Oestrogen is a hormone pivotal to female reproductive health, but it also plays a key role in numerous other aspects of the body, including muscle mass, collagen production, bone health, brain function, cholesterol levels, and circulation.
This is why, when oestrogen levels decline during menopause, many women experience a broad variety of symptoms including hot flushes, vaginal dryness, and difficulty concentrating.
Hormone replacement therapy (HRT), and specifically, oestrogen replacement, is a medication that you take to replace the oestrogen that your body stops making during menopause and it’s highly effective in alleviating menopause symptoms.
There are many different types of oestrogen replacement and understanding your options can help you to make the best choice for your health and well-being.
For those who still have a womb (uterus) progesterone is required alongside oestrogen to protect the womb lining from thickening and increasing the risk of womb cancer.
What happens to oestrogen levels in menopause?
In premenopausal women, oestrogen is produced primarily in the ovaries and plays a pivotal role in your menstrual cycle by triggering ovulation, thinning the cervical mucus and thickening the lining of your uterus.
During perimenopause, the ovaries stop making oestrogen and levels begin to decline, eventually causing your periods to stop altogether, which is the key indicator of menopause and marks the end of your reproductive years.
In postmenopause, your body still produces small amounts of oestrogen, but it's made differently than before menopause. Rather than coming predominantly from the ovaries, it is made by converting hormones called androgens.
The declining and then permanently lowered oestrogen levels experienced in perimenopause, menopause and post menopause can cause a variety of undesirable and challenging symptoms, which is why many women choose to utilise HRT to stabilise their oestrogen levels.
Signs of low oestrogen
One of the key indicators of low oestrogen at perimenopause is absent or irregular periods. You may find your skip months or that bleeding or lighter. However, low oestrogen can also cause a variety of other physical and emotional symptoms including:
- Dry skin
- Hair loss
- Breast tenderness
- Weak or brittle bones
- Difficulty concentrating
- Mood changes, irritability and/or depression
- Vaginal dryness or atrophy which can lead to painful sex
- Hot flushes and night sweats
- Fatigue
- Poor sleep
- An increase in urinary tract infections
- Headaches or exasperation of existing migraines
Using oestrogen during menopause
Oestrogen replacement can be instrumental during menopause, helping to counterbalance the natural dip in hormone levels and improve your overall well-being.
It’s a safe and effective way to treat menopause symptoms, which is why an estimated 1.93 million patients were prescribed HRT in 2021/2022.
Benefits of menopause oestrogen replacement
Relieving menopause symptoms
Oestrogen replacement therapy directly addresses some of the most common and disruptive menopause symptoms. By stabilising fluctuating hormone levels, oestrogen can help reduce hot flushes, night sweats, and mood swings, providing a more balanced and comfortable daily life. It can also help alleviate vaginal dryness and discomfort, a less talked-about symptom that impacts sexual health and overall quality of life for many women during menopause.
Preventing osteoporosis and fractures
Oestrogen plays a key role in bone health. With menopause, the drop in oestrogen can accelerate bone density loss, leading to a heightened risk of osteoporosis and fractures. Oestrogen replacement helps slow this bone loss, preserving bone strength and structure, which can protect against fractures as you age.
This long-term benefit makes oestrogen replacement an important consideration for those at risk of osteoporosis or who have a family history of bone density issues.
Maintaining muscle strength
Muscle mass and strength naturally decline with age, but the drop in oestrogen during menopause can quicken this process. Oestrogen supports muscle maintenance, and its replacement can help women retain strength and mobility. This benefit has broader implications for overall health, as maintaining muscle strength is closely linked to better balance, reduced fall risk, and a higher quality of life as women age.
