HRT: The Different Types

HRT – The different types

During the perimenopause, the ovaries start to fail, leading to reduced production of estrogen, progesterone and testosterone.  After the menopause, this production stops. For women who suffer symptoms, replacement of these hormones can restore their quality of life but how do you know what is right for you?

NICE guidelines recommend individualised care; it is only when women are given the correct balance of hormones for them that symptoms improve. The decision on what HRT is best should be made in partnership with the woman and her doctor and should reflect her lifestyle and her goals for treatment.
 

Estrogen

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.

Studies have shown that taking estrogen orally as a tablet is associated with a slightly increased risk of clot. This becomes more important as we age when our risk of clot increases naturally. Women who smoke, are obese or have an underlying medical condition that puts them at increased risk of clot and women who suffer migraine should not take HRT as a tablet but can use transdermal estrogen.

Estrogen is usually started as a patch or a gel. Patches come in strengths from 25 to 100 micrograms permitting the correct starting dose to be selected for each woman. The gel can be used 1-4 measures each day so the dose can easily be adjusted if symptoms are not controlled.

Lenzetto is a spray that delivers estrogen to the skin. This is a more recent addition to HRT choices. It can be used 1-3 sprays per day.

Estrogen delivered across the skin is absorbed directly and avoids passing through the liver resulting in no increased risk of clot.

Some patches and tablets contain both estrogen and a progestogen. These combination patches and tablets can be useful for some women who wish to have a simple HRT regime. However, the patches only come in one strength which limits the ability to individualise the estrogen dose to relieve symptoms.

 

Type of Estrogen

Application

Pros

Cons

Gels

Applied once daily to clean dry skin on the upper outer arm or inner thigh

Easy to use

Flexibility of dose

No visible sign of HRT treatment

Needs to be left to dry for 5 minutes before dressing

Higher doses can require a large area of skin for application

Need to avoid contact of the application area with others for 60 minutes to avoid transfer of medication

Patches

Applied to clean, dry, non-hair bearing skin below the waist and usually changed twice weekly (FemSeven is changed once weekly)

Easy to apply

Deliver a steady dose of estrogen so can be useful in migraine

Twice weekly application only so minimum disruption

No need to wait before dressing

Can leave a slight residue of glue around the patch

Some women react to the glue and develop itchy red patches

Some women do not like the visibility of the patch

Spray

Applied once daily to the inner aspect of the forearm or inner thigh

Easy to apply

Rapidly absorbed – only 2 minutes to absorb

Smaller area of application

Need to avoid contact of the application area with others for 60 minutes to avoid transfer of medication

New product – not available on the NHS in all areas


 

Gels

  • Gel should be rubbed in with a similar effort required to apply moisturiser
  • Apply to a large area
  • Wash your hands after application
  • Allow 5 minutes after application before getting dressed
  • Allow 60 minutes before using any other skin application including sun cream
  • Allow 60 minutes before contact with another person
  • If another person, particularly a child, touches the area of application before 60 minutes has elapsed, tell the person to wash the area with soap and water immediately
  • Do not let pets touch or lick the site of application
  • Return empty containers to the pharmacy for safe disposal
     

Patches

  • Remove patch from packet and peel back one half of the protective backing
  • Avoid contact with the adhesive
  • Apply to clean, dry, non-hair bearing skin below the waist. Skin should be free of powder, oil, moisturiser or lotion
  • Most women apply to the buttock, upper thigh or lower abdomen
  • Roll the patch onto the skin while removing the second part of the protective backing
  • Ensure the patch is flat and adhering well
  • Press the patch firmly in place with the palm of your hand for about 10 seconds
  • Change twice weekly – alternate sides
  • Baby oil on a dry flannel can be used to remove any residue of glue
  • Patches can be work in the shower, bath, during exercise or swimming
  • When changing the patch, peel it off and fold it in half with the sticky side inwards and dispose of safely
     

Spray

  • Before using a new spray for the first time, prime the pump by spraying 3 times with the cover on. Hold the container upright while doing this
  • Apply to healthy, clean, dry skin of the inner forearm
  • Each day, remove the plastic cover, hold the spray upright, and rest the plastic cone flat against the skin of your inner forearm
  • Ensure there are no gaps between the cone and your skin
  • Push the button down fully and hold. Release.
  • If another spray is needed, move the cone along the forearm so that it is beside the area that has already been sprayed
  • Avoid overlap of the areas
  • Push the button down fully and hold. Release.
  • Repeat if 3 sprays are prescribed
  • Allow 2 minutes for the spray to dry
  • Allow 60 minutes before contact with another person
  • If another person, particularly a child, touches the area of application before 60 minutes has elapsed, tell the person to wash the area with soap and water immediately
  • Do not let pets touch or lick the site of application
  • If sun cream is required to the area of application, apply 1 hour before application of Lenzetto
  • Return all empty sprays to the pharmacy for safe disposal
     

Progestogen

All women who use estrogen replacement and who have a womb (uterus) require the addition of a progestogen to protect the lining of the womb. Some tablets and patches are combined and contain estrogen and a synthetic progestogen. This combination can limit the ability of the doctor to adjust the estrogen dose to control symptoms. As a result, estrogen and a progestogen are often prescribed separately. 

