Hormone Replacement Therapy explained

Hormone replacement therapy (also called menopause hormone therapy) is used to treat symptoms associated with the menopause.

More than 75% of women experience symptoms during the perimenopause and menopause that affect their lives at home, socially and at work. For 25% of women, the symptoms are severe.

There are several ways to help relieve symptoms: healthy lifestyle changes, hormone therapy (such a HRT or hormonal contraception), cognitive behavioural therapy, non-hormonal prescribable therapies, complementary and alternative therapies. It is important to talk with a health professional if your symptoms are affecting your quality of life.

Let’s clarify the definitions:

• Perimenopause is the time leading up to a natural menopause – when periods become different (lighter, heavier, closer together, further apart) and menopausal symptoms start to happen.
• Menopause (for women 45 years or older) is the day one year after the last natural menstrual period. The average age in the UK is 51, but this age varies between different cultures.
• Postmenopause is the time after menopause. As the average life expectancy of a woman in the UK is now 82, women can spend, on average, 30 years of their lives after menopause.
• Surgical menopause is the day the ovaries are removed during an operation (before a woman has gone through her menopause)
• Induced or iatrogenic menopause (may be permanent or temporary )and is when periods stop because the ovarian function is affected by chemotherapy, radiotherapy, or hormone blockers.
• Early menopause is when menopause happens between the ages of 40-45 years.
• Premature ovarian insufficiency (POI) is when menopause occurs before the age of 40 years.

What are the symptoms of perimenopause and menopause

The ovaries have two main roles. They produce eggs, which are essential for fertility, and they produce hormones, primarily oestrogen, progesterone and testosterone, which regulate your menstrual cycle and support many functions throughout your body, including bone strength, heart health, brain function, mood, sleep and the health of the vagina and bladder.

After menopause, the ovary does not produce eggs or hormones in the way it did. As oestrogen receptors are all over the body, the changing hormone levels in perimenopause and low hormone levels after menopause can lead to widespread symptoms. Read our article: click here.

What is hormone replacement therapy?

This article discusses Hormone replacement therapy (HRT) which is the use of hormone treatments to relieve the symptoms of perimenopause and menopause.

The hormones

• Oestrogen: is the main hormone – helps to relieve the symptoms of menopause. The dose can be adjusted to relieve symptoms.
• Progesterone: women who have a womb (uterus) will need both oestrogen plus progesterone in a balanced dose. Taking oestrogen can lead to thickening of the lining of the womb. Progesterone acts as a lawn mower, it keeps the lining of the womb thin. Those who have had a hysterectomy (had their womb removed using an operation) don’t usually need to take progesterone and can take oestrogen only. There are some exceptions, for example a hysterectomy if you have endometriosis, a subtotal hysterectomy or use of HRT after an endometrial ablation.
• The role of testosterone: Testosterone is not needed by everyone. It can be added to oestrogen and a progestogen and may improve sexual desire, arousal, and satisfaction in some women. There is no current good quality evidence that it has other benefits.

These hormones are taken in a way to absorb them into the blood stream (this is called systemic HRT).

There is no single right way to take HRT. Menopause care is individualised, and there are many HRT regimes to choose from.

The decision about whether to start HRT, at what dose, and for how long, should be made together with your prescriber, based on your symptoms, medical history, family history, and personal preferences.

What types of HRT are available?

Oestrogen

Oestrogen forms the main part of HRT. The type of oestrogen usually used now is called oestradiol, which is structurally identical to the oestrogen your ovaries produced before menopause, so it is known as a body identical or bioidentical oestrogen. It can be taken in several ways (gel, patch, spray or oral tablet), and the dose can be adjusted to suit you.

Transdermal oestrogen (absorbed through the skin) is the preferred route for most women, as it does not carry the small increased risk of blood clot that is associated with oral oestrogen tablets. Transdermal options are gel, patch and spray but oestrogen can also be taken as an oral tablet.

The table below summarises the key differences in oestrogen products to help you think about which might suit your lifestyle.

