HRT (Hormone Replacement Therapy)

HRT may be used by women and people who identify as female.

Hormone replacement therapy (HRT)

How does HRT work?

Before the menopause, your ovaries produce three main types of hormones:

1. Oestrogens
2. Progestogens
3. Androgens (testosterone)

It’s the loss of oestrogens after the menopause that causes most menopause symptoms. HRT aims to replace the declining levels of oestrogen that your ovaries used to make, and this helps to reduce your menopause symptoms.

It also has some long-term health benefits.

The types of HRT

Oestrogen, progestogen and testosterone can all be given as HRT. Oestrogen is needed to manage most menopause symptoms.

If you still have a womb (you have not had a hysterectomy) it is essential to take oestrogen AND progesterone to make sure that the womb lining does not become thickened. If it does, the womb lining can become abnormal, and over a long time can even turn into a cancer.

Taking progesterone as well reliably prevents this abnormal thickening from happening.

When considering hormones, there are two main types of HRT:

• Combined HRT contains oestrogen and a progestogen. This can be sequential (taking oestrogen alone for the first half of the month and both hormones for the second half of the month) or continuous (taking both hormones together all the time).
  
  – Sequential HRT – oestrogen is taken every day and the progestogen is taken for half
  of the month. This produces a monthly bleed.
  
  – Continuous combined HRT – oestrogen and progestogen are taken together, every
  day. This approach results in no bleeding.
• Oestrogen only HRT. Oestrogen is taken throughout the month.
  
  – If you have had a hysterectomy you don’t need a progestogen so will take what is
  known as oestrogen-only HRT.

Your doctor will discuss the different types of HRT and help you decide which type is best for you. If it has been less than 12 months since your last period, you’ll need to take sequential HRT. You can take this type of HRT for around five years, or until you reach 55 years old (whichever comes first). By the age of 55, your periods may have stopped.

If it has been 12 months or more since your last period, you can start continuous combined HRT – with no monthly bleed. However, if you begin this treatment too early in the menopause transition while still having periods, you may have irregular, frequent bleeding.

Special cases

Endometriosis – If you have had a hysterectomy for endometriosis, you may be advised to take a continuous combined HRT.

Subtotal hysterectomy – If you have had a subtotal hysterectomy where the womb is removed but the cervix is left behind, you may need to take combined HRT as some of the womb lining may remain.

Endometrial ablation for heavy periods – If you have had an endometrial ablation procedure where the womb lining is destroyed, you would still need to take combined HRT.

How is HRT taken?

HRT is available in the following forms:

Tablets

What you need to know

• Easy to take every day.
• Increases the risk of blood clots, stroke and gallbladder disease.

Hormones

• Oestrogen and progesterone or oestrogen only. There are several different brands and different doses.
• The oestrogen is usually oestradiol which is body identical.
• Premarin is a type of oestrogen derived from horse urine. Tibolone is fully synthetic with oestrogen, progestogen and androgen-like action.

Gels

What you need to know

• Use daily – usually to the back of the arm or inner thigh.
• Does not affect the risk of blood clotting or stroke at standard doses.
• A safer option where you are at higher risk of blood clots or stroke (for example smoking, obesity, or are a migraine sufferer).

Hormones

• Oestrogen only. If you have a womb, you need a progestogen also.
• The oestrogen is oestradiol which is body identical.

Patches

What you need to know

• To use – stick to the skin below the waist. Usually changed twice weekly (or weekly depending on the brand).
• Does not affect the risk of blood clotting or stroke at standard doses. A safer option where you are at higher risk of blood clots or stroke (for example smoking, obesity, or are a migraine sufferer).

Hormones

• Can be oestrogen only – if you have a womb, you need a progestogen also.
• Can be oestrogen plus progestogen.
• The oestrogen is body identical. The progestogen is not.

Spray

What you need to know

• Use daily. Should not affect the risk of blood clotting or stroke at standard doses.
• A safer option where you are at higher risk of blood clots or stroke (for example smoking, obesity, or are a migraine sufferer).

Hormones

• Oestrogen only. If you have a womb, you also need a progestogen.
• The oestrogen is body identical.

Micronised progesterone (Utrogestan™)

What you need to know

• Capsule – swallowed at night. Can help with sleep disturbance.
• Likely to have a lower risk of breast cancer compared with alternatives.
• Unlike synthetic progestogens, it should not affect your risk of heart disease or blood clotting.
• Often better tolerated than synthetic progestogens.

Hormones

• Progestogen only. Used with oestrogen.
• Prevents the lining of the womb from thickening. This progestogen is body identical.

