Hormonal Replacement Therapy (HRT) Repeat Prescription Request

Page {{ paginatorProps.current }} of {{ paginatorProps.total }} ({{ paginatorProps.percentage }}% completed)
Prescription Details

Please note if you do not know which type of HRT you are taking, please leave this blank and a clinician can complete this part for you.
From the time you start your HRT, you will need a review at month 3 and thereafter, annually. The following things need to be checked when you are due for your 3 month/annual review: 


Blood pressure (can check this at home if you have a machine, local pharmacy or check at reception)

Weight (can check this at home or check using the scales at the surgery)


Breast cancer screening up to date? (This applies if you are of the age 50 years and over)

Symptom control i.e. is the medication helping your condition? Are you experiencing any side effects? If HRT is not helping your condition or you are experiencing side effects from the medication you will be booked in for a review with the GP or the practice pharmacist.

Are you over 60 years old and currently on HRT? 
If you have answered yes, are you aware we recommend stopping HRT from the age of 60 due to the increased risks associated with this treatment?  

(For more information about the risks please see Patient information summary on page 3. If have answered yes to this question you will be booked in for a review with a GP or practice pharmacist.)

Smoking Status
Alcohol Status
Further Questions

Please answer all the questions on the form by ticking the relevant box, sign and date the form. Incomplete forms will not be processed. If you are unsure how to answer, please organise an appointment with the practice pharmacist.

If you have answered yes to any of the questions above please book yourself in for review with a GP or the pharmacist.

Patient Information Summary

HRT is a safe and effective treatment option for most healthy women with symptoms, who are going through the menopause at the average age in the UK (about 51 years). The risks and benefits of HRT will vary according to your age and any other health problems you may have. Your doctor will be able to discuss any potential risks of HRT with you in detail.

HRT helps to improve menopausal symptoms usually improve and this can make a big difference to quality of life in some women:

  • HRT works to stop hot flushes (also known as 'hot flashes') and night sweats.
  • HRT will reverse many of the changes around the vagina and vulva. This means that HRT can:
    • Improve symptoms of vaginal dryness.
    • Improve discomfort during sexual intercourse as a result of this vaginal dryness.
    • Help to reduce recurrent urine infections.
    • Improve any increased frequency of passing urine.
  • There is some evidence that HRT itself improves your mood and your sleep.
  • HRT may also help to improve joint aches and pains and it may improve muscle strength.
  • HRT improves sexual function and libido in many women.
  • Many women notice that the texture of their hair and skin improves when taking HRT.
  • Reduced risk of 'thinning' of the bones (osteoporosis) thus their risk of having fractures due to osteoporosis is also reduced.

There are also some risks/ side effects associated with having HRT which someone may or may not experience. However it is important to be aware of these risks.  

  • Blood clot in the veins called deep vein thrombosis (DVT). These clots can travel sometimes to the lung causing pulmonary embolism (PE). Taking HRT you have a increased risk of developing clot and more likely to develop clot if you have other risk factors such as being obese, smoker or having had a clot in the past.

(Note: increased risk of clots is not present for women who use patches or gel at standard doses rather than HRT tablets. You should see a doctor urgently if you develop a red, swollen or painful leg, or have shortness of breath and/or sharp pains in your chest.)

  • Increased risk of breast cancer however, this depends on the type of HRT you take and for how you take it for.
  • Increased risk of uterine cancer due to oestrogen part of HRT. This risk reduces completely when taking combined HRT containing oestrogen and progesterone.

If you notice any abnormal vaginal bleeding which develops after starting HRT e.g. heavy bleeding, irregular bleeding or bleeding after sex, see your GP.

  • Increased risk of heart disease or stroke in women who start or are on HRT from 60 years and over, this is why the advice is to stop HRT at this age.

For more information regarding HRT please see the Patient.Info website


I understand that the hormonal replacement therapy has certain risks associated with its use outlined in the patient information leaflet provided with my medicine and that smoking and/or drinking excess alcohol can increase these risks. The information above is correct to the best of my knowledge.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.


There appears to be a problem loading the form, please refresh the page.
If the error persists please contact us.