Side effects and risks of menopause oestrogen replacement
In most cases, the advantages of hormone replacement therapy far exceed any risks. However, all medications have side effects and possible risks. Side effects of oestrogen are often mild and usually improve within three months of starting HRT. Side effects of oestrogen include:
- Headaches
- Nausea
- Leg cramps
- Breast pain or tenderness
- Unexpected vaginal bleeding or spotting
- Diarrhoea
- Mild rash or itching
- Mood changes, including low mood or depression
Oestrogen tablets slightly increase the risk of blood clots and stroke. Patches, gels, and sprays do not increase the risk, as oestrogen is safer when absorbed through the skin.
Oestrogen-only HRT can slightly increase the risk of breast cancer, with the risk becoming greater the longer it is used, however it is less than combined HRT (oestrogen with progesterone). When HRT is stopped, the risk gradually declines. Oestrogen-only HRT also slightly increases the risk of ovarian cancer. In somebody with a womb oestrogen only can increase the risk of endometrial cancers, however this can be counteracted by adding in progesterone alongside oestrogen.
Delivery methods and types of oestrogen HRT
There are several different ways to deliver oestrogen replacement to the body. Oral tablets, patches, gels and sprays are the most commonly used methods in the UK. In addition there are localised vaginal oestrogens such as a vaginal tablet, cream or pessary.
We prefer to prescribe what we call ‘transdermal’ oestrogen, which is oestrogen that is delivered via the skin into the bloodstream. These are body identical options which are similar to the natural oestrogen produced in our body. This is the safest delivery method, either as a gel, a patch or a spray. This is because transdermal oestrogen does not need to pass through your stomach or liver so you can take a much lower dose. Transdermal oestrogen appears to have little or no impact on clotting factors and so can be used safely in women with a history of blood clotting or migraines.
They are all excellent delivery methods, so it’s up to you how you prefer to receive oestrogen. This will be dependent on the ease of use, absorption or lifestyle factors.
For those with a womb, progesterone is prescribed alongside the oestrogen to protect the endometrium.
Oestrogen patch for menopause
Oestrogen patches are useful because they are applied as a translucent plaster placed below the waist, to the hip, outer thigh, lower tummy or bottom and are only changed twice a week. They may be a good option if you have difficulty swallowing tablets.
Unlike tablets, oestrogen patches do not increase your risk of blood clots and they can also help you avoid some of the side effects of HRT, such as indigestion. They can be useful in those who suffer from migraines as they provide an even dosing of oestrogen which can reduce migraines.
They can be worn in the bath or shower or to swim, delivering a specific continuous dose. They come in varying strengths, but the dose is harder to alter.
Some women find the patches irritating, react to the glue, or have sticking problems, whereas other women really find patches very easy to use, often forgetting about them entirely between changes.
Types of oestrogen patches
There are oestrogen-only patches as well as some combined patches containing both oestrogen and progesterone. Which type you are prescribed depends on your circumstances and medical history.
Estradot is a brand of oestrogen-only patch and comes in five different strengths, giving flexibility of dosing. Each prescribed carton contains 8 Estradot patches, enough for a 4-week cycle. This can be used on its own (in those without a womb) or alongside progesterone to give flexibility of dosing.
It is soft, small and often sticks well. You apply it to the hairless skin on your hip, thigh or bottom and change your patch twice weekly. You should not put the patches on top of cuts, spots or anywhere where the skin is irritated and should avoid using cream, moisturiser or talc before application. You also need to rotate where you place each new patch so as not to apply on the same area of skin twice in a row.
The patch delivers a continuous and controlled dose of estradiol that is absorbed by the skin and into the bloodstream. There are other brands including Evorel which are slightly larger.
Evorel Sequi and Conti patches are a type of continuous sequential HRT. They come as oestrogen-only or a combined product containing body-identical oestrogen with a synthetic type of progesterone called norethisterone. The oestrogen-only patches are used for two weeks and then the oestrogen and progesterone patches are used for the following two weeks.
These are useful if you still have a womb or need progesterone cover for other reasons. The disadvantage of them is they only come in one dose so the dose can not be altered.
Oestrogen gel for menopause
Oestrogen gel is an increasingly popular form of HRT and works by being applied to the skin and being gradually absorbed into your body. It can be started at low doses and increased as needed, giving the patient some flexibility.