Mirena™ Intrauterine system

What you need to know

• A ‘coil’ inserted through the neck of the womb into the cavity of the womb. Inserted by GPs, family planning clinics, gynaecologists and some menopause clinics. Lasts for five years for HRT. Also acts as contraception.

Hormones

• Progestogen only. Used with oestrogen. Very effective at preventing the lining of the womb from becoming thickened.

Vaginal preparations

What you need to know

• Creams and pessaries inserted directly into the vagina to help symptoms of oestrogen loss – for example, dryness and irritation.

Hormones

• Oestrogen only.
• No need for progestogen if used as advised by your doctor.
• May also help some bladder symptoms.

Tibolone

What you need to know

• Tablet. Helps menopause symptoms.
• Small risk of breast cancer. Risk of stroke over 60 years old. Provides some protection to bones against osteoporosis.

Hormones

• Fully synthetic with effects similar to a weak oestrogen, weak progestogen and weak androgen.
• Best started after your periods have stopped, like continuous combined HRT.

These are the most common combinations of hormones if you are prescribed combined HRT:

Oestrogen

• Gel.
• Spray.
• Oestrogen only patch.
• Combined patch.
• Combined tablet.

Progestogen

• Utrogestan™ (micronised progesterone) capsules or Mirena™ intrauterine system (coil) or synthetic progestogen tablets.
• Combined patch.
• Combined tablet.

Tibolone

Tibolone is a synthetic form of HRT that mimics the activity of oestrogen and progestogens – and may also have some androgen (male hormone) activity.

• Tibolone is a tablet taken daily, usually after twelve months of no periods.
• It has shown to be effective in managing menopause symptoms.
• It may not be as effective as HRT.
• It protects bones against osteoporosis.
• Like HRT, it increases the risk of breast cancer by a small amount.
• After age 60 there is a significant increase in the risk of stroke.

Tibolone has been talked about as a treatment for improving libido, but the evidence for this is not strong.

Premarin

Premarin is derived from horse urine (the name comes from PREgnant MARes’ urINe), so it’s ‘natural’ but contains several different types of oestrogen. This is available in tablet form only.

Micronised progesterone

Micronised progesterone is biochemically matched to your own progesterone – it’s bioidentical – and is available on prescription as a small capsule. Compared to synthetic progestogens (which are versions of the same hormone) micronised progesterone has several advantages:

• It is often better tolerated.
• It can help improve sleep quality.
• There is evidence that the risk of breast cancer is significantly lower when compared with synthetic alternatives.
• Unlike synthetic progestogens, micronised progesterone should not affect your risk of heart disease or blood clotting.

Body identical hormones – what are they?

You may have come across the term’s bioidentical and body-identical hormones. They both refer to hormones that are biochemically the same as the hormones made naturally by your ovaries. The British Menopause Society (BMS) supports the term body identical hormones. The term bioidentical is confused when it is used in ‘compunded’ preparations (laboratory mixtures) which are not tested for safety and effectiveness under the same strict regulations as conventional HRT. Here’s a quick guide to help you understand them:

Regulated body identical hormones (rBHRT)

Regulated body identical hormones (rBHRT) derived from plants are available on a standard, regulated prescription – they can be prescribed by our clinic or your GP/specialist in the NHS. They include oestradiol and micronised progesterone which are commonly prescribed in the UK.

Compounded bioidentical hormones (cBHRT)

These are also derived from plants and are made by private clinics in a process known as compounding. Compounded bioidentical hormones are not regulated and not available on the NHS. They are marketed as precise duplicates of the hormones from your ovaries after blood test analysis. The hormone combination is then made up by a private pharmacy.

These combinations do not follow the same regulations as conventional HRT and haven’t been through the same strict testing processes for effectiveness and safety.

The blood tests and hormones are also very expensive – significantly more than the cost of private or NHS prescription. More expensive does not necessarily mean better. The BMS does not support this practice and we do not prescribe this type of HRT.

Risks and Benefits of HRT

The benefits of HRT

HRT is a suitable option for many and those who start HRT report that their quality of life has been changed for the better.

HRT is the most effective way of managing most menopause symptoms.

The small risks of HRT are generally far outweighed by the benefits. HRT can make all the difference because it is an effective way of managing a wide range of menopause symptoms.

HRT can help alleviate common menopause symptoms including:

• Hot flushes and night sweats.
• Low mood and anxiety.
• Brain fog and memory issues.
• Vaginal dryness.
• Painful sex.
• Loss of libido/sex drive.
• Bladder issues.
• Skin and tissue quality.
• Joint and muscle aches and pains.