Type	How it is applied	Advantages	Things to be aware of
Oestrogen gel Pump or sachet	Apply gel once daily to clean, dry skin on the upper outer arm or inner thigh. Dose is measured in pumps or sachets.	Easy to use. Dose is flexible and easy to adjust.	Allow 5 minutes to dry before getting dressed. Avoid applying moisturiser or sun cream to the area for 2 hours. Avoid skin-to-skin contact with others/pets for 2 hours after application.
Oestrogen patches Different brands are available A range of doses are available from 25mcg to 100mcg	Applied to clean, dry, non-hair-bearing skin below the waist. Changed twice weekly (FemSeven once weekly).	Delivers a steady level of oestrogen. Change once or twice a week (depending on the brand). Can be worn in the shower, bath or during exercise.	May leave adhesive residue (removed with baby oil). Some women develop skin irritation, try a different brand with a different adhesive if this happens, which often resolves this. If a patch falls off replace it with a new one and then return to your usual changing regime.
Oestrogen spray	Applied once daily to the inner forearm or inner thigh. Same circular area each time and do not overlap circular areas.	Absorbs quickly (around 1 minute). Small area of application.	Avoid skin-to-skin contact with others for one hour after application. Apply sun cream to the area at least one hour after the spray.
Oestrogen oral tablet	Swallowed at the same time daily	Convenient	Passes through the liver, which is associated with a slightly higher risk of blood clot than if oestrogen is taken via the transdermal routes.

How to use an HRT patch: read our article: click here

How to use oestrogen spray: read our article: click here

How to use oestrogen gel: read our article: click here

Progestogen: protecting the womb lining

The word progestogen includes progesterone and synthetic versions of this (also known as progestins).

Women who have a uterus and take oestrogen as part of HRT need to also take a progestogen. This is extremely important – oestrogen therapy taken alone leads to thickening of the lining of the womb and, over time, an increased risk of endometrial cancer (cancer of the lining of the womb). A progestogen (in a balanced dose with oestrogen) protects the lining of the womb from thickening and from developing endometrial cancer.

There are several types of progestogen

The right one for you will depend on your medical history, your previous response to hormones (for example in contraception), whether you have experienced premenstrual syndrome, and how well you tolerate different preparations. There is no one-size-fits-all.

• Micronised progesterone is structurally identical to the progesterone your body produces (body identical or bioidentical). It is taken as an oral capsule, ideally at bedtime, as it has a mild sedative effect that can help with sleep. It is better absorbed with food. For some women who experience side effects with the oral capsule, it can be taken vaginally, but do not change how you take it without speaking to your prescriber first.
• Dydrogesterone is a good alternative, particularly for women who experience breakthrough bleeding or side effects with micronised progesterone.
• The 52mg LNG-IUD is a hormonal coil inserted into the womb by a clinician. It releases a small amount of progestogen locally, protects the womb lining, and lasts for five years as part of HRT. Many women find this option appealing because, once fitted, there is nothing to remember daily. It also acts as effective contraception and can reduce heavy periods, which are common in perimenopause. Some women experience symptoms similar to premenstrual syndrome when the coil is first inserted; these usually settle.
• Other progestogens such as norethisterone, medroxyprogesterone acetate, drospirenone, desogestrel and dienogest can be prescribed in combination patches or oral tablets. Some women find they tolerate these synthetic options better than micronised progesterone.

Progestogens act on different receptors in the body, and some women may experience side effects for this reason.

Sequential versus continuous HRT

The way progestogen is taken depends on whether you are still having periods when you start HRT for the first time.

• Sequential (cyclical) combined HRT is usually recommended if you have had a natural period within the last 12 months. You take oestrogen every day, and progestogen for approximately 14 days of each 28-day cycle – typically two weeks on, two weeks off. The aim is for you to settle into a regular, predictable bleed of three to seven days at the end of the progestogen phase. Some irregular spotting is common in the first three to six months. Any heavy, prolonged or unexpected bleeding should always be reported to your prescriber.
• Continuous combined HRT is recommended for women who have not had a period for at least 12 months. Both oestrogen and progestogen are taken every day with the aim of no bleeding at all. Some unscheduled spotting in the first three to six months is normal, but after six months any bleeding should be reported and investigated.

Your prescriber will advise you when the right time is to move from sequential to continuous HRT.

Testosterone

Testosterone is the third hormone that may be considered as part of your care. It can be added where women continue to experience low libido, reduced arousal or poor sexual satisfaction despite adequate oestrogen replacement.

