Hormone Replacement Therapy (HRT)

What is it?

Hormone replacement therapy refers to the replacement of one or more of the hormones estrogen, progesterone and testosterone. 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. HRT has been shown to offer the most effective relief from symptoms and for the majority of women the benefits outweigh the risks.

The Hormones

  • Estrogen – the type of estrogen mostly used in HRT is 17 beta-oestradiol and it is derived from the root vegetable, the yam. This has an identical biological structure to the estrogen produced in the body. It can be given as a patch, gel or spray delivered across the skin, 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 with an increased risk of abnormality and cancer. The progestogen keeps the lining of the womb thin and prevents this from becoming abnormal.  Natural progesterone (Utrogestan in the UK) is taken orally as a capsule and is also derived from the root vegetable, the yam. It is used as part of Body Identical HRT. The Mirena coil is often a good choice as it releases progestogen (levonorgestrel) into the womb to prevent the lining from thickening and 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 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. This is often accompanied by fatigue and brain fog. For these women a trial of testosterone can be of benefit. Currently there are no testosterone products licensed for use in women in the UK, but menopause doctors and some GPs are happy to prescribe a cream or a gel off license and under supervision.
  • Local vaginal estrogen – 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. This can be used alone or in combination with HRT. Vaginal estrogen can be used as a pessary, cream, gel or a ring that remains in the vagina for 90 days.

When should I start HRT?

HRT is best started when you start to experience symptoms. For many women this is in the perimenopause, the time before menopause. NICE guidelines recommend HRT first line for the treatment of symptoms and for the majority of women who start HRT below the age of 60, the benefits 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 the menopause. There is no need to wait until your periods have stopped before taking HRT.

What can I expect from HRT?

  • Relief of your symptoms. This is the primary indication for the use of HRT. Often the dose needs some adjustment, but generally hot flushes and night sweats are relieved within a few weeks of starting; low mood, anxiety and sleep disturbance take longer to settle but have usually improved within 3 months. Symptoms of vaginal dryness can take longer to settle and, in some women, can take up to a year.
  • Reduced risk of osteoporosis. After the menopause there is a period of rapid bone loss. HRT reduces this bone loss resulting in reduced risk of osteoporosis and future bone fracture.
  • Reduced risk of cardiovascular disease. 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.

Are there any risks from taking HRT?

NICE guidelines state that for the majority of women, the benefits of HRT outweigh the risks. For each individual this decision is based on your personal and medical history, any pre-existing medical conditions, your family history and whether or not you still have a womb (uterus).

Many women worry about two risks:

  • Breast cancer
  • Blood clots

Breast Cancer

Your personal breast cancer risk depends on many things including age, family history, age at puberty, number of pregnancies etc. Lifestyle factors play an important role in breast cancer risk with obesity, smoking and alcohol consumption of 2 or more units per day all increasing breast cancer risk while regular moderate exercise of 2 ½ hours per week reduces this.

Studies have shown that women who take estrogen only HRT do not have an increased risk of breast cancer. Women who take combined HRT, containing estrogen and progestogen, may have a small increased risk of breast cancer. This risk can be minimised by using Body Identical HRT (estrogen through the skin in combination with micronised progesterone if required) as some studies have shown the risk of breast cancer with HRT is reduced if micronised progesterone is used.

Blood Clots

There are many risk factors for thrombosis (blood clots) and the risk increases with age. 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. HRT taken across the skin as an estrogen patch, gel or spray carries no increased risk of blood clot.

If you are struggling with symptoms that are having a negative impact on your quality of life, speak to a healthcare professional with an interest in menopause to understand what is the right combination for you.

Dr Alice Duffy

Last updated May 2021

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