It can help the lesser-known symptoms too, though there may be less evidence for these.

HRT and osteoporosis

HRT replaces the oestrogen in your body. This helps keep your bones healthy, reducing your risk of osteoporosis and preventing fractures.

Osteoporosis can be prevented and treated by using HRT, particularly where premature ovarian insufficiency (POI) is also an issue, and also in those in menopause below the age of 60.

HRT and cardiovascular disease (CVD or heart disease)

Heart disease is important. While you may worry most about dying from breast cancer, it is a fact more women die of heart disease overall. This in no way diminishes the importance of breast cancer, but it does highlight how important it is to be aware of heart disease too.

There’s a lot of conflicting, and sometimes worrying, advice on the internet connecting HRT with heart disease. Here’s what we know for certain:

• If HRT is started within ten years of the menopause or before the age of 60 HRT can help prevent CVD and reduce the risk of dying from CVD. So, even if you have risk factors for CVD like high blood pressure or high cholesterol, it doesn’t mean that you can’t take HRT.
• If you start HRT more than ten years after the menopause – HRT may not prevent CVD, but there is no evidence of an increase in CVD, such as heart attacks or strokes.

HRT and dementia

The evidence for HRT and the prevention of dementia is not clear. There is some evidence to suggest that HRT started early in the menopause may help prevent dementia. What is certain is that starting HRT should not increase the risk of dementia.

Other benefits

There is evidence to suggest that the risk of bowel cancer is reduced in those who take HRT. HRT may protect against or help osteoarthritis and joint pains can improve along with glucose control in type 2 diabetes.

The risks associated with HRT

The media often focuses heavily on HRT risks, yet the reality of the scientific data shows that the risks are very low for most.

The risks of harm from HRT vary from person to person and the type of HRT taken. The following factors can affect your long-term health and may affect the risks of HRT for you:

• Your age.
• Your weight.
• Whether you smoke.
• How much alcohol you drink.
• Other existing medical conditions.
• Your family history.

It’s essential that HRT is tailored to suit you by an experienced healthcare professional, as menopause management is not a ‘one-size-fits-all’ solution.

A healthy diet and regular exercise will help you to reduce the risks and reap the maximum benefit from HRT.

Breast cancer

Increasing the risk of developing breast cancer is the biggest concern people have in connection with HRT. What we know for certain is that:

• Everyone has a different background risk of breast cancer before HRT is added into the equation.
• The risk of developing a breast cancer at some point in your life, without HRT, is a 1 in 8 chance.

You may worry about dying from breast cancer, but in fact far more women die of heart disease. This in no way diminishes the importance of breast cancer but it does highlight how important it is to be aware of heart disease too.

The risk of breast cancer is likely to increase the longer you take HRT but is still low. This risk slowly reduces when you stop HRT. The longer you have been on it, the longer this ‘tailing off’ time may be. If you take body-identical progesterone, some studies have shown that the risk of breast cancer is lower when compared with older, synthetic progestogens.

For more information on how different factors affect your risk of breast cancer, have a look at the summary results from the Women’s Health Initiative Study. It clearly shows that lifestyle factors, such as drinking alcohol and being overweight, have a greater impact on your risk of breast cancer than taking HRT.

Breast cancer risks with:

Oestrogen-only HRT

Studies show that after five years, there is little or no increase in the risk of a breast cancer diagnosis if you who take oestrogen-only HRT.

It’s likely that there is only a very small increase in the risk of breast cancer year-on-year if you take oestrogen-only HRT.

Combined HRT

There’s a very small increase in the risk of being diagnosed with breast cancer if you take combined HRT (oestrogen and progestogen) but this doesn’t mean there is an increased risk of dying from breast cancer.

Other cancers

If you have a womb and take oestrogen-only HRT in a tablet, gel, spray or patch, the risk of cancer of the womb will increase. That’s why it’s important to take a progestogen alongside oestrogen or have an ‘in-date’ Mirena™ coil (within five years) to protect your womb.

If you only use vaginal oestrogen, you don’t need to add a progestogen as the amount you absorb into your body is tiny.

Some studies have shown a link between HRT and some types of ovarian cancer. The risk is very low. There is no evidence that taking HRT will increase your risk of dying from ovarian cancer.

Other risks to be aware of:

Blood clots

Oral HRT (oestrogen in tablet form) can increase the risk of blood clots in blood vessels, such as deep vein thrombosis in the legs and pulmonary embolism in the lungs.

