HRT is generally recognised as the gold standard treatment for managing difficult perimenopause and menopause symptoms, such as hot flushes, and is recommended by both The National Institute for Health and Care Excellence (NICE) and the British Menopause Society (BMS). Put simply, HRT helps to replace hormones – primarily oestrogen and progesterone but sometimes testosterone - that your body is no longer producing as you go through the perimenopause and menopause. HRT, however, isn’t one standardised homogenous medication but comes in a range of strengths and modes of delivery (gels, creams, tablets, sprays and pessaries) so how do you know which type is best for you – or if HRT is even the right choice at all?
Dr Hannah Allen, a GP with a special interest in menopause says, ‘When a patient comes in to see me wanting HRT I will initially explore her symptoms with her – are they mainly vasomotor ones like hot flushes and night sweats or more psychological ones like brain fog and/or anxiety and depression? Or a combination of both. I then try to build a 3D picture of what else is going on in her life at home and at work – is she eating well, exercising regularly, sleeping enough, does she have supportive people around her, is she feeling overwhelmed and/or insecure at work and/or in her relationship? And I never assume her symptoms are automatically menopausal so I also need to rule out other possibilities.’
She adds, 'When we have done a full assessment I might suggest making some lifestyle adjustments initially – evidence shows that exercising regularly and/or eating more hormone-balancing phytoestrogens can be highly beneficial in alleviating symptoms. It might be that a talking therapy such as CBT is a more appropriate line of treatment than HRT. If she then decides that HRT is the best way forward, I will talk through the various options. I also stress that just because one type of HRT has worked well for a friend or relative that doesn’t mean to say it will necessarily have the same effect on you.'
The HRT options available
The type of HRT that is best for you depends on a whole range of factors from whether you are perimenopausal, menopausal or post-menopausal; your general health; have had a hysterectomy to personal preferences such as whether you would rather take it in convenient tablet form or would prefer to use a gel, spray or patch. How often you take it is also another factor to weigh up – some you need to take daily and continuously, others sequentially. If you are using an HRT patch you will have to remember to change it a couple of times a week. It can also be helpful to bear in mind that it can take up to three months to feel any beneficial effects and your dosage and type of HRT may be tweaked or changed accordingly after 12 weeks. The HRT choices can seem slightly overwhelming, and your doctor will help to guide you through them but it can help to go in armed with some background information. Here’s what can be helpful to consider:
If you have menopausal symptoms but are still having periods
You’ll usually be recommended to take sequential (also referred to as cyclical) HRT. If your periods are still fairly regular you take oestrogen daily and then progesterone alongside it for the last 10-14 days of your menstrual cycle (you can help track your cycle using the Health & Her menopause app) every month. If your periods are more erratic and irregular, a three month course of HRT is usually prescribed – this is where you take oestrogen every day and then progesterone alongside it for around 10-14 days every three months. You should have a period-like bleed at the end of each ‘progesterone cycle.’
If you are post-menopausal and have not had a period for over a year
Continuous combined HRT is usually recommended to alleviate your symptoms. This means taking oestrogen and progesterone together every day and you will not have periods on this form of HRT.
If you have a history of, or family history of, breast cancer
Studies in the past1 have suggested that using HRT increased the risk of developing breast cancer but more recent research suggests the subject is more complex. Some types of HRT – notably combined HRT - do appear to increase the risk and the longer you take it the higher that risk becomes but these are relatively small when compared to other risk factors such as regularly drinking alcohol2 or being overweight3. The current guidelines suggest you can take HRT if you have a family history of breast cancer but you need to discuss it carefully with a doctor or menopause specialist to decide if the benefits outweigh the risks. Other non-hormonal treatments or lifestyle changes might be suggested as a first line of treatment. If you have had breast cancer in the past, current NICE guidelines4 suggest you should avoid HRT.
If you've not had a hysterectomy
You should take both oestrogen and progesterone (combined HRT). This is because taking oestrogen on its own is known to cause the lining of the womb to thicken abnormally and increases the risk of womb cancer.5 However taking progesterone alongside the oestrogen effectively removes this risk - helping to protect you from womb cancer as it counteracts the effects of the oestrogen.
Oestrogen can be found in tablet, spray, gel, pessary or patch form, progesterone is generally taken as a tablet or is found in hormonal coils or intrauterine device (IUD) such as the Mirena, Levosert and Benilexa (these are inserted into the womb and gradually release progesterone. They also work as a form of contraception and relieve heavy periods).
If you have had a hysterectomy
Oestrogen-only HRT is recommended as you no longer have any womb lining so are not at risk of it thickening and potentially leading to cancer .
If you are experiencing menopausal vaginal dryness and/or sex is painful
Low dose vaginal oestrogen may be the right option for you. Available as a gel, cream, tablet, pessary or ring you insert it inside your vagina to help relieve symptoms. This form of oestrogen does not carry any of the same risks of HRT generally as it is not absorbed into the bloodstream. It can be used on its own or alongside systemic HRT.
