by Dr Shilpa McQuillan, ⊕ medically reviewed by Dr Rebecca Tomlinson on 5th September, 2022
What is Hormone Replacement Therapy (HRT), and could it be for you? Our GP Shilpa McQuillan has created the really useful guide to demystify HRT: what it is, how it works, the options available, the risks, and the benefits.
As the name suggests, Hormone Replacement Therapy (HRT) is a treatment designed to replace the hormones in your body that you no longer make around the menopause.
But before we dive into what HRT is and how it works, let’s recap on the role your hormones play during menopause. Oestrogen (one of your female hormones) is mainly produced in the ovaries and is responsible for controlling many functions in the body including the production of an egg each month (ovulation). But as you get older, the store of eggs in your ovaries naturally declines. Menopause – your last period – happens when your ovaries stop producing eggs and your body’s oestrogen levels fall. This drop in oestrogen is the cause of many symptoms we associate with the menopause.
What is Hormone Replacement Therapy (HRT)?
The main type of hormone in HRT is oestrogen. However, you may need to replace other hormones such as progesterone and testosterone, which are available in some treatment regimes. HRT mainly aims to relieve symptoms related to oestrogen deficiency such as hot flushes, urogenital irritation (bladder and vaginal area), joint pains, headaches and mood disorders.
Which kind of HRT regime is best for me?
The type and dose of hormones you need varies between women – HRT is tailored to your individual needs. If you choose to try HRT, your GP or gynaecologist will talk to you, look into your medical history and make suggestions about what might work best for you. So now let’s take a closer look at the options you might discuss…
HRT regime #1: oestrogen alone
For most women who had had their womb removed (hysterectomy) then you will be prescribed an oestrogen-only HRT. This is because most of the benefits of HRT come from the oestrogen, whilst the progestogen is only used to protect the lining of the womb.
Important: There are certain medical cases such as endometriosis, where you may be advised that you need a combination HRT even after having a hysterectomy – please check with your surgical team or GP if you are one of these women.
What are the different types of oestrogen HRT and how do you take it?
Most HRT containing oestrogen works systemically and is circulated throughout the body.
It comes in a variety of forms. For example:
- You can take a tablet every day – like a contraceptive pill.
- Transdermal oestrogen is the kind that you apply to the skin, either in the form of a patch, gel or spray.
Patches
Patches are stuck onto the skin, often on your bottom or upper thigh and are changed every few days. One worry some women have is whether the patch will fall off especially when wet, for example during showering, swimming, exercising, or even those dreaded hot flushes and sweats. Fear not, these patches are designed to stick on really well!
Women also sometimes ask about how to remove the patch, and whether it will leave a mark. Though these patches can stay on well through most activities, they are quite easy to remove when you are ready – like a waterproof plaster. You can gently wipe away any residue left from the adhesive with makeup remover or baby oil and a dry cloth.
Oestrogen gel
Oestrogen gel usually comes in a pump, tube, or sachet. It can be rubbed anywhere on the body but it should not be applied on the breasts and is not for use in the vagina.
It usually takes around an hour for the gel to be absorbed and you should avoid applying anything else – such as moisturisers – in that period. The amount of gel you need varies between women and your doctor will discuss how much you should use. I usually start at the lowest dose and adjust this depending on how well symptoms are controlled. It is important to wash your hands thoroughly after use.
Oestrogen Spray
Oestrogen Spray comes in a hand held pump with a wide circular spray cone. You place the spray cone in direct contact with the flat hairless skin of your inner forearm. Once one spray has been released onto the skin you leave this to absorb into the skin for at least 2 minutes – you do not rub it in. Further sprays, if needed, are sprayed onto different patches of the same or alternative forearm. You can get dressed soon after it has all be absorbed and should wait 60 minutes or more before bathing or swimming.
How to choose between a tablet or transdermal (patch/gel)?
I’m a firm believer in patient choice. However there are some advantages and safety reasons for using transdermal HRT:
- It is easier to adjust the dose of transdermal HRT. This is especially important in those whose requirements change over the course of treatment. For example older women usually require a lower strength or some women have symptoms or side effects that fluctuate.
- Transdermal HRT carries a lower risk than oral tablets for clots and stroke.
- Transdermal is safer for those who suffer from conditions such as migraines and epilepsy.
- Transdermal HRT does not lower libido, something which can be linked to oral tablets.
