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Everything you need to know about HRT

06 Jun 2023 • 10 min read

Some women sail through menopause with very few symptoms, but unfortunately the majority don’t. If you’re struggling, it might be worth considering Hormone Replacement Therapy (HRT).

HRT replaces the hormones that are at lower level as you approach menopause.1

The majority of symptoms are caused by declining oestrogen levels, so HRT is prescribed to redress the balance.

How to take HRT

You need to take oestrogen to manage your symptoms. Oestrogen is known as a steroid hormone and its main role is in the growth and differentiation of reproductive issues.2

Taking oestrogen on its own can cause thickening of the lining (endometrium) of your womb, so you’ll need to take progesterone as well to prevent this happening unless you’ve had a hysterectomy.3 This is known as combined HRT.4

Oestrogen is available as:

  • Tablet
  • Transdermal preparations - through the skin -  as a patch, gel or spray
  • Vaginally (to help with vaginal dryness, by itself or alongside HRT)5

Progesterone is also a steroid hormone that is produced by the adrenal cortex and the ovaries.6 Its main role is to stimulate and regulate bodily functions such as your menstrual cycle, pregnancy and sexual desire – but in HRT it is used to protect the uterine lining.6 

Progesterone is available as:

  • a tablet
  • as a combination tablet with oestrogen
  • in a combination patch with oestrogen
  • as a mirena coil. These are synthetic (man-made) products.
  • It can also be taken as a tablet called utrogestan, a natural form of progesterone. This tablet can be taken orally or is sometimes used vaginally.7

Testosterone is an androgen and is known to regulate libido in both men and women.8

It therefore may also be prescribed for low libido, and is used in addition to HRT. It comes as a gel or a cream. 

It’s reassuring to know that there isn’t a one-size fits all approach, the right dose and hormones will be prescribed for your specific symptoms and need. The way you take it also varies.

However, it’s important to highlight that HRT is not a contraceptive (apart from mirena) and you still need to use contraception. If your last period is under 50, you need it for 2 years, and if over 50, you need contraception for an extra year.9

How often to take HRT

How often to take HRT

The frequency depends on what type of HRT you are taking.

Oestrogen tablet, gels and sprays are used daily. Patches (both oestrogen only and combined oestrogen and progesterone) are changed twice a week.

The stage of the menopause affects how often you take the progesterone. When you’re still having periods, you’ll be on sequential HRT. This means you’ll have oestrogen continuously and take progesterone for half the month.10

After your periods have stopped for a year, or over the age of 53, you’ll progress to continuous HRT and have progesterone every day.

If you choose to use the Mirena coil, it delivers continuous progesterone, so you won't need more. The Mirena provides progesterone for 5 years.

Testosterone use varies depending on the product.

Your healthcare professional, such as GP, will be able to give you advice on how to use your HRT.

Other ways to take HRT

 
HRT risks

Some women are reluctant to take HRT because of the perceived risks, but the chances of it having an adverse effect on your health are actually very small.14

Your doctor or nurse will assess your personal and family history before prescribing it to ensure that it’s safe for you to take. 

You may have heard that HRT has been linked with a slightly increased risk of breast cancer.15

This is true, but it needs to be looked at in context. There are an additional 4 cases of breast cancer per 1000 women aged 50-59 taking combined HRT (oestrogen and progesterone) per year, but 4 fewer cases per 1000 women who only take Oestrogen.16

Some types of progesterone - utrogestan - have a lower risk of breast cancer.17

Although some HRT may slightly increase your risks of developing breast cancer, it doesn’t increase your risks of dying from it. To put this in context, drinking alcohol also results in a slightly increased risk of breast cancer.18

Other factors increasing your risk include a family history of breast cancer, being overweight or smoking.19

There is also a small risk of developing a blood clot in your leg or lungs when taking HRT as a tablet, but this isn’t the case if you take it as a patch, gel or spray.20

Although taking HRT tablets (but not gels or patches) are associated with a slightly increased risk of stroke, the NICE guidelines state that starting HRT if you’re below 60 does not increase the risk of cardiovascular diseases.

It’s also important to keep in mind that the risk of stroke in women under 60 is very low anyway.14

HRT side effects

While HRT can help you manage some symptoms of menopause, you may experience the following symptoms on:

Oestrogen

 

Progesterone

 

How can HRT help?

How can HRT help?

HRT can help with the following:

  • It helps a wide variety of menopausal symptoms including hot flushes and night sweats, urinary issues, mood and sexual function.
  • It helps to reduce the risk of osteoporosis by maintaining bone density.
  • It can reduce the risk of developing heart disease when started under the age of 60.
  • It may help to reduce the risk of colorectal (bowel) cancer.
  • It may reduce the risk of developing Alzheimer’s disease.14,22
Non-hormonal HRT alternatives for helping with menopause symptoms

If you have been considering HRT, you may have come across the two terms ‘body identical’ and ‘bioidentical HRT’. 

Body identical is the HRT that you will be prescribed by your GP, and it is a regulated and evidenced based product.

Some menopause practitioners offer bioidentical HRT which are precise duplicates of human hormones that are produced by specialist pharmacies and do not follow the same regulatory pathway as conventional HRT.

