What is HRT? Hormone Replacement Therapy, refers to taking of one or more of the hormones estrogen, progesterone and testosterone. These are hormones already made by your body. NICE guidelines from 2015 recommend the use of HRT as the first choice for women who have symptoms caused by low or fluctuating hormone levels. It has been shown to offer the most effective relief from symptoms, and for the majority of women the benefits of taking HRT outweigh the risks. At Rowena Health Menopause Clinic we will discuss everything with you if you are considering taking HRT, and are delighted to answer any questions during your appointment.
Hormones in hormone replacement therapy
- Estrogen, the type of estrogen mostly used in HRT is called 17 beta-estradiol and it is derived from the root vegetable, called the yam. This has an identical biological structure to the estrogen produced in your own ovary. It can be given as a patch, gel or spray delivered across the skin, this is called a transdermal application, and also as a tablet taken orally.
- Progestogen, all women who still have a womb and who use estrogen replacement will also need a progestogen. If given alone, estrogen causes the lining of the womb to thicken, like applying a fertiliser to the lawn, with an increased risk of abnormal cells developing or an endometrial cancer. The progestogen keeps the lining of the womb thin, like using a lawn mower, and prevents this from becoming abnormal. Natural micronised progesterone called Utrogestan in the UK, is taken orally as a capsule at bedtime, as it can make you feel sleepy, and is also derived from the yam plant. It is used as part of Body Identical regulated HRT. The Mirena coil is also a great choice, it releases a progestogen called levonorgestrel 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 continue to experience symptoms of low libido, low arousal and poor sexual satisfaction despite adequate replacement of estrogen. For some of these women a trial of testosterone can beneficial. Currently there are no testosterone products licensed for use in women in the UK, but we can prescribe a testosterone gel off license, and under our supervision. Some GP’s can do this, too, if it is on their prescribing formulary.
- Local vaginal estrogen, can be added to HRT or taken on it’s own if you have 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, cream or gel, or a ring that remains in your vagina for 90 days and then is replaced.
Starting Hormone replacement therapy
When you start taking Hormone Replacement Therapy, HRT, you might be a bit nervous. Will you feel wonderful, or might you get some side effects, as your body gets used to the new hormones? How long will it take for you to feel better? What will you do if you don’t feel better? What product is right for you? Don’t worry, these feelings are normal for many women. When you are starting HRT you may experience some side effects, but they often settle within a few weeks.
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. NICE guidelines recommend HRT as first line treatment for managing the symptoms, and for the majority of women who start HRT below the age of 60, the benefits of taking HRT outweigh the risks. The long-term health benefits of HRT are best achieved if HRT is started below the age of 60 or within 10 years of your 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, and we will discuss each case individually.
How do I take HRT?
There are two ways to take HRT:
Estrogen is taken every single day, this could be as a patch which is changed twice a week, daily gel or daily spray or daily oral tablet. If you start HRT in your perimenopause, when you are still having periods, estrogen is best started in the first 5 days of your period, if you can.
Progesterone or progestogen can be taken in two ways:
- 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
Once you have been on sequential combined HRT and your own hormones have settled we will change you to continuous combined HRT so you no longer bleed.
Don’t forget that 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. However your 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.
Estrogen as part of HRT can be taken as a patch, gel, spray or a tablet. Estrogen delivered across the skin as a patch, gel or spray is called transdermal. Estrogen can also be taken as an oral tablet.
Side effects of estrogen can be:
- Leg cramps
- 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.
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
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. This is the main reason for using of HRT. The dose may need some adjustment, but generally your hot flushes and night sweats will be relieved within a few weeks of starting it; low mood, anxiety and sleep disturbance can take a. bit longer to settle but usually these will have improved within about 12 weeks.
- Reduced risk of osteoporosis. After the menopause there is a period of rapid bone loss for women. HRT reduces this bone loss resulting in reduced risk of osteoporosis and future bone fracture, both of which can have a significant impact upon your quality of life. Remembering to add calcium in your diet, a Vitamin D tablet and regular weight bearing exercise, too.
- Reduced risk of cardiovascular disease (heart and blood vessel disease like heart attack and stroke). 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 disease. Cardiovascular disease is the second most common cause of death in post-menopausal women.
- Reduced future risk of type 2 diabetes, depression and bowel cancer. HRT may also help protect against osteoarthritis.
What are the risks of taking Hormone replacement therapy?
NICE guidelines state that for the majority of women, the benefits of HRT outweigh the risks. For you as an individual this decision is based on your medical history, current medical conditions, your family history and whether or not you still have a womb (uterus). This website Wellspring can be helpful when looking at risk and benefit.
HRT can have some risks and you may worry about risks of breast cancer and blood clot. There is a small association between taking HRT and ovarian cancer and gall bladder disease. We only prescribe the HRT that is safest for you, and we consider your medical conditions, your medications, your health and your age before prescribing. We will discuss all the evidence with you before we prescribe and it may be that there are a number or regimes we can consider, each one with risks and benefits. We will explain everything.
Your personal breast cancer risk depends on many things including your age, your family history, your age of starting your periods, the number of pregnancies you have had etc. Your lifestyle plays an important role in your risks of breast cancer. An unhealthy BMI, smoking and alcohol consumption of 2 or more units per day all increasing breast cancer risk; whilst taking regular moderate exercise of 2 ½ hours per week reduces your risk.
Studies have shown that women who take estrogen-only HRT do not have an increased risk of breast cancer. Women who take combined HRT, which is HRT containing both estrogen and progestogen, may have a small increased risk of breast cancer. We can discuss the numbers with you at your consultation. This risk can be minimised by using body identical HRT (17- beta-estradiol) combination with micronised progesterone, called Utrogestan, if required) as some studies have shown the risk of breast cancer with HRT is reduced if micronised progesterone is used.
There are many risk factors for thrombosis (blood clots) and your risk increases with age, particularly over the age of 60. HRT taken orally as a tablet is associated with a small increased risk of blood clot ,and should be avoided in anyone with a personal history of blood clot, liver disease or migraine. Studies show that HRT taken across the skin as an estrogen patch, gel or spray carries no increased risk of blood clot. If you have a history of blood clot, you still may be able to take HRT, but we may discuss your risk with a haematologist and some women need to take blood thinners, too.
My HRT doesn’t seem to be working as well, what can I do?
We may need to adjust the dose of your estrogen, if your symptoms are not settling after time, or adjust the dose, preparation or way you take your progesterone. If this happens you may have some side effects while you get used to the new dose, but these should resolve within a few weeks. Please contact us if you are having unexpected bleeding that is still happening three months after changing your HRT dose or preparation.
I’m bleeding on my HRT what can I do?
When you first start HRT, or change product or dose you might have some unexpected bleeding, which should settle in 3-6 months, please talk with your Dr if this is not settling after 3 months so we can review things.
If you take progesterone for part of the month only in a cyclical way, we expect, once you have settled on HRT, for you to bleed each month once, but not irregularly or after sex, for example.
If you take progesterone every day, we do not expect you to bleed and please let us or your GP know if you are.
Sometimes we need to adjust the dose of hormones, to examine you to see where the bleeding is coming from, to arrange a scan, or occasionally to arrange a small camera to be inserted into the womb to check all is ok. We can then talk with you about the best options including a Mirena IUS, which is often so helpful in perimenopause.
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.
Are the reasons not to take HRT?
There are very few reasons we would not advise you take HRT, and there are some cautions to prescribing HRT and we need to make sure the benefits outweigh any risks to you, and that you are on the best and safest preparation for you, at the right dose for you.
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.
Last updated June 2023 Dr Carys Sonnenberg