Hormone Replacement Therapy, HRT, is an effective treatment for menopause symptoms. Treatment involves taking oestrogen and many women need to take progesterone. Testosterone can be added to HRT, off license, to help improve low libido.
Hormones in hormone replacement therapy
Oestrogen
Oestrogen can be taken as a pill, patch, gel or spray.
All women who taken oestrogen as HRT, and still have a womb (and for some who do not have a womb) need to take a progestogen to provide protection against cancer of the lining of the womb.
Progestogen
- Progestogen can be taken as a natural micronised progesterone called Utrogestan or Gepretix, in the UK, is taken orally as a capsule at bedtime, as it can make you feel sleepy.
- The 52mg LNG IUD (commonly called a Mirena) is also a great choice, it releases a progestogen into the womb, to prevent the lining from thickening, and it can remain in place for 5 years before it needs to be changed. It is also an effective contraceptive and can help to reduce heavy periods that can happen in the perimenopause.
- Other progestogens are available and can be taken in combination patches or tablets.
Testosterone
Some women experience symptoms of low libido, low arousal and poor sexual satisfaction despite adequate replacement of oestrogen in HRT. For some people testosterone added to HRT can help improve this.
Localised vaginal oestrogen
- This can be taken alongside HRT, or taken on it’s own ,to relieve symptoms of vaginal dryness, pain on intercourse, soreness of the vulva and vagina, recurrent urinary tract infection and urinary frequency benefit from treatment with vaginal estrogen.
- Vaginal estrogen can be used as a pessary, tablet, cream, gel, or a vaginal ring.
Starting Hormone replacement therapy
When should I start taking HRT?
It is best to start taking when you start to experience symptoms that have any negative impact on your quality of life. For many women this is in the perimenopause, which is the time before menopause. You do not need to wait until your periods have stopped to start taking HRT. HRT can be started when you are older than this, after menopause. Each person needs an individual discussion.
How do I take HRT?
There are two ways to take HRT:
Oestrogen
This could be absorbed through the skin through a patch which is changed twice a week, or applied as a daily gel, spray or taken as an oral tablet. If you start HRT in your perimenopause, when you are still having periods, oestrogen is best started in the first 5 days of your period, if you can.
Progestogen
This can be taken:
Cyclically – sequential combined HRT
- This is usually given if you have had a natural period in the preceding 12 months of starting HRT.
- Progesterone is taken for part of the month only, to mimic the luteal phase of your own menstrual cycle hormones and to try and avoid irregular bleeding on HRT.
- Usually you take progesterone daily for 14 days in a row and then you do not take it for 14 days, and then repeat this 28 day cycle.
- We will advise you when to start taking it in your cycle, usually you start it on day 15 of your menstrual cycle, but this can be difficult if your own cycle is irregular. The aim of this type of HRT is for you to settle into a monthly bleed.
Continually every day -continuous combined HRT .
- The aim of this type of HRT is for you not to bleed and this way of taking HRT is usually given to people who start HRT in menopause, after not having had a period for more than a year.
- Once you have been on sequential combined HRT we will advise you about the right time to change to continuous combined HRT so you no longer bleed.
Is HRT contraceptive
HRT is not a contraceptive, unless you use the Mirena IUS.
When will I feel better if I start HRT?
- Some women notice a difference in their symptoms within a few days, but most women see a slow and steady improvement in their symptoms over weeks and months.
- You may notice physical symptoms get better first, for example, at the correct dose of estrogen, hot flushes and night sweats are often much better after 6 weeks.
- Psychological symptoms, such as low mood, anxiety and your brain fog can take a few more months to improve.
- It is important to take HRT for at least 3-6 months before deciding whether it is the right dose and is right for you.
What side effects might I have if I take HRT?
- Each hormone in HRT affects the body differently.
- Keeping a symptom diary helps us work out what symptoms you are having and when you are having them.
- We may need to make an adjustment to your HRT, to give you the balance of hormones that are right for you.
- This can take time to settle when you start HRT, particularly if you start in perimenopause, as your own hormones are fluctuating.
- Any side effects that have not settled down by 3 months please let us know at your follow-up appointment, especially if you only notice them in the two weeks of taking progesterone.
If you are using patches, they can leave sticky marks from the glue which can be removed with baby oil and a cotton pad or dry flannel. If your skin becomes red from the patch, stick the next patch onto a different area of skin. If your skin irritation persists, please let us know, as there are often other brands to try, that may not cause the same irritation.
Side effects of estrogen can be:
- Bloating
- Leg cramps
- Swelling
- Breast tenderness or swelling and nipple sensitivity, make sure you have a well fitting bra
- Feeling sick
- Headaches or migraine attacks
- Vaginal bleeding as estrogen thickens the womb lining, it is common to get some bleeding or spotting when you start taking HRT which should settle at 3-6 months. Please talk to us if you are still having this problem at 3 months. If you are having heavy prolonged bleeding with clots, or you are bleeding after sex please see your GP.
- Indigestion
Progesterone all women who use estrogen replacement HRT and who have a womb (uterus) require the addition of a progestogen to protect the lining of the womb from the thickening effect of estrogen. If you are taking progesterone, you may notice a dip or change in your mood initially. It is important to take progesterone or a progestogen if you take estrogen, we can work with you to change the type of progestogen you take or how you take it if you are having side effects, but you must take this, if you have a womb.