If you have history of, or family history of, blood clots
Taking HRT in tablet form has been associated with a slightly higher risk of thrombosis and blood clots6 than using it in gel, patch or spray form - so the transdermal routes should always be considered first (even then, the overall risk is still small). Any risk is also dependant on other factors like whether you are a smoker, your weight and your age. 7,8
If you are over 60
There is no age limit to how long you can take HRT and if you started to take it before 60 or within 10 years of the menopause it has been associated with a reduction in heart disease. A statement from the British Menopause Society suggests that if you start taking it after 60 you should start on a low dose ‘preferably with a transdermal route of estradiol [oestrogen] administration.’ 9
How should you take your HRT?
Weighing up the pros and cons of how to take HRT can also help steer you towards the best mode of delivery for you:
Tablets
These are a convenient choice for many women and may be a preferable option if you have skin allergies or sensitivities and might struggle with, say, a gel, cream or spray. Oral HRT is known to produce more side effects (such as headaches, nausea, breast tenderness, mood changes and itchy skin or a rash)10 than getting it via the skin using a patch or gel (although some women report that taking their tablet at night and with food can alleviate these side effects). HRT tablets can also slightly increase the risk of blood clots but that risk still remains low. If you are someone who finds it difficult to swallow tablets, or remember to take them, a patch or gel might be a better option for you.
Patches
These are quick and easy to apply and most last for three or four days so you only need to worry about changing them a couple of times a week. The downsides are that they can sometimes fail to stick properly and can cause skin irritation. Many women also report finding it hard to get the sticky glue residue off their skin. Others have noticed that the amount of hormone they are getting through their skin (either in a patch or gel or cream) can also vary according to the brand they are using so it can be helpful to experiment to find the best one for you.
Gels
These are usually applied (in a measured dose either via a sachet or pump dispenser) to the outer arm or inner thigh and need to dry for five minutes before you put your clothes on and left for around an hour before washing or applying skin products (say moisturiser). These are generally popular as the dose is easy to control, can be adjusted accordingly and the gel is easy to carry around and apply. The drying time might be a bit of deal breaker for some.
Sprays
This is a relatively mess and stress-free way to get your HRT and the spray dries quickly. However there is only one of these currently available - called Lenzetto - and it is oestrogen only so if you still have a womb you will need to take progesterone with it to protect your womb lining.
Vaginal HRT
These are oestrogens which are available as tablets, gels, creams and pessaries that are applied directly to the vaginal area and only treat genitourinary symptoms (including itching, burning and painful sex). Vaginal oestrogen is only available on prescription except for a brand called Gina which can be bought from the chemist without prescription. They are easy to apply but will not be of benefit for other common menopause symptoms such as hot flushes, brain fog and mood swings.
Hormonal coil
These are a small plastic device that sit inside the womb and gradually release progesterone and once inserted can be used for five years as part of your HRT regimen. An hormonal IUD is a reliable form of contraception and also tends to make your periods lighter and less frequent. You can add an oestrogen only patch, gel, spray or tablet to complete your HRT. The benefits of the hormonal coil is that they tend to cause fewer progesterone related side effects making it potentially a better choice if you are sensitive to progesterone.
References
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6780820/
- https://breastcancernow.org/about-breast-cancer/awareness/breast-cancer-causes/alcohol-and-breast-cancer-risk/
- https://breastcancernow.org/about-breast-cancer/awareness/breast-cancer-causes/weight-obesity-and-breast-cancer-risk/#:~:text=In%20a%20group%20of%20100%20obese%20women%2C%20about%2011%20or,you%20can%20reduce%20this%20risk.
- https://www.nice.org.uk/guidance/ng101/
- https://www.cancerresearchuk.org/about-cancer/womb-cancer/risks-causes#:~:text=Oestrogen%20causes%20the%20cells%20in,your%20risk%20of%20womb%20cancer.
- https://www.bmj.com/content/364/bmj.k4810
- https://www.nhs.uk/medicines/hormone-replacement-therapy-hrt/benefits-and-risks-of-hormone-replacement-therapy-hrt/#:~:text=HRT%20patches%2C%20sprays%20and%20gels,or%20gel%20rather%20than%20tablets.
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9399360/
- https://thebms.org.uk/publications/consensus-statements/bms-whcs-2020-recommendations-on-hormone-replacement-therapy-in-menopausal-women/#:~:text=HRT%20initiated%20before%20the%20age,transdermal%20route%20of%20estradiol%20administration.
- https://www.nhs.uk/medicines/hormone-replacement-therapy-hrt/continuous-combined-hormone-replacement-therapy-hrt-tablets-capsules-and-patches/side-effects-of-continuous-combined-hrt/
