Hormone Replacement Therapy, refers to taking of one or more of the hormones oestrogen, progesterone and testosterone. Menopausal symptoms are caused by lack of oestrogen. There are oestrogen receptors all over our bodies and in our brains, that is why HRT is the most effective treatment for these symptoms. By replacing the oestrogen, you feel better. 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.
HRT is not dangerous. The science is now clear that for healthy women under 60, the benefits of HRT outweigh the risks.
Hormones in hormone replacement therapy
You can take oestrogen as a pill, patch, gel or spray. Patches are transparent, stick anywhere below your waist and are changed twice a week. Gels and sprays rub into the skin and dry invisibly in a few minutes.
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 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.
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.
Starting Hormone replacement therapy
When you start taking Hormone Replacement Therapy, HRT, you might have questions. How long until I feel better? Can I get pregnant using HRT? How long do I take this for? What if it doesn’t work? Will I have side effects? Will my periods come back?
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, and we will discuss each case individually.
How do I take HRT?
There are two ways to take HRT:
Oestrogen 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, oestrogen 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 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.
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.
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 and reduced risk Alzheimers disease when oestrogen started early. Reduced risk colorectal cancer and reduced risk Type 2 diabetes mellitus.
What are the risks of taking Hormone replacement therapy?
Our FAQ on benefits and risks of HRT discusses this in more detail, click here for more information about breast cancer, blood clots, cardiovascular disease, ovarian cancer and endometrial cancer.
Breast cancer risk is probably increased slightly after a minimum of 5 years’ using of combined HRT (oestrogen and progestogen) in people over the age of 50, this is about an extra 3-4 cases per 1,000 women. Risk of breast cancer associated with oestrogen alone is very much less. Breast cancer risk is also associated with family history and with lifestyle: body weight, alcohol, exercise and smoking.
Understanding breast cancer the risks
Wellspring HRT risks and benefits
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 on HRT.
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, but please let us know about this.
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. If you take progesterone every day, we do not expect you to bleed.
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, there are some contraindications and we discuss these with you, 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.
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