Side effects of progesterone HRT can be:
- Breast tenderness
- Swelling and bloating
- Mood swings and feelings of low mood
- Vaginal bleeding
- Abdominal pain
- Acne
Testosterone -at present there are no testosterone products licensed for use in women in the UK, all Testosterone products are prescribed off licence, NICE guideline NG23. Testosterone is usually given as a gel and is applied once daily to the outer thigh or lower abdomen. To reduce the small risk of localised hair growth at the site of application it is best to rotate the site you apply it.
Side effects of Testosterone can be:
- Local hair growth to the application site
- Acne and greasy skin
- Increased hair growth
- Weight gain and appetite change
- Male pattern baldness
- Enlargement of the clitoris
- Deepening of the voice
If you are struggling with HRT side effects, and things aren’t settling down in a few weeks, please let us know. We can help and may change your HRT dose, or the type of hormones you take, or change the way you take your hormones.
What is good about taking Hormone replacement therapy?
- Relief of your symptoms
- Maintenance of bone mineral density and reduced risk osteoporotic fractures. Remember to look at the Royal osteoporosis website for advice about calcium in the diet, vitamin D and exercise for bones.
- There is evidence that HRT started within 10 years of the menopause, or below the age of 60 is associated with a reduced risk of cardiovascular (heart and blood vessel) disease.
- Potential benefits include a reduced risk coronary heart disease is started early.
- Reduced risk colorectal cancer and reduced risk Type 2 diabetes mellitus.
What are the risks of taking Hormone replacement therapy?
As with any medication there are risks and benefits. With HRT they are generally regarded as low, and depend upon the type of hormones that you take and upon your own medical conditions and health profile.
Studies show that taking combined HRT, that is an oestrogen plus progesterone, there may be a small increased risk of breast cancer. The risk may vary with the type of progestogen used and with the length of time HRT is taken for. There may not be an increased risk if you take oestrogen only HRT, but if you have a womb, it is vital that you take progesterone as well in order to reduce the risk of endometrial cancer.
The links below give you more information in pictorial form.
- NICE guidance HRT and the likelihood of some medical conditions
- Understanding breast cancer the risks
- Wellspring HRT risks and benefits
Oral oestrogen tablets have been associated with an increase with blood clot and stroke. Using oestrogen through the skin transdermally, as a gel patch or spray does not carry this same risk.
Limited evidence suggests that HRT may be associated with a risk of ovarian cancer, about 1 extra case per 1000 women.
Risk from lifestyle and HRT
Lifestyle and being overweight play a significant role in the chance of developing breast cancer – in some cases they play a
much greater role than that of HRT.
It is estimated that 23 women in every 1000 will develop breast cancer over a period of 5 years between the ages of 50-59 (background risk).
- If you take the contraceptive pill or combined HRT that figure rises by 4 cases/1000 to 27/1000 women
- If you drink more than 2 units of alcohol a day it rises by 5 cases/1000 to 28/1000.
- If you smoke there are an extra 3 cases taking it to 26/1000.
- If you have a BMI of more than 30 the risk more than doubles with an extra 24 cases/1000 women or 47/1000.
- If you take oestrogen only HRT the rise decreases by 4 cases/1000 to 19/1000.
- If you exercise 30 min daily for 5 days a week, it drops by 7 cases down to 16/1000.
It is recommended that women who have had a hormone receptive breast cancer do not take systemic HRT and choose non-hormonal options, but vaginal oestrogen is increasingly being considered safe as there is little to no systemic absorption after
the initial loading dose. These are discussions to be had with your healthcare provider, balancing out your individual health
benefits for quality of life and side effects or risks.
Tips for remembering your HRT
Find a way that works for you to remember to regularly take your HRT. It needs to be applied it at the same time every day, usually when getting up and dressed or when going to bed. You should avoid the application of moisturiser or sun cream to the area within one hour of application of your gel or spray. If you split your dose of gel or spray into a morning and evening application, leave about 12 hours between doses, if you can.
If you are taking Utrogestan, please take it before bed as it can act as a sedative. If you find that difficult and it doesn’t make you too sleepy, then any time of day is ok. The most important thing to do is to take it regularly to protect your womb. If you find that you are forgetting this please talk with us so we can change your preparation to something that is easier to use like putting in a Mirena IUS or having a patch or combined tablet which contains your progesterone.
We advise an annual review when you take HRT, to check your medical history, family history, medication, supplements, BP and weight.
Lifestyle helps
Even if you take HRT, it is not a magic pill that will do it all, healthy lifestyle choices like prioritising sleep, having a healthy balanced diet, moving every day aerobic and strength, reducing alcohol, not smoking, keeping a healthy body weight and managing your stress are so important. HRT work hand in hand with these choices and will help manage any symptoms and protect your future health. You can complement HRT and lifestyle choices by finding social support like time with family and friends, practicing yoga, trying acupuncture and using reflexology.
For an appointment at Rowena Health Menopause Specialist Clinic online if you are in the UK or in person at our Guildford Clinic, please visit the booking page of the website.
British Menopause Society Videos
Last updated July 2024 Dr Carys Sonnenberg