If you don’t like the idea of taking HRT, your GP can recommend alternative options:

  • Antidepressants, such as venlafaxine, sertraline and fluoxetine may help to manage vasomotor symptoms such as hot flushes and night sweats, as well as depression and anxiety.24
  • Gabapentin – this is a nerve stabiliser which may help with hot flushes and night sweats.25
  • Clonidine – this is a blood pressure medication which may help with menopausal symptoms.26

In addition, Cognitive Behaviour Therapy (CBT) and lifestyle measures are hugely important and can help with hot flushes and night sweats.27

Try to get plenty of cardiovascular exercise and keep an eye on your weight. Wearing lighter clothes or layers and avoiding triggers like smoking, alcohol, caffeine and spicy foods can all help you feel more comfortable.

Black Cohosh may help relieve some menopausal symptoms.28

These products are not recommended by NICE or the BMS. 23   

FAQs

Does HRT work straight away?

 

Is it true that it’ll only delay my menopause/symptoms?

 

Who can and who can’t take it?

 
The final say

We hope you’re feeling clued up on all things HRT and menopause after reading our expert written article – and more confident in deciding whether it is right for you or not.

Disclaimer

 

Sources

  1. https://www.nhs.uk/conditions/hormone-replacement-therapy-hrt/
  2. https://www.sciencedirect.com/topics/agricultural-and-biological-sciences/estrogen
  3. https://www.wuth.nhs.uk/media/18102/pl1003-endometrial-hyperplasia.pdf
  4. https://www.nhs.uk/conditions/hormone-replacement-therapy-hrt/types/
  5. https://www.nhsinform.scot/tests-and-treatments/medicines-and-medical-aids/types-of-medicine/hormone-replacement-therapy-hrt
  6. https://www.healthywomen.org/your-health/progesterone
  7. https://www.ncbi.nlm.nih.gov/books/NBK558960/ 
  8. https://thebms.org.uk/publications/tools-for-clinicians/testosterone-replacement-in-menopause/ 
  9. https://www.fsrh.org/documents/fsrh-guidance-contraception-for-women-aged-over-40-years-2017/
  10. https://www.nhs.uk/conditions/hormone-replacement-therapy-hrt/types/#:~:text=Cyclical%20HRT%2C%20also%20known%20as,days%20of%20your%20menstrual%20cycle
  11. https://thebms.org.uk/publications/consensus-statements/premature-ovarian-insufficiency/
  12. https://www.nice.org.uk/guidance/ng23/chapter/Recommendations
  13. https://bjgp.org/content/70/693/203#:~:text=Testosterone%20can%20be%20important%20in,%2C%20sexual%20function%2C%20and%20energy.&text=Adequate%20levels%20of%20testosterone%20are,possibly%20vascular%20and%20brain%20function.
  14. https://www.nice.org.uk/guidance/ng23/ifp/chapter/benefits-and-risks-of-hrt
  15. https://www.nhs.uk/conditions/hormone-replacement-therapy-hrt/risks/#:~:text=Combined%20HRT%20can%20be%20associated,if%20you're%20taking%20HRT.
  16. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8827222/
  17. https://www.liverpoolwomens.nhs.uk/media/3548/taking-utrogestan-patient-information-leaflet.pdf
  18. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3832299/
  19. https://www.cancerresearchuk.org/about-cancer/breast-cancer/risks-causes/risk-factors
  20. https://www.nhs.uk/conditions/hormone-replacement-therapy-hrt/risks/
  21. https://www.nhs.uk/conditions/hormone-replacement-therapy-hrt/side-effects/
  22. https://patient.info/doctor/hormone-replacement-therapy-including-benefits-and-risks
  23. https://thebms.org.uk/publications/consensus-statements/bioidentical-hrt
  24. https://www.nhs.uk/mental-health/talking-therapies-medicine-treatments/medicines-and-psychiatry/antidepressants/overview/
  25. https://journals.lww.com/menopausejournal/Abstract/2020/04000/Gabapentin_for_the_treatment_of_hot_flushes_in.17.aspx
  26. https://www.nhs.uk/conditions/hormone-replacement-therapy-hrt/alternatives/
  27. https://thebms.org.uk/2017/02/new-factsheets-cognitive-behaviour-therapy-cbt-menopausal-symptoms/
  28. https://www.nccih.nih.gov/health/black-cohosh
  29. https://thebms.org.uk/publications/consensus-statements/bioidentical-hrt
  30. https://patient.info/news-and-features/what-to-do-if-you-think-your-hrt-has-stopped-working
 
rachel-hines

Dr Rachel Hines

Author

Menopause Specialist

MRCGP, Royal College of General Practice 2006, Advanced menopause special study module, FSRH, British Menopause Society Specialist Register 2020, DFSRH 2006, DCH 2005, DRCOG 2004

Dr Rachel Hines is a Menopause specialist and GP specialising in women’s health.

Rachel has always specialised in Women’s health as a GP and worked in Community Gynaecology for 4 years. This developed her interest in the menopause which led her to completing the advanced menopause special study module  with the Faculty of Sexual Reproductive Healthcare. She has continued this interest and works a menopause specialist in a private clinic in central London, and also works as a menopause specialist for the H&B Meno app. She is passionate about providing holistic care and support for women at all stages of life, and particularly when going through peri menopause and menopause. She focuses on the importance of lifestyle as well as using both hormonal and non hormonal therapies.

In her spare time, Rachel is kept busy by her 2 sons, and enjoys walking, travelling and reading.

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