“Taking HRT is a personal choice based on patient preference, medical and family history. No two women are the same and every woman needs a holistic plan tailored to her own individual needs.” - Dr Naomi Potter- Founder of Menopause Care.
As we age, our ovaries produce less oestrogen and testosterone. Symptoms women experience during menopause are due to fluctuating and then declining oestrogen and sometimes a decline in testosterone.
Menopause can cause symptoms in every organ system. However, replacing the hormones that decrease during menopause using hormone replacement therapy (HRT) can reduce these symptoms.
Here we share what HRT is, what it does and how it can help you during menopause.
What is HRT?
HRT stands for hormone replacement therapy and is a medication that contains female hormones. It’s a treatment that replaces hormones that the body is no longer producing to improve symptoms of menopause and sometimes reduce risks of other long-term health changes.
What does hormone replacement therapy do?
The aim is to replace the female hormones in the body that naturally decline as you experience menopause by flattening out, fluctuating, and topping up declining levels. This can manage or relieve many of the symptoms of menopause, improving physical and psychological well-being.
HRT has other uses too. It can be used in gender transitions, with those assigned male at birth prescribed antiandrogens to block testosterone production. They can also receive feminising hormone therapy that helps make their skin softer, reduces facial and body hair, shrinks the testicles, reduces muscle mass and increases body fat.
HRT can also be an effective treatment option for women experiencing sexual dysfunction by alleviating symptoms including dryness, itching, and painful intercourse, and by improving blood flow and sensation to vaginal tissues.
What is in HRT?
HRT is a medication that contains female hormones including oestrogen, progesterone or both. Some women are also prescribed testosterone. The hormones we most commonly use are ‘body-identical’, also known as regulated bioidentical hormone replacement therapy. This means they are very similar to the ones naturally occurring in the body. These are the safest to use and have the lowest risk of side effects.
Body-identical oestrogen and progesterone are derived from a natural chemical found in yam plants. Some older forms of HRT contain a mixture of oestrogen and are made from pregnant mares’ urine. Body-identical testosterone is also derived from plant sources such as yams or soy.
Synthetic hormones including other types of oestrogen and progesterone are also regulated and may be useful during this time, particularly if there are sensitivities, bleeding problems or where contraception needs to be considered.
There are also compounded bioidentical hormones, often formulated as creams or lozenges which are unregulated and currently not recommended by the British Menopause Society owing to lack of certainty about safety.
The hormones in HRT
Oestrogen
Oestrogen replacement is the key feature of providing HRT and improving symptoms associated with perimenopause and menopause.
It is a sex hormone that plays a key role in the female reproductive system, thickening the uterine lining, stimulating ovulation and inhibiting follicle-stimulating hormone (FSH) so that only one egg matures in each menstrual cycle.
During menopause, levels of oestrogen decline significantly and this gives rise to many of the common symptoms women experience including hot flushes, night sweats and brain fog.
Providing the body with oestrogen HRT helps replenish what has been naturally lost to alleviate physical, emotional and mental symptoms and improve overall well-being.
There are a number of different ways of delivering oestrogen replacement to the body. Most commonly used in the UK are oral tablets, patches, gels and sprays.
Progesterone
Progesterone is also pivotal to the menstrual cycle, preparing the uterine lining for pregnancy. If you do fall pregnant, it thickens the uterine lining and levels continue to rise, preventing your body from ovulating while pregnant.
As with oestrogen, levels reduce during menopause and when out of ratio with oestrogen, progesterone can contribute to vaginal dryness, vaginal atrophy and decreased clitoral sensitivity.
All women who still have their uterus (womb) or women who have had a hysterectomy but have a background diagnosis of endometriosis require progesterone as part of their HRT.
As part of HRT, progesterone is responsible for regulating the lining of the womb, preventing overgrowth and the development of irregular cells. Some women also notice that it may have a calming effect and help with sleep when taken at night.
There are many options for progesterone provision as part of HRT. These include body-identical micronised progesterone and a larger group of synthetic types of progestogen. There are benefits and side effects associated with all types and tailoring both the dose and type of progesterone is an important part of prescribing HRT.
Testosterone
Testosterone is also a female hormone, produced by the ovaries and adrenal glands, with ovarian production gradually declining between the ages of 20 and 40.
