HRT2023-06-23T08:15:27+00:00

Hormone Replacement Therapy (HRT)

Managing the range of symptoms that may accompany the menopause transition can be complex and challenging – there is no ‘one size fits all’.

Managing the menopause

There are a wide variety of management options available beyond the use of hormone replacement therapy (HRT),  ranging from vaginal oestrogen for vaginal dryness and urinary symptoms to cognitive behavioural therapy (CBT) which can be used both for psychological symptoms and to help cope with some symptoms.

Whilst for most women a straightforward prescription for HRT may be what’s needed to control symptoms, some women will require several different treatments, and on occasion may end up trying a few different options and/or different doses before they find a method and a dose that works well for them.

The majority of women can safely take HRT but some women may choose not to and for others the risks of HRT may need to be more carefully considered due to past or current medical conditions. These women may want to try alternative methods.

Types of HRT

Combined HRT

Women who have a womb require 2 hormones in the prescription for HRT.

The oestrogen is to try and alleviate the physical symptoms and is given continuously but if oestrogen is given on it’s own to a woman with a womb then the lining of the womb is stimulated and thickens which hugely increases the risk of the cells in the womb lining becoming cancerous.

To prevent this from happening we prescribe a second hormone- progesterone. The progesterone prevents the lining of the womb from becoming too thick and is very  effective at protecting the womb from cancer.

Oestrogen only HRT

Women who have had a hysterectomy (had their womb removed) do not usually require progesterone as without a womb there is no need to protect against womb cancer.

**women who have had a hysterectomy for severe endometriosis or who have had a subtotal hysterectomy (where the neck of the womb has not been removed) may require progesterone with the oestrogen for a period of time.

How do we give combined HRT?

There are two main ways to prescribe combined HRT (where two hormones are given).

Sequential combined HRT

Oestrogen is taken all the time because that’s the hormone that will improve symptoms but for two weeks of each month they would take the additional hormone progesterone to protect the womb from cancer. At the end of every two weeks of the progesterone they would have an expected vaginal bleed (similar to the bleed you would have during each cycle in the combined contraceptive pill). Technically this is not a real period- we call it a withdrawal bleed and it’s stimulated artificially by the cyclical progesterone to allow the womb to shed its lining.

We tend to use this option for women who are still having some menstrual periods. If the woman’s periods are still fairly regular we try and time the prescription to allow the withdrawal bleed to coincide with when the woman would have her usual period.

The main reason we use this type of sequential pattern of hormones is that in women still having some natural cycles, taking progesterone every day would cause irregular vaginal breakthrough bleeding which is not only irritating for the woman but also causes significant anxiety for both the woman and the clinician and may lead to invasive and unnecessary investigations.

Continuous combined HRT

In women who have not had a period for a year or for those who do not have periods because of a contraceptive method such as the Mirena coil or the progesterone only pill we tend to prescribe what we call a continuous combined regimen of hormones. In this type of HRT a woman would take two hormones (oestrogen and progesterone) every day but the progesterone is given at a lower dose than in the sequential regimen described above. There is no expected withdrawal bleed with this type of HRT though irregular bleeding in the first few months is common and often settles with time.

Frequently asked questions about HRT

Does HRT delay menopause?2022-12-02T16:46:49+00:00

No it does not. Menopause is an intrinsic process inside a woman’s body that goes on behind the scenes whether you’re taking HRT or not. HRT helps with the symptoms of the Menopause as well as offering the other benefits mentioned above but it does not change the overall process of a woman’s ovaries winding down to retirement.

What types of HRT are available?2022-12-02T16:41:05+00:00

There are different ways in which HRT can be given. The different routes of delivery have different risks associated with them and some women may be strongly advised to take one form of HRT over another due to pre-existing medical conditions. Personal choice also comes into which method would be prescribed.

In addition it is important to note that if a woman is taking combined HRT (with two hormones) then these can be given together in one route or separated out and given by different methods eg oestrogen as a patch and progesterone as a tablet or a combined patch with both hormones.

Oestrogen

  1. Transdermal (through the skin)

This is the safest way to give oestrogen as it has the lowest risk of blood clots and is a bioidentical form of oestrogen which has the same structure as the oestrogen we produce in our own bodies.

Transdermal oestrogen has the advantage that it is absorbed through the skin and thus avoids being broken down in the gut and the liver and may give fewer gastric side effects such as nausea.

It is also a better choice for women who have medical problems that affect their gastrointestinal tract such as Crohn’s disease and ulcerative colitis or in those with liver disease.

The options to take oestrogen in a ‘through the skin’ preparation are via a gel, spray or a patch.

The patches come as oestrogen only or as a combined patch with progesterone. The patches are applied twice weekly and there is a once weekly preparation available in the combined patch.

The spray and gel is oestrogen only and would require separate progesterone if a woman has a womb (and therefore needs both oestrogen and progesterone). The spray and gel are applied daily.

See below for progesterone preparations

  1. Oral tablets

These can be given as oestrogen alone or in a combined tablet with progesterone and is taken daily.

The tablets are broken down and absorbed in the gastrointestinal tract.

Progesterone

  1. Transdermal

Progesterone can be given through the skin in a combination patch with oestrogen. The progesterone in the patches is a synthetic progesterone (progestogen).

  1. Oral tablets

Progesterone is available as a combined tablet with oestrogen or can be given separately. Most of the combination tablets contain progestogen (synthetic).

Body identical progesterone (micronized progesterone) is mostly given as a separate tablet but there is one preparation that is a combined tablet with oestrogen.

Micronised progesterone has the same structure as progesterone we produce naturally in our bodies and is made from yams. It is not available as a transdermal preparation as it has not been shown to be safe in protecting the lining of the womb.

