Hormone replacement therapy (HRT) essentially replaces one or more of the hormones oestrogen, progesterone and testosterone and it is the most effective treatment for menopause and perimenopausal symptoms.
These hormones are produced by the ovaries, and changing levels of these hormones in perimenopause, and low levels after menopause, has wide-reaching effects from hot flushes and sweats to joints pains, loss of libido (sex drive) and vaginal dryness.
What are the benefits of HRT?
Most women notice an improvement in their wellbeing after a relatively short period of time (2-3 months), but it can take longer for things to return to normal.
In addition to improving symptoms, depending upon the age and stage of menopause HRT is started, current evidence shows that HRT can also reduce the risk of some chronic health issues including cardiovascular (heart disease), diabetes and osteoporosis (fragile bones which can break more easily).
In the majority of women who start HRT before the age of 60, the risks of HRT are outweighed by the benefits.
When should I start taking HRT?
This is a personal choice, however there is significant benefit for other long term health issues (heart disease/osteoporosis) if HRT is started early, certainly within 10 years of menopause, but you do not need to wait for your periods to stop, you can start taking HRT in perimenopause, when you are having symptoms and are still having periods, which may be changing in nature. You could also use the combined contraceptive pill during perimenopause, if it is safe for you to take this, and some of the newer versions of this type of contraceptive contain oestrogen in the form of E2 and E4, instead of the ethinylestradiol, which may pills contain and they may be choices for some women.
There is no arbitrary time limit to using HRT, providing there is benefit, there is no specific cut-off and women are increasingly choosing to take HRT beyond the age of 60.
In women with Premature ovarian insufficiency, POI, HRT is advised to be taken, if not contraindicated, and continued until menopausal age, after this time it is an individual decision on continuing care.
How to take HRT?
Oestrogen
This can be replaced either through the skin as a patch, gel or spray, or in a tablet or implant. Most of these formulations contain oestrogen in a form identical to the oestrogen which women naturally produce called 17 B-estradiol, which is derived from the yam plant. Oestrogen is the key hormone that improves the majority of menopausal and perimenopausal symptoms.
Progestogen
This is needed alongside oestrogen if women have a uterus (womb) as taking oestrogen without progestogen can lead to thickening of the womb lining and an increased risk of womb lining (endometrial) cancer. Women with a uterus should therefore use combined HRT (oestrogen + progestogen). Progesterone, as a bioidentical / body identical hormone, is available in capsule form, as part of HRT, or a synthetic progestogen (similar to progesterone but not exactly the same) can be taken.
There are various ways in which you can take progestogen.
- A patch which contains oestrogen and a progestogen which is absorbed through the skin
- It is available combined with oestrogen in an oral tablet
- As a separate oral tablet or capsule to be used with oestrogen taken as a gel, patch, spray or oral tablet
- A hormone device containing progestogen (Mirena 52mg Levonorgestrel IUD) – up to 5 years at a time and also providing contraception and help to lighten heavy periods
One of the safest ways to take progestogen is as a capsule containing body identical micronised progesterone (Utrogestan or Gepretix), this is usually taken orally but some women use the same preparation and vaginally with advice from their Dr about dose and safety.
Testosterone
This is another key female hormone, although we produce much smaller amounts than men, it has important roles in libido, sexual arousal, metabolism, muscle and bone strength, mood and cognitive function. Some women find that, despite oestrogen being used, symptoms such as low libido, reduced orgasm, fatigue, low mood, brain fog and muscle fatigue are still an issue. In
these women, testosterone therapy (in addition to oestrogen) can be beneficial.
Testosterone is available as a gel or cream which is rubbed into the skin. While there are no specific products licensed for female use in the UK, it is widely used and safe when prescribed by your menopause specialist who will carefully monitor the dose and blood levels during your treatment.
Low dose vaginal oestrogen
This treatment can be added to your HRT, or taken without HRT, to help if you suffer from vaginal and bladder symptoms.
Risks of HRT
Breast cancer
Using oestrogen and progestogen (combined HRT) is associated with a small increased risk of developing breast cancer, using oestrogen only HRT may be associated with a small increased risk of breast cancer. The risk is lower than the risk of breast cancer associated with obesity, and about the same as the risk of other lifestyle choices like smoking and drinking a large glass of wine each night. Please discuss this individual risk with your Dr.
E3N studies reported on the risk of breast cancer risk in users and micronised progesterone and dydrogesterone appear safer compared to other progestogens, for the first 5 years.
Blood clots
Oestrogen given in an oral (tablet) form increases the risk of blood clotting, however studies in healthy women taking moderate doses of oestrogen transdermally, as a gel, spray or patch, absorbed through the skin, do not show an increased risk of blood clot.
If you are high risk for blood clot, for example, you have a BMI at 30 or above, you have a personal history of blood clots or other conditions which increase the risk of blood clots or strokes, you have a family history of a blood clotting disorder or inherited thrombophilia, using an oestrogen preparation through the skin (as a gel/patch/ spray) is preferred. Your Dr may need to get the advice of a haematologist before starting HRT if you have high risk of blood clot.
Stroke
Taking oral oestrogen (but not transdermal at moderate doses) is associated with a small increase in the risk of stroke, but the risk of stroke in women aged under 60 years is very low so many women can choose to take oral oestrogen after discussion with their Dr. For women over the age of 60 using transdermal oestrogen is preferred as risk of blood clot increases with age.
Ovarian cancer
There may be association with use of oestrogen only HRT and combined HRT with oestrogen and progestogen, and ovarian cancer. With 5 years of HRT use, there could be 1 additional ovarian cancer per 1000 users and 1 additional death per 1700 users among women of all ages.
Dementia
Evidence currently shows that HRT is unlikely to increase the risk of dementia or to have a detrimental effect on cognitive function in women initiating HRT before the age of 65. More studies are needed in this area.
Type 2 diabetes
Taking HRT (either orally or transdermally) is not associated with an increased risk of developing type 2 diabetes. If you have diabetes, HRT use has not been shown to have adverse effect on blood glucose control, but some progestogens are preferable due to their effect on lipids (blood fats) and insulin resistance, oral synthetic progestogens can increase glucose so body identical progesterone may be preferred.
Side effects of HRT
Side effects are not common but include nausea, tender breasts and bleeding. Usually, these resolve after a few months, so it is important to allow time for your body to adjust to using the hormones and keep going! If side effects do not settle or worsen, please discuss these with your menopause specialist or GP as some simple adjustments to your dose or regimen can often resolve
these.
Bioidentical compounded HRT
The use of compounded bioidentical hormone replacement therapies is not recommended given the issues related to their purity, potency and safety.
There are different ways to take the different hormones in HRT and we will tailor make this for you, depending on your choice, your health conditions and your family history. We will recommend the safest preparation and dose for you. Please do talk with us about your preferences, some women love the gel and others don’t. Some women remember to take a tablet every night for 2 weeks of the month and other’s would never remember that, don’t worry, we’ll work together to find the right HRT for you.
We can discuss which preparation may suit you and your lifestyle best.
For an appointment at Rowena Health please click on the link, we will be delighted to see you.
Dr Carys Sonnenberg Rowena Health July 2024