Low testosterone levels can lead to symptoms such as reduced libido, diminished sexual desire and impaired sexual function. Additionally, anecdotal evidence and smaller studies suggest that low testosterone may contribute to other issues, including low mood, poor cognitive function, reduced musculoskeletal health, and a general decline in well-being, though conclusive data is limited.
Current guidelines recommend addressing menopausal symptoms with oestrogen replacement first. If specific symptoms persist and testosterone levels are notably low, a trial of testosterone therapy may be considered. When used in small doses, specifically for women, it should not cause masculine side effects. Once treatment begins, a review process involves monitoring for side effects, evaluating symptom improvement, and conducting blood tests to ensure safe hormone levels.
In the UK, the only testosterone product tested and approved for women is AndroFeme Cream, available by private prescription. Other testosterone products licensed for men, such as Testogel sachets and pumps, can be used off-label in low doses for women.
How does HRT help during the menopause?
Menopause is a natural part of ageing, but the changes it brings can sometimes feel overwhelming. As hormone levels fluctuate and decline, many women experience unwanted symptoms. This is where HRT can make a real difference. It can help ease some of the most common symptoms of menopause including:
- Hot flushes
- Night sweats
- Sleep problems
- Mood swings
- Anxiety
- Vaginal dryness
- Joint pain
- Brain fog
- Headaches and migraines
Taken in perimenopause and menopause, HRT can also help prevent hormone-related health problems including osteoporosis and heart disease.
How long does HRT take to work?
Every woman’s body will respond differently to HRT, so the time it takes to notice improvements can vary. For many, improvement in symptoms like hot flashes or night sweats can be seen within a few weeks. However, it may take up to three months to experience the full benefits of HRT.
How does HRT make you feel at first?
It can take time for your body to adjust to HRT so it’s not uncommon for women to see improvements in their menopause symptoms but also experience side effects from the medication, such as headaches, breast tenderness and vaginal bleeding when they first start taking it.
However, side effects usually improve over time as your hormone levels stabilise, so it’s recommended that you maintain your treatment plan for at least three months. If side effects persist, then your HRT plan can be reviewed with your doctor or nurse as sometimes, it can take a little time to find the right type of dose of HRT that suits you.
What are the different types of HRT?
There are several different ways of taking HRT including gel, patches, tablets, creams, spray, pessaries and vaginal rings.
There are also different regimens for taking HRT such as cyclical/sequential, which is taken in 28-day cycles, and continuous, where medication is taken every day without a break. The types you are prescribed will be based on whether you are perimenopausal or menopausal, also taking into account your symptoms, medical history and other factors.
Oestrogen tablets, patches, gel and spray
The most common form of oestrogen used in HRT is known as estradiol. It can be prescribed to you as tablets that you swallow, or as patches, a gel or a spray that you put on your skin. Brand names for this form of oestrogen include:
- Tablets: Elleste Solo, Kliofem, Progynova and Zumenon (Should this list match the one lower?)
- Patches: Estraderm, Estradot, Evorel, Femseven and Progynova
- Gel: Oestrogel and Sandrena
- Spray: Lenzetto
If you are taking tablets or have been prescribed a gel or spray, you’ll typically use them at the same time each day, every day. With oestrogen patches, you’ll need to change them once or twice a week.
We most commonly and prefer to prescribe what we call ‘transdermal’ oestrogen, which is delivered via the skin into the bloodstream. This is the safest delivery method as a gel, patch or spray.
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 migraine.
They are all excellent delivery methods and the reason for choosing one particular product is often patient-dependent based on preference, ease of use or lifestyle factors.
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 only changed once or twice a week. They can be worn in the bath or shower or while swimming, delivering a specific and continuous dose. They come in varying strengths but the dose is less easy to alter for the patient. Some women find the patches irritating, react to the glue, or have sticking problems and other women find patches very easy to use, forgetting about them between changes.
The gel and the spray can be titrated according to patient symptoms, with allowance for patient adjustment sometimes being particularly useful in patients who want to start at a very low dose and work up. They are applied daily, usually in the morning, and allowed to dry fully before dressing.
Tablets can be convenient for use and are still widely prescribed in the UK, especially when other risk factors are low, there are skin problems such as widespread eczema or problems of absorption using transdermal products are found.
There is also a new body-identical tablet called Bijuve which is suitable for postmenopausal women containing body-identical oestrogen and progesterone.
