back-to-back. Slynd® contains 4 inactive pills which would usually be taken if you were using it for contraception. They allow you to experience a “period” or withdrawal bleed. A withdrawal bleed is not indicated when using Slynd® during HRT treatment, so these inactive pills are omitted. Omitting the inactive pills does not reduce contraceptive cover.
Slynd® is compatible with breastfeeding.
For more information, see Who can take the progestogen-only pill – NHS
Micronised progesterone (as Gepretix® and Utrogestan®) is either used cyclically/ sequentially where it is taken for 2-weeks out of a 4-week cycle and a withdrawal bleed is still expected, or continuously, where it is taken every day without a break with no expected monthly withdrawal bleed.
Recently, guidelines have been updated to reflect that higher doses of micronised progesterone may be needed depending on your daily dose of estrogen to avoid unscheduled/ unplanned bleeding and to prevent thickening of the lining of the womb.
Micronised progesterone does not provide contraceptive cover.
Micronised progesterone is body identical, it is compatible with breastfeeding.
You can read more from e-lactancia on progesterone.
Medroxyprogesterone is available as a contraceptive (as Depo-Provera® injection and Sayana® Press injection), and in combination with estrogen in some combined HRT preparations. It is also available as an oral tablet (as Provera®) for unscheduled (unexpected) vaginal bleeding when taking HRT.
Medroxyprogesterone is considered compatible with breastfeeding.
You can find out more about Pregnancy and breastfeeding while having medroxyprogesterone contraceptive injections – NHS and Pregnancy, breastfeeding and fertility while taking medroxyprogesterone tablets – NHS
Norethisterone is available as a contraceptive tablet, and as an ingredient in CHC tablets and combined HRT patches. It is also available in a higher dose tablet used to suppress or delay periods.
Oral norethisterone can increase your risk of blood clots.
Specialist resources report no concerns with the use of norethisterone while breastfeeding. Norethisterone is considered compatible with breastfeeding.
Some anecdotal reports of changes in milk supply may be associated with its estrogen-like effects due to some norethisterone changing to ethinylestradiol (estrogen) in the body. If you experience a reduction in milk supply, this may be significant if breastmilk is your child’s main or sole source of nutrition.
Norethisterone is an efficient progestogen for endometrial protection.
It may also have a positive benefit to bone mineral density, though evidence is limited and more research is needed.
- Norethisterone and its acetate – what’s so special about them? | BMJ Sexual & Reproductive Health
- Effects of norethisterone on bone related biochemical variables and forearm bone mineral in post-menopausal osteoporosis – PubMed
The dose of norethisterone used in HRT is a lot lower than the dose of norethisterone in contraception, or when used to delay periods for special events, or travelling.
You can find out more from e-lactancia about norethisterone.If you are taking systemic estrogen for HRT or contraception, it is used to protect the lining of your uterus. It may also be used alongside estrogen if you have had a subtotal hysterectomy or if you have a history of endometriosis.
You can find out more about different types of HRT in the Women’s Health Concern – HRT – types, doses and regimens factsheet.
Related Factsheets
Related Factsheets
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Bibliography
Click to see full bibliography
British National Formulary – https://bnf.nice.org.uk/
Drugs and Lactation Database (LactMed®) – https://www.ncbi.nlm.nih.gov/books/NBK501922/
Specialist Pharmacy Service: https://www.sps.nhs.uk/
NHS medicines website: https://www.nhs.uk/medicines/
E Lactancia website: https://www.e-lactancia.org/
NICE Clinical Knowledge summaries: https://cks.nice.org.uk/topics/
Hale T. W. Medications in Mothers Milk. www.halesmeds.com
Dr Wendy Jones, Breastfeeding and Medication website: https://breastfeeding-and-medication.co.uk/
Overview | Menopause: identification and management | Guidance | NICE
NG23 Menopause: Genitourinary (GU) symptoms associated with menopause: Visual summary 07/11/2024
NG23 Menopause: HRT discussion aid 07/11/2024
Tools and resources | Menopause: identification and management | Guidance | NICE
BMS Tools for Clinicians – British Menopause Society
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BMS Joint Guidelines – British Menopause Society
Women’s Health Concern | Confidential Advice, Reassurance and Education
Black women in menopause, Black Women Menopause
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www.ncbi.nlm.nih.gov- Physiology, Progesterone Last update 1st May2023:
Herrera, A. Y., Nielsen, S. E., & Mather, M. (2016). Stress-induced increases in progesterone and cortisol in naturally cycling women. Neurobiology of stress, 3, 96–104. https://doi.org/10.1016/j.ynstr.2016.02.006 www.sciencedirect.com – Stress-induced increases in progesterone and cortisol in naturally cycling women
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©The Breastfeeding Network. Version 1.0. Published April 2026
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