Natural micronised progesterone is chemically identical to the progesterone produced by the ovary and is derived from the root vegetable, the yam. In the UK, the licensed medication is a capsule called Utrogestan. Micronised progesterone has several advantages over synthetic progestogens:

  • It is more selective in where it acts in the body leading to less side effects
  • It is often better tolerated
  • It is sedative so, when taken at night, it can help sleep
  • Studies have shown that micronised progesterone is associated with a lower breast cancer risk than synthetic progestogens
  • There is no increased clot risk with micronised progesterone

Micronised progesterone can be used in combination with estrogen patch, gel or spray and in either a sequential (cyclical) or continuous combined HRT regime.
 

Top Tips

  • Micronised progesterone should be taken on an empty stomach (one hour before eating or two hours after eating)
  • Take 30-60 minutes before bedtime, the sedative effect will help you sleep
  • If taken as part of sequential HRT, micronised progesterone is usually taken 2 capsules at night for 12-14 days out of 28. For convenience women are usually advised to take it in a pattern of 2 weeks off, 2 weeks on
  • If taken as part of continuous combined HRT, micronised progesterone is usually taken 1 capsule at night, every night. Some women benefit from taking it for 25 nights out of 28.

The Mirena intrauterine system (coil) can also be used to provide the progestogen component of HRT. It is inserted into the womb through the cervix, a minor procedure that can cause some discomfort but is usually well tolerated by most women. It has the following advantages:

  • Reducing menstrual blood loss
  • Provides contraception
  • Acts as the progestogen part of HRT for 5 years

The Mirena can be particularly useful in the perimenopause when conception is still possible and when periods are often heavy.
 

Testosterone

At present there are no testosterone products licensed for use in women in the UK, all Testosterone products are prescribed off licence as supported by NICE guideline NG23. This is usually a cream or gel and is applied once daily to the outer thigh or lower abdomen. The site should be rotated to reduce the small risk of localised hair growth at the site of application.

For more information on Testosterone use in women see Testosterone.
 

Localised vaginal estrogen

Women who have symptoms of vaginal dryness, itch, soreness, pain on intercourse, frequent passage of urine, getting up in the night to pass urine, recurrent urinary tract infection etc may be prescribed vaginal estrogen for relief of their symptoms. This can be used alone or in combination with estrogen as a patch, gel, spray or tablet. If used alone, there is no need for a progestogen as the dose of estrogen absorbed is so low that no stimulation of the lining of the womb occurs.

Vaginal estrogen can be used as a tablet, pessary, gel, cream or ring.
 

Type

How is it used

Pros

Cons

Tablet

Vagifem, Vagirux

Inserted high into the vagina using an applicator for 2 weeks and then continued twice weekly

Usually inserted at night

No mess

Easy to use

Vagirux has a reusable applicator so more environmentally friendly

Vagifem has a daily plastic applicator so lots of plastic waste

 

Vagirux requires the small tablet to be reloaded into the applicator so good eyesight and coordination are required

Pessary

Imvaggis

Inserted into the vagina using the fingers

Used once daily for 3 weeks and then continued twice weekly

No applicator so no waste

Can damage latex condoms

Can produce a slight waxy discharge

Cream

Ovestin

One applicator full inserted into the vagina once daily for 2 weeks and then continued twice weekly

Can be quite soothing if the vagina is very dry

Can be used on the vulva if this is dry and sore

Can be messy

Gel

Blissel

One applicator full inserted into the vagina once daily for 3 weeks and then continued twice weekly

Gel is rapidly absorbed

Itching or irritation may occur when first used

Ring

Estring

Inserted into the vagina by the woman herself or by a healthcare professional

Stays in place for 90 days

No daily or weekly treatment

May interfere with sex – can be removed and replaced if required

 

Intrarosa is a pessary that does not contain estrogen but does contain prasterone which is converted to estrogen and testosterone in the body. It can be used once daily in the vagina to help women who are suffering from painful sex. It is easy to use but can damage latex condoms.

For further information please see our resource on Vaginal Dryness.

Dr Alice Duffy

Last updated May 2021

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