HRT regime #2: topical vaginal oestrogen
Some women may only experience symptoms that affect the vagina or bladder area. Therefore, it may be more suitable to prescribe a treatment that can be applied to this local area and does not affect the whole body. There is no evidence that giving oestrogen alone in this form increases the risk of womb cancer, so these regimes do not require women to take added progestogens.
How do you take Vaginal Oestrogen?
Vaginal oestrogen comes in the form of creams, vaginal tablets, and rings. You can rub the cream on the vulva and lower vaginal area. The vaginal tablets are inserted higher up using an applicator. How often you use the cream and tablets varies but usually women use them everyday for two weeks, and then twice a week thereafter.
Vaginal rings are inserted into the vagina and steadily release a small amount of hormone. They are changed every three months. Most women do this themselves, but your GP or nurse may be able to do this for you.
Important: topical vaginal oestrogen should not be confused with the oestrogen gel (mentioned above) which circulates around the body and is used to treat more widespread symptoms such as hot flushes and joint pains.
HRT regime #3: Adding progestogen to oestrogen HRT
This regime is recommended if you still have your womb. This is because the progestogen helps to keep your womb lining thin and reduces your risk of developing womb cancer. How much progestogen you need depends on whether you are still having periods which we will cover in more detail below.
How do you take Progestogen?
There are a few ways you can take HRT containing both oestrogen and progestogen. The easiest way is in a single combined pill or patch.
Another way is the separate the oestrogen and progestogen. This is particularly useful when a woman’s oestrogen requirements need adjusting over the course of treatment, but you only need a small consistent dose of progestogen to protect the womb lining. The oestrogen HRT is provided continuously in the form of a tablet, patch or gel and is taken as directed in the section above ’What are the different types of oestrogen HRT’.
There are two approaches to providing the progestogen hormone:
- In the form of an oral tablet.
- Using a Mirena IUS coil. This is a small device that is fitted in the womb and can stay there for up to four years. I really encourage women to consider this as there are many benefits including: not having to remember to taking a pill everyday in addition to the oestrogen HRT you choose; and providing a reliable long lasting contraception if this is still required. It is also one of the best treatments for heavy, painful periods if this is something you suffer from.
Cyclical HRT (adding Progestogen to Oestrogen HRT)
When you last had a period affects how much progestogen you need. If you are still having periods or your periods stopped less than a year ago you will be advised to have ‘cyclical’ HRT. This regime mimics the monthly cycle and oestrogen is provided throughout the month but the progestogen is only needed for part of it.
Like taking the the contraceptive pill, there is a ‘withdrawal’ bleed, which occurs in the days following the course of progestogen, as the womb lining is shed. In some regimes, there may only be a ‘withdrawal’ bleed every few months.
How do I take cyclical HRT?
The easiest way to take cyclical HRT is in a single combined pill or patch. In the first half of the month, the tablet or patch will contain oestrogen only and in the second half, it will contain both progestogen and oestrogen.
You may prefer or be advised to take the oestrogen and progestogen separately. You will be offered the various options of oestrogen HRT regime as directed in the section above ’What are the different types of oestrogen HRT’.
You can then take a seperate oral progestogen tablet in the last 12-14 days of the month or have a Mirena coil fitted which will last four years.
Continuous HRT (adding Progestogen to Oestrogen HRT)
If you have not had a period for over a year or you have already been using cyclical HRT for more than a year you may be advised to start ‘continuous’ HRT.
These regimes contain both oestrogen and progestogen hormones that are are released steadily throughout the month without a break and are used to achieve a ‘period-free’ HRT.
How do I take continuous HRT?
The easiest way to take continuous HRT is in a single combined pill or patch. Unlike cyclical HRT, it will contain both progestogen and oestrogen throughout the entire month.
If you choose to separate the oestrogen and progestogen hormones (or are advised) then you will be offered the various options of oestrogen HRT regime as directed in the section above ’What are the different types of oestrogen HRT’.
You can then take a seperate oral progestogen tablet. Unlike cyclical HRT, you will take this every day of the month. Alternately you can have a Mirena coil fitted which will last 4 years.
HRT regime #4: Tibolone
This is a synthetic hormone which mimics the effects of oestrogen, progestogens, and testosterone. It has similar benefits to continuous HRT and is taken continuously to achieve a ‘period free’ HRT. It is similarly prescribed in those who have not had a period for over a year or who have already been using cyclical HRT for more than a year.