• There is currently one licensed product for women in the UK (Androfeme), but because it is not available on the NHS, most prescribers use small doses of testosterone gel intended for men at much lower doses for this purpose. This is known as off-label prescribing and is accepted practice in specialist menopause care.
• Blood tests to monitor your testosterone level are recommended on initiation, after three months of use and annually thereafter, to ensure levels remain within the female physiological range.
• The gel is applied once daily to the outer thigh or lower abdomen, rotating the site each day to minimise the small risk of local hair growth.
• Some women taking testosterone report wider benefits beyond libido, including improvements in energy, concentration, mood and sleep, but robust trial evidence for these additional effects is still emerging. A thorough discussion about the possible causes of low libido and a review of oestrogen levels should always happen before testosterone is started.
• Side effects can include local hair growth at the application site, acne and greasy skin and, at higher doses, other signs of androgen excess. These are usually avoidable with careful dosing and monitoring.
• It is important to let your prescriber know if you are a competitive athlete.

Local vaginal oestrogen: a separate consideration

Up to 80% of women experience symptoms of genitourinary syndrome of the menopause (GSM) — a term that includes vaginal dryness, soreness, discomfort during sex, recurrent urinary tract infections, urinary urgency and frequency. Unlike hot flushes, which often improve with time, these symptoms tend to be progressive and can significantly affect quality of life and intimate relationships.

Local vaginal oestrogen delivers a low dose of oestrogen directly to the tissues of the vagina and vulva, with minimal absorption into the bloodstream. Because the absorption is so low, women using vaginal oestrogen alone do not need to take a progestogen alongside it. It can be used indefinitely, it is a long-term treatment, not a short course, and works well alongside good vulval care, non-hormonal vaginal moisturisers and lubricants.

It can be taken alongside HRT if these symptoms are not controlled with the systemic HRT hormones above, or it can be used on it’s own.

The table below compares the available forms to help you decide which might suit you.

Type	How it is used	Advantages	Things to be aware of
Tablet / pessary 10mcg estradiol	Inserted into the vagina using an applicator, usually at night. Used daily for 2 weeks then twice weekly ongoing.	Clean and easy to use. Can be bought without prescription from the pharmacy for women over 50 years who have not had a period for 12 or more months.	Comes with either a single-use plastic applicator or a reusable applicator depending on which brand is chosen.
Waxy estriol bullet pessary	Inserted into the vagina using the fingers. Used daily for 3 weeks then twice weekly ongoing.	No applicator. The waxy texture has a lubricating effect that can help with dryness.	Can produce a slight waxy discharge. Can damage latex condoms
Estriol cream Two strengths Estriol 0.1% (0.5mls per dose) Estriol 0.01% (5mls per dose)	Inserted into the vagina daily for 2-4 weeks then twice weekly. Can also be applied to the vulva with a finger	Soothing and can be applied with the applicator or a finger	Can be a bit messy The 0.1% cream does not affect a condom The 0.01% contains peanut oil so avoid if you or your partner has a peanut allergy and it can damage latex condoms
Estriol gel	Inserted into the vagina daily for 3 weeks then twice weekly.	Rapidly absorbed and soothing	Mild itching or irritation when first using it usually settles.
Estradiol vaginal ring	A soft silicone ring inserted into the vagina by you or a health professional. Stays in place and releases oestrogen continuously for 90 days.	You don’t need to remember to apply a regular cream or pessary	Does not usually interfere with sex, but you can remove it beforehand and reinsert afterwards
DHEA pessary	Inserted into the vagina once daily.	Does not contain oestrogen directly — prasterone (DHEA) is converted to oestrogen and testosterone within vaginal cells.	Can damage latex condoms

Other options include an oral tablet, if dexterity is difficult.

If symptoms are not improving after two to four months, it is important to have an examination to rule out other causes for symptoms, such as lichen sclerosus. The dose of your low dose oestrogen product could be adjusted or you could try another product.

Women who have had a hormone-receptor-positive breast cancer are usually advised not to take systemic HRT, but vaginal oestrogen is increasingly considered safe in this group due to its minimal systemic absorption. Women using an aromatase inhibitor who develop symptoms should speak to a menopause specialist.

The benefits of HRT

The evidence for HRT is substantial and covers several areas.

