Much new information on menopausal hormone therapy (MHT) has become available since the publication of the first report of the Women’s Health Initiative in 2002 and a consensus is now emerging. The risk of breast cancer depends on type of MHT, duration of use, body mass, breast density and interval between menopause and starting MHT. The risk of breast cancer is generally increased by MHT, particularly in lean women with no previous MHT who start estrogen–progestin therapy near the menopause and continue for several years, but there is no increased risk 5 years after stopping MHT. The risks of venous thrombo-embolic disease (VTE), stroke and coronary heart disease (CHD) depend on age on starting MHT, dose, nature and route of administration of MHT. The risk of VTE is increased in women over 60 years of age and in women who are obese or have had a VTE but may not be increased by transdermal estrogens. The risk of stroke is very small in women under 60 years of age and may not be increased by low dose oral and low dose transdermal estrogen. MHT is of benefit in preventing atherosclerosis and CHD in healthy younger postmenopausal women (under the age of 60) but is not of benefit, and may be harmful, in older women with clinical or subclinical atherosclerosis. MHT prevents bone loss and osteoporosis but is not generally recommended in women over 60 because of the risks of VTE, stroke and CHD, and if stopped at 60 years does not prevent fractures in later life. MHT reduces the overall mortality in women under 60. MHT is by far the most effective treatment, and greatly improves the quality of life in women with menopausal symptoms. A simplified approach to MHT is suggested as a framework for the care of women at and after the menopause.