Vaginal oestrogen
Vaginal oestrogen is a local HRT that comes as a tablet, pessary, cream gel or ring that you insert into the vagina. It’s used to treat symptoms such as vaginal dryness and irritation. The dosage depends on the type of vaginal oestrogen you are using. Brand names for vaginal oestrogen include:
- Vaginal tablets: Gina, Vagifem, Vagirux
- Vaginal ring: Estring
- Vaginal pessaries: Imvaggis
- Vaginal gel: Blissel
- Vaginal cream: Ovestin
Micronised progesterone
Micronised progesterone is currently considered to be the safest body-identical progesterone with the lowest chance of side effects. It’s usually taken orally, but some women use it vaginally, particularly if they have been sensitive to progesterone or experienced side effects.
Progesterone is dosed either as a continuous regime, normally prescribed to women who have stopped their periods for more than a year or those who have been on HRT for at least a year. It is used in a low dose taken daily leading to a bleed-free regime.
Alternatively, women who are within a year of their last period or still having regular periods usually require a sequential regime, meaning a higher dose for a shorter period, taken for only part of the month. This creates an artificial withdrawal bleed in women who are in perimenopause.
Utrogestan is one type of micronised progesterone. It comes as a capsule that you typically swallow but can be used vaginally in women who do not tolerate oral progesterone very well. It is taken alongside oestrogen as part of a combined hormone replacement therapy regimen.
Gepretix is another brand of micronised progesterone and is one of the newest types of HRT medication. It is a soft capsule and there are two ways to take it. Your doctor may prescribe two capsules to be swallowed each day at bedtime for twelve consecutive days in the last half of each cycle or one capsule to be taken each day at bedtime every day from day 1 to day 25.
You’ll need to take combined HRT if you have a womb. This is because oestrogen-based HRT can thicken the womb lining which slightly increases the risk of womb cancer. Taking progesterone stops the womb lining from becoming too thick, reducing the risk.
Intrauterine system (IUS)
If you have a womb and are taking oestrogen, the Mirena coil, which is an intrauterine system (IUS), is often used as an excellent way of providing progesterone cover that also provides contraception and bleeding control. It is a small, plastic T-shaped device that is inserted into the womb and slowly releases progesterone into your body to protect the endometrium (lining of the womb). The Mirena coil can stay in place for up to five years when being used for HRT. When using a Mirena coil for contraception alone it can be effective for up to 8 years.
Every option comes with its advantages and disadvantages. The Mirena coil is convenient because once it’s in place, it can be forgotten about, though you’ll still need to remember to take oestrogen. However, some women are uncomfortable with the idea of having it inserted or are not eligible for it. In contrast, oral progesterone is typically straightforward to take, but it requires consistent use to maintain effectiveness, making it something you need to actively remember.
Tibolone
Tibolone, which is known by the brand name Livial, is a form of synthetic hormone HRT tablet. Your body breaks it down to produce substances that behave similarly to oestrogen, progesterone and testosterone.
It can help to improve some menopausal symptoms such as hot flashes, low mood and vaginal dryness and it can also be prescribed post-menopause to reduce the risk of osteoporosis.
Continuous combined HRT
Continuous combined HRT is used to treat symptoms of menopause and to prevent osteoporosis. It comes as tablets, capsules and patches under the following brand names:
- Tablets and capsules: Bijuve, Elleste Duet Conti, Femoston-conti, Indivina, Kliofem and Kliovance
- Patches: Evorel Conti and FemSeven Conti
It is suitable for women who have not had a menstrual bleed for a year or more. It isn’t recommended for those in perimenopause as it can cause irregular bleeding. You take continuous combined HRT every day without a break and it’s common to stay on a combined HRT regimen for up to five years.
Sequential combined HRT
Sequential combined HRT is suitable for women who are experiencing menopause symptoms but are still having periods, or those who had their last menstrual period less than 12 months ago.
It involves taking oestrogen every day and progesterone for 10-14 days in each 28-day cycle. You’ll usually have a withdrawal bleed after each round of progesterone but it is not a concern if you do not have a bleed. Sequential combined HRT is available as tablets or patches under the following brand names:
- Tablets: Elleste Duet, Femoston, Novofem, Tridesta and Trisequens
- Patches: Evorel Sequi and FemSeven Sequi
What are the benefits of HRT?
The main benefit of HRT is that it is effective in relieving disruptive perimenopause and menopause symptoms including hot flashes, night sweats, sleep problems, low mood and vaginal dryness.