• Improvement in symptoms: HRT is the most effective treatment for hot flushes, night sweats, sleep disturbance, low mood, anxiety, brain fog, joint pain and fatigue. Physical symptoms such as hot flushes and night sweats often begin to improve within six weeks at the right dose. Psychological symptoms, mood, concentration, anxiety may take a few months longer. It is important to give HRT at least three to six months before deciding whether it is working for you.
• Bone health. HRT maintains bone mineral density and reduces the risk of osteoporotic fractures.
• Cardiovascular protection. Evidence suggests that HRT started within ten years of the menopause, or before the age of 60, is associated with a reduced risk of cardiovascular disease.
• Improvement in quality of life. The improvements that come with effective symptom control — better sleep, more stable mood, greater energy, improved sexual health — have a meaningful impact on daily life, relationships and work.

The risks of HRT

As with any treatment, HRT has risks as well as benefits. The risks are generally low and depend on the type of hormones used, how long they are taken, and your individual health profile.

Breast cancer

This is the risk that concerns most women.

Around one in seven women in the UK will develop breast cancer during their lifetime. This background risk is influenced by many factors: age, family history, weight, alcohol intake, smoking and exercise levels. Studies show that taking combined HRT (oestrogen plus a progestogen) for more than five years carries a small increased risk of breast cancer. The risk increases with longer duration of use.

Healthy lifestyle choices can affect risk of developing cancer.

Blood clots and stroke

Oral oestrogen tablets carry a small increased risk of blood clot (venous thromboembolism) and stroke. Transdermal oestrogen (gel, patch or spray) does not carry this same risk.

Your individual medical history, family history and current medications will influence whether HRT is right for you and which type is safest.

What if you don’t think your HRT is working?

If you feel that your HRT is not working, it is important not to give up without speaking to your prescriber first. There are several common reasons why HRT may not seem to be helping.

• It may simply be a matter of time — HRT often needs three to six months to reach its full effect, and stopping too soon means you may not have given it a fair chance. The dose may need adjusting, as the starting dose is not always the right dose for you. If you are using a gel or spray, absorption through the skin can vary between women, and switching to a patch or changing the application technique can sometimes make a significant difference. The type of hormone or the way you are taking it may also need reviewing.
• It is also worth reflecting on lifestyle factors. High levels of stress, poor sleep, low physical activity, alcohol and an unhealthy diet can all undermine how well you feel, even on HRT. HRT works best alongside a healthy lifestyle, and if these factors are significant, addressing them may make a real difference to how you respond.
• It is also worth considering whether there is another explanation for your symptoms. Some conditions — such as thyroid problems, anaemia or low mood — can cause symptoms that overlap with menopause, and these will not improve with HRT alone. If symptoms persist despite good HRT optimisation, your prescriber may recommend further investigation.
• It may be that low dose localised vaginal oestrogen needs to be added to your HRT, if bladder, vaginal and vulval symptoms are not relieved on systemic HRT.
• It could be that instead of your HRT not working, you are actually experiencing side effects from use of the hormones of HRT. Keep a symptom diary which can help to decide if this could be happening.

With the right adjustments, most women do find a regime that works for them.

Side effects of HRT

Side effects are common when starting HRT, particularly in perimenopause when your own hormones are still fluctuating. Most settle within three months with the right adjustments. Keeping a symptom diary can help your prescriber identify patterns.

• Common side effects of oestrogen include breast tenderness, bloating, nausea, headaches, leg cramps and skin sensitivity at the application site (for patches). Some women experience vaginal spotting when first starting, which usually settles by three to six months.
• Common side effects of progestogen include breast tenderness, bloating, mood changes and abdominal discomfort. If you notice these mainly during the fortnight when you are taking progestogen, mention this at your review — it may be that a different progestogen, a different dose, or a different route of administration would suit you better.
• Testosterone side effects are usually dose-dependent and include local hair growth at the application site, acne and greasy skin. These are minimised by rotating the application site and using the prescribed dose accurately.

If side effects are troublesome and have not settled after a few weeks, contact your prescriber. There are many adjustments we can make before concluding that HRT is not for you.

When is HRT not recommended?

There are very few conditions where taking HRT is contraindicated, but there are certain medical conditions where taking hormonal therapy is not recommended. This is usually because the risks of taking hormone therapy outweigh the benefits. It is important to discuss your symptoms with your health professional and discuss the options for treatment for your own individual case. In complex cases, it can be helpful to make an appointment with a BMS registered menopause specialist with expertise in menopause.