Gels are applied daily, usually in the morning, and allowed to dry fully before dressing. You need to wait at least an hour after application before bathing or swimming.
Like patches, oestrogen gels do not increase your risk of blood clots. If you still have a womb, you have to use these forms of oestrogen replacement in combination with progesterone.
Examples of oestrogen gel:
Oestrogel
Oestrogel is a body identical oestrogen product containing estradiol (which is derived from plants) and delivers a metered dose of oestrogen from a pump.
Easy to use and gentle on the skin, oestrogel is clear and colourless. Your prescribed dose of the gel is applied to the outer upper arms, shoulders or inner thighs every morning and allowed to dry. Each pump contains 64 doses.
Sandrena Gel
Sandrena Gel is similar to oestrogel but comes as sachets in two different strengths so you can choose your dose. There is less quatity of gel for the same dose compared to oestrogel so it can be more practical in higher doses.
It is applied daily to clean, dry skin on the upper outer arms or the inner thighs. It dries within a few minutes, and you must not wash the area where you applied the gel for at least one hour
Oestrogel Spray for menopause
Oestrogen spray is a body identical oestrogen, derived from plants (yams), which is a spray onto the skin and is gradually absorbed. There is one option of oestrogen spray which is Lenzetto.
Lenzetto spray
Lenzetto is a body identical oestrogen product which contains small amounts of a natural hormone called estradiol.
It is an easy-to-use, daily spray. You apply it to the forearm or inner thigh, on clean dry skin and it dries quickly. It gradually passes through the skin into your bloodstream where it then travels throughout the body to help with menopause symptoms.
Each device contains 56 sprays but the number of sprays you use each day will depend on the severity of your symptoms and your doctor’s instructions. It can be difficult to know when it runs out, so marking off sprays on the box can be helpful.
Although it dries within around 2 minutes and leaves no residue, women should wait a few minutes before dressing and avoid swimming or bathing within the first few hours of using it. If using sun cream, this must be applied at least an hour before using Lenzetto.
In women who still have a womb, it needs to be used alongside progesterone to provide endometrial protection.
Oestrogen tablets for menopause
Tablets can be convenient and are still widely prescribed in the UK – especially when other risk factors are low, if you have skin problems such as widespread eczema, or if you struggle to absorb transdermal products.
You usually take them once a day. Some of the risks of HRT, such as blood clots, are slightly higher than when using transdermal forms, although the overall risk is still minimal.
There’s also a new body identical tablet called Bijuve which is suitable for postmenopausal women and contains body identical oestrogen and progesterone.
Vaginal oestrogen for menopause
Vaginal oestrogen is a form of low-dose oestrogen that doesn’t carry the usual risks of HRT or increase your risk of breast cancer. It can be used without progesterone, even if you’ve not had a hysterectomy and comes as a gel, cream, vaginal tablet, pessary or ring that you place inside your vagina.
Vaginal oestrogen is beneficial for treating vaginal dryness and discomfort and can also improve urinary symptoms caused by menopause, but it will not help with other common menopausal symptoms such as hot flushes, night sweats, sleep issues or mood changes.
It can be used either alone for vaginal symptoms or alongside other HRT if there are other symptoms present. Unlike other forms of HRT, it can be used long term as low risk and often symptoms come back if it is stopped.
When to take oestrogen during menopause
Your experience of menopause is unique so when to start oestrogen replacement will be a personal choice. You don’t need to wait until your periods stop completely to start treatment – you can begin HRT in perimenopause.
If you’re bothered by your symptoms and they’re impacting your day-to-day life, it may be a good time to speak to someone. At Menopause Care, we have a team of menopause doctors who are experienced in supporting women navigate their menopause symptoms. With one of our specialists, you can discuss your history and symptoms, and they’ll talk you through your recommended treatment options based on your personal circumstances and evidence-based information. To get started, book a consultation with a menopause doctor.
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