By contrast, oestrogen taken through the skin (transdermal oestrogen) in the form of patches, gels and sprays does not carry these same risks. Some of the older synthetic types of progestogen can also increase the risk of blood clots by a small amount.

Of course, you may already be at risk of blood clots if you smoke, are overweight or have had a blood clot in the past. If this is the case, transdermal HRT (patches or gel) should not add to your risk.

Stroke

As with the risk of blood clots, HRT tablets increase the risk of stroke. Taking oestrogen through the skin, at normal doses, does not carry the same risk. The risk of stroke increases as you get older, so if you are younger and healthy, the blood clot risk for HRT is low.

Gallbladder disease

Your gallbladder is the small sack that sits under your liver and helps you to digest fat. HRT tablets may increase the risk of gallbladder disease by a small amount.

Where HRT may be more risky

There are some medical conditions where HRT may be too risky. We can’t list all the medical conditions here, but they include uncontrolled high blood pressure, active liver disease, active medical conditions where the risk of blood clotting is very high, after certain (but not all) cancers, and where you have abnormal vaginal bleeding that has not been investigated.

The benefits and risks of HRT are different for everybody and it is important that you talk through your situation with a menopause specialist. It’s also important to discuss your medical history in full before thinking about starting HRT.

If you have been diagnosed with menopause under the age of 40

If you go through the menopause before you reach the age of 40 (also known as premature ovarian insufficiency – POI), it’s important to talk to your healthcare professional about HRT. Experiencing the menopause at a young age has significant health risks of its own, such as:

• Cardiovascular disease.
• Osteoporosis.
• Loss of cognitive (brain) function.

HRT can significantly decrease these risks, and it’s important to take it until you are 51 years old – the average age for reaching the menopause in the UK. If you’re concerned that it will mean you have been on HRT for years, it’s worth remembering that all you are doing is replacing the oestrogen your body would produce naturally at that age. You are not taking more than your body naturally needs.

What are the side effects of HRT

You may experience some of the side effects of HRT listed below when you start it, and they generally settle in the first three months. Side effects can vary depending on the type of HRT you take.

Possible oestrogens side effects

• Rash / itching.
• Nausea (feeling sick).
• Headache / migraine.
• Vaginal bleeding.
• Breast tenderness or breast swelling.
• Dizziness.
• Low mood or anxiety.
• Leg cramps.
• Fatigue.
• Fluid retention (e.g., ankle swelling).

Possible progestogens side effects

• Rash / itching.
• Nausea (feeling sick).
• Headache / migraine.
• Vaginal bleeding.
• Breast tenderness or breast swelling.
• Dizziness.
• Low mood or anxiety.
• Backache.
• Drowsiness.
• Changes in vaginal discharge.
• Acne / greasy skin.
• Tummy pains
• Bloating.

You may bleed when you start HRT or change your HRT dose. This bleeding may last 3-6 months and is usually light.

Contact your doctor if:

• Your bleeding is heavy.
• You bleed for longer than 6 months.
• You bleed after having sex.

A word about weight

As we get older our metabolism (the way our body turns food into energy) slows down and the way that we store fat changes. This can lead to weight gain. Many people link taking HRT with gaining weight but this is not the case. It is important to look at diet and exercise as we transition through the menopause and beyond. As we are living longer it is even more important to maintain good health for as long as possible and eating well, moderating alcohol consumption, exercising, ensuring good sleep patterns and managing stress all make us feel better and live well. For some, HRT may significantly increase their sense of wellness but it will not do so without generally healthy lifestyle habits.

Progestogen intolerance

Sometimes you can be intolerant of progestogens. You may experience depression, anxiety and feel like your brain isn’t fully functioning and have severe premenstrual type symptoms when taking progestogens. This may be limited to a single type of progestogen or may apply to all of them.

If this happens to you, speak to a doctor who may be able to tailor your regimen to help. Progestogens are important and changing from the recommended licensed regimen may significantly increase the short-term risk of irregular bleeding or the long-term risk of developing endometrial cancer. Reducing the dose or number of days that the progestogen or progesterone is taken should only be taken under specialist guidance.

Informed Consent

This leaflet is provided to supplement verbal information that will be given to you by your healthcare provider (Doctor/ Surgeon/ Nurse) as part of the consent process prior to your procedure. Information sharing between you and the clinician is essential to ensure that your decision to consent is fully informed.

Please ask questions if you don’t fully understand or have any concerns about what is proposed. You have a right to be involved in these decisions and should feel supported to do so. Please take the time to consider what is important to you to ensure the information you receive is specific and individualised.

Further information and support