How long can I take HRT?

There is no fixed cut-off age or maximum duration for taking HRT. What matters is an annual review in which you and your prescriber weigh the benefits against the risks in the context of your current health, and confirm that there is a clear clinical reason to continue. At each review your blood pressure and weight should be checked, your symptoms assessed, your medication and supplements reviewed, and reminders given about appropriate health screening.

If you decide to stop systemic HRT, it is often worth continuing local vaginal oestrogen, as GSM symptoms do not improve with time and will return without treatment.

HRT is not contraceptive

HRT does not provide contraception unless you are using a 52mg LNG-IUD such as the Mirena or a progestogen only method of contraception.

You can take a progestogen-only contraceptive alongside HRT if contraception is needed. A barrier method such as a condom also offers protection against sexually transmitted infections. Your prescriber can clarify whether your current HRT regime provides contraceptive cover.

A note on lifestyle

HRT works most effectively alongside healthy lifestyle choices. Prioritising sleep, eating a balanced diet, moving daily (both aerobic exercise and strength training), reducing alcohol, not smoking, maintaining a healthy weight and managing stress are all important. These are not just extras, they affect your risk profile for breast cancer, cardiovascular disease and osteoporosis.

In England, the HRT Prescription Prepayment Certificate (HRT PCC) allows you to pay a single annual fee covering all eligible HRT prescriptions. HRT prescriptions are free in Wales, Scotland and Northern Ireland.

What about bio-identical HRT?

The term “bio-identical” is widely used but can be confusing because it covers two very different things.

• Regulated bio-identical (or body-identical) HRT is manufactured by the pharmaceutical industry to MHRA standards, and includes products like oestradiol gels, patches and sprays, and micronised progesterone. They are structurally identical to the hormones your body produces, and they follow a conventional regulatory pathway, which means their safety and efficacy are well established.
• Compounded bio-identical HRT is produced by specialist pharmacies to individual prescriptions, often using saliva or serum testing to guide the formulation. While the hormones themselves may also be structurally identical to the body’s own, they are not subject to the same regulatory oversight as licensed medicines. There is insufficient evidence to support the complex and often costly testing protocols associated with this approach.

Nine things to discuss before starting HRT

If you are thinking about HRT, the following checklist covers the key conversations to have with your prescriber before starting.

1. What are your main symptoms? Identifying what is most troublesome: hot flushes, poor sleep, mood changes, joint pain, vaginal symptoms, brain fog, low libido guides the choice of treatment and dose.

2. What is your menstrual pattern? Whether you are still bleeding, and whether your periods are regular or irregular, determines whether you need sequential or continuous HRT, or whether any investigations are needed first.

3. What is your medical history? Conditions such as high blood pressure, migraine, a clotting disorder, thyroid disease or previous cancer all influence whether HRT is appropriate and which type is safest for you.

4. What is your family history? Note any history of breast, ovarian or endometrial cancer, early cardiovascular disease, or osteoporosis.

5. What medications and supplements do you take? A full review of everything you take, including thyroid replacement, antidepressants, antihypertensives and herbal supplements is essential to check for interactions.

6. What is your preferred route of oestrogen? Patch, gel, spray or tablet.

7. What is the right progestogen for you? If you have a uterus, this is required.

8. What are your lifestyle factors? Alcohol intake, smoking, diet, physical activity and weight all affect risk and should be part of the conversation.

9. What is the review plan? HRT requires at least an annual review, and sooner if you change formulation, experience unexpected bleeding, or develop new symptoms.

In summary

HRT is a safe and highly effective treatment for most women with menopausal symptoms. It is not one-size-fits-all — and it should not be. The right type, dose and route of administration will depend on you as an individual: your symptoms, your history, your preferences and your values. When prescribed with care and reviewed regularly, HRT can make a profound difference to how you feel and to your long-term health.

If you have questions about whether HRT is right for you, or would like to discuss your current treatment, you are welcome to book an appointment with Dr Sonnenberg at Rowena Health: click here

This article is for informational purposes only and does not constitute medical advice. Please consult a qualified healthcare professional before starting or changing any hormone treatment.

Reference: https://thebms.org.uk/publications/tools-for-clinicians/

Further reading for you: https://www.womens-health-concern.org/help-and-advice/factsheets/

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