Tibolone is taken as an oral tablet once a day. However it may only be prescribed by specialists, and you will need to discuss this with your doctor.
HRT regime #5: Testosterone
This is known to most people as the ‘male hormone’. However, women also produce this hormone and like oestrogen, these levels can fall reaching the menopause. Low levels of testosterone can result in symptoms such as low sex drive (libido); low energy; and poor concentration. If you experience these symptoms, it is important to discuss with your doctor whether testosterone may be a safe treatment option. Testosterone may be prescribed alongside all the approaches above
Testosterone is usually given as a cream or gel which you rub into your skin. Depending on the brand, you may take this every day or a few times a week. It is important to wash your hands thoroughly after use.
Here is how menopause can affect testosterone levels
“As well as symptom management, HRT can also help to protect your bones and safeguard heart health”
Is HRT suitable for me?
If you are interested in taking HRT, your GP can check which regimes are safe and suitable for your individual needs. The risks and benefits of each type of HRT will depend on your age, your general health, and any personal or family medical problems – there’s more information on that later in this article.
Benefits of HRT
There are many ways you can manage menopause, but HRT has been shown to be the most effective treatment to reduce your symptoms and reduce your risk of osteoporosis and heart disease. It is especially important to help protect bone health in those with premature menopause.
A recent study has connected HRT with reduced dementia risk.
Risks of HRT
Below I outline the main risks of HRT, but be aware that risks vary depending on your individual circumstance as well as type and dose of treatments.
HRT is not generally recommended for women with a history of stroke or deep vein thrombosis (clots in the veins); breast cancer; womb cancer; or severe liver disease.
It is also not usually appropriate to start HRT in those over the age of 60 . However, this does not mean that women who started it before the age of 60 should stop on reaching this age – in fact, there are benefits of longer-term usage. As well as symptom management, HRT can also help to protect your bones and safeguard heart health.
Breast cancer
This is probably the risk most women worry about. It is important to note that the risk is very small (one extra case of breast cancer in one thousand women taking HRT per year. That is less than 0.1%).
Good to know:
This risk only applies to those taking a combined HRT (HRT with progestogen) and not in those taking oestrogen-only HRT. In addition, there is no increased risk in those under the age of 51 taking HRT. It is also worth noting that your individual risk of developing breast cancer depends on underlying risks factors including as high alcohol intake, smoking and being overweight.
Stroke and clots in veins
Women taking HRT in the form of oral tablets can have an increased risk of stroke or clots in the veins.
- This risk is very small especially if you are below the age of 60 and is more likely in those with risk factors such as smoking, being very overweight, or a history of stroke or clots.
- Furthermore, there is no increased risk in those taking HRT in the form of skin patches or gels.
What are the side effects of HRT?
Side effects of HRT are – medically speaking – not serious and depend on the type of HRT you take. They usually occur the first three months of starting HRT and settle down over time.
The most common side effects are:
- breast tenderness
- bloating
- feeling sick (nausea)
- leg cramps
- skin irritation from skin patches.
You should discuss any side effects at your HRT review as they may be overcome by changing the brand, dose, route, or regime.
Irregular light bleeding or ‘spotting’ is also a common side effect in the first 4-6 months of taking continuous HRT. However, you should consult your doctor if you experience heavy bleeding within this time; bleeding that lasts more than 6 months; or bleeding that starts suddenly after 3-6 months, when you previously had no bleeding at all.
Managing menopause symptoms with HRT in the long term
HRT is a medicine you should review regularly with your GP or gynaecologist. You should have an initial review three months after starting HRT, and yearly thereafter.
These reviews should include:
- checking symptoms control
- any side effects
- ensuring appropriate type and dose of HRT.
Good to know
- There is no set time limit for how long you should be on HRT.
- For some women long term use of HRT may be required for symptom relief
The decision on how long to continue HRT should be shared between a woman and her doctor.
About Dr Shilpa McQuillan MRCGP MRCOG DFSRH
Dr Shilpa McQuillan is a GP with a difference; she brings a wealth of specialist knowledge when it comes to women’s health. Previously a Hospital Registrar in Obstetrics and Gynaecology, Shilpa now works in general practice, providing patients with resident expertise and knowledge on women’s health concerns.
Read Shilpa’s full biography here
You might also be interested in reading:
Nutritionists’ Guide to Menopause by Rosie Letts, Qualified Nutritional Therapist
Menopause, perimenopause and post menopause – a GP’s overview