HRT also helps prevent hormone-related conditions such as osteoporosis and improves muscle strength, which can diminish as you reach menopause.
What are the risks and side effects of HRT?
Like most other medications, HRT can cause side effects, although these can differ depending on each individual and the type of HRT you are taking. Many women experience no side effects whatsoever or mild, short-lived ones.
Side effects of HRT and symptoms of menopause can be similar so it might not always be the HRT if you notice new bodily changes. If you have side effects for longer than three months, you can review your regimen with your doctor or nurse, as the form and dosage of your medication may need adjusting.
Side effects of HRT can include:
- Acne
- Breast pain or tenderness
- Changes to your period
- Diarrhoea
- Dizziness
- Feeling sick (nausea)
- Hair loss
- Headaches
- Leg cramps
- Mild rash, itching or skin irritation
- Mood changes
- Stomach or pelvic pain
- Tiredness
- Thrush
- Unusual hair growth
- Vaginal bleeding or spotting
- Vaginal discharge
- Weight gain
While there are risks associated with taking HRT, these are low and are usually outweighed by the benefits. However, it’s important to be fully informed about any medication you are taking so that you can make the right choice for you.
Risks of HRT can include:
Breast cancer
When it comes to HRT and breast cancer, there is a slightly increased risk, although it is low.
According to the NHS, there are around five extra breast cancer cases in every 1,000 women who take combined HRT for five years. There is little or no increase in the risk of breast cancer for oestrogen-only HRT.
The risk of breast cancer increases the longer you are on HRT and the older you are. However, the risk falls again once you stop taking it. You can reduce the risks by taking HRT only for as long as you need to manage your symptoms. Women who have previously had breast cancer will usually be advised against taking HRT.
Blood clots
HRT tablets can slightly increase your risk of blood clots. HRT patches, spray and gel do not increase the risk of blood clots. This is because the oestrogen is absorbed through the skin which is a safer method of delivery into the body.
If you’re susceptible to blood clots, you’ll usually be advised to use HRT patches, gel or spray rather than tablets.
Stroke
HRT tablets can also slightly elevate your risk of stroke. However, the risk is still incredibly low, and even more so if you are under the age of 60.
Read more on risks and benefits of HRT.
When should you take HRT?
There is no definitive time when you should start taking HRT – it’s different for everyone. Menopause usually affects women between the ages of 45 and 55 but symptoms can occur earlier.
You don’t need to wait until your symptoms are severe or your periods stop altogether to explore treatment options. If you are experiencing symptoms that are affecting your life or mood, then it’s a good idea to speak to a professional about starting HRT.
Who can’t take HRT?
If you are experiencing menopause symptoms, then you can usually take HRT, although the type and dosage will depend on a range of factors, including your age and medical history. There are some people that HRT may not be suitable for including those who:
- Have had breast, women or ovarian cancer
- Are pregnant
- Are susceptible to blood clots
- Have untreated high blood pressure
- Have liver disease
- Are taking hormonal contraception
- Have ever had an allergic reaction to oestrogen or progesterone
What are the alternatives to HRT?
If you can’t take HRT, or you simply don’t feel it is the right choice for you, there are alternatives that can help you manage the symptoms of menopause. These include:
- Regular exercise to reduce hot flashes and improve your sleep routine
- Maintaining a healthy diet that helps with weight management and bone health
- Wearing loose clothing made from natural fibres to help with temperature regulation
- Cutting down on alcohol, caffeine and spicy foods as they can trigger hot flashes
- Quitting smoking to reduce hot flashes
- Using a vaginal lubricant or moisturiser to reduce vaginal dryness and discomfort during sex
- Antidepressants that can help with the mood symptoms of menopause
- Clonidine which can be used to treat hot flashes and night sweats
- Herbal remedies including angelica, black cohosh, evening primrose oil, ginseng, red clover and St John’s wort to manage menopause symptoms
- Massage, acupuncture or aromatherapy to alleviate symptoms and help you relax
If you are experiencing menopause symptoms that you’re finding difficult to manage, having an open and honest discussion with a Menopause Care doctor about HRT can help you to decide the next best steps. If HRT is the right choice for you, then Menopause Care can also prescribe you an HRT regimen that can be delivered directly to your door. Book a consultation with a menopause doctor to get started.
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