  1. Intrauterine device

The progesterone component of HRT can be given straight into the womb via an interuterine device. The only licensed option for this for HRT in the UK is with a Mirena coil and this can be used for 5 years as part of HRT and of course provides contraception at the same time. Here are other interuterine devices available for contraception but they are not licensed for use as part of HRT.

This is a very low dose of synthetic Progestogen  that mostly stays locally in the womb so for many women this option has fewer side effects than other synthetic progestogens in the patches or tablets.

Can you change from one regimen to the other?2022-12-02T15:59:36+00:00

Yes very easily. If a women starts on a sequential regimen we usually advise staying on this for a minimum of a year before trying to change over to a continuous type of HRT.

If a woman changes to a continuous HRT and develops irregular bleeding it is sometimes necessary to change back to the sequential hormones for a length of time before trying the continuous again.

What side effects can I get from using testosterone?2022-12-01T09:53:16+00:00

Common side effects include increased hair growth at the site of application; we will give you advice on how to apply your medication during your consultation to prevent this.

If you are experiencing weight gain, acne, hair loss on the front area of your head or a deeper voice then we would advise booking a review appointment with Chelvey Menopause because these side effects may indicate that you are taking too high a dose.

Can testosterone help with symptoms other than low libido?2022-12-01T09:52:53+00:00

Testosterone is an important female hormone. Many women find it has a very positive impact on their libido.  Although evidence is lacking with regards to using testosterone to treat other symptoms, many women find that testosterone also helps to improve energy levels, mood and concentration.

Do you prescribe testosterone?2022-12-01T09:52:27+00:00

Yes. If a woman on a stable HRT regime is experiencing symptoms of low libido and loss of sex drive then, as per current NICE guidelines we can prescribe testosterone. In order to do this safely we will need to do some baseline bloods and then regular follow up bloods to monitor levels and ensure that these remain within the female range.

Do you offer coil fitting?2022-12-01T09:52:06+00:00

Yes, we will be offering this soon. Please email us to go on the waiting list for a Mirena coil appointment- enquiries@thecheley.com

How much does HRT cost?2022-12-01T09:51:49+00:00

This varies depending on the treatment prescribed. On average each medication costs £10-40 per month.

What are the alternatives to HRT?2022-12-15T21:01:37+00:00

Please follow this link to our webpage on alternatives to HRT

What are the benefits of HRT?2022-12-02T16:44:04+00:00

1.Breast cancer– current research shows that HRT taken for 5 years or less has very little to no increased risk of breast cancer depending on the type of HRT used.

Oestrogen alone and combined HRT using oestrogen and micronized progesterone has no increased risk (oestrogen alone has actually been shown to reduce risk).

Combined HRT with a progestogen has a very small increased risk over 5 years.

After 5 years the risk of all combined HRT confers a slightly increased risk of breast cancer which reduces on stopping the HRT.

2.Blood clots– tablet form of HRT has been shown to cause a small increased risk of blood clots. This has to be taken into context with other risk factors for blood clots such as smoking and BMI and the pros and cons carefully discussed and in some circumstances a transdermal preparation may be suggested instead.

Some women may have a strong family history of blood clots or may be known to have a medical condition that increases the risk of blood clots in which case transdermal oestrogen would be strongly recommended.

There is good evidence that transdermal oestrogen does not increase clot risk.

Some progestogens are higher risk for blood clots than others and this may also need to be taken into consideration when prescribing HRT.

3.Ovarian cancer- we do not have good studies looking into the risk of ovarian cancer with HRT but one study showed a very small increased risk of 1 in 2,500. Other studies have not shown a significantly increased risk.

4.Heart disease- the relationship between HRT and heart disease has been one of controversy over the years. Current thinking is that there is a ‘window of opportunity’ where HRT is beneficial for the heart (within 10 years of the menopause or < age 60) and after this the effect is likely to be neutral on the heart rather than harmful. However in women who have unstable cardiovascular disease HRT is contraindicated until the heart disease is considered ‘stable’ and even then may require discussion with a heart specialist if restarting HRT is desirable.

5.Endometrial cancer- giving oestrogen alone to a woman with a uterus incurs a significant increased risk of endometrial cancer (cancer of the womb). This is reduced by using a progesterone/progestogen in a combined HRT but the risk is not completely removed and sequential HRT in particular has a very small increased risk of endometrial cancer if given for longer than 5 years.

What are the risks of HRT?2022-12-15T21:01:03+00:00

Please follow this link to our webpage on risks of HRT

Does HRT cause breast cancer?2022-12-01T09:49:53+00:00

The current evidence suggests that 5 years of body identical HRT including oestrogen delivered through the skin does not increase your risk of breast cancer. After this time the risk of breast cancer increases very slightly (see link below).

WHC Factsheet on breast cancer

What should I do if I forget to take my HRT?2022-12-01T09:48:56+00:00

Do not take the doses you have missed, just continue to take the next dose when you remember.

Why do I have tender breasts on my HRT?2022-12-01T09:48:38+00:00

This is a very common initial side effect that can be due to either the oestrogen or the progestogen component of your HRT. These symptoms should settle with time. We advised all women to have their regular mammograms and to be breast aware and self-examine regularly. Many women find Starflower Oil very helpful for breast tenderness symptoms, this is available over the counter.

What happens if I start bleeding on HRT?2022-12-01T09:48:20+00:00

It is very common to experience some irregular and heavier bleeding when starting HRT or increasing your dose of HRT. This can take 3-6 months to settle. If symptoms persist or worsen after this time, we advise booking for a review appointment at Chelvey Menopause or with your own GP. Sometimes further investigations may be needed.

When should I stop my HRT?2022-12-02T16:45:27+00:00

Current NICE guidelines state that there is no maximum or minimum time frame for a woman to continue taking HRT.

Every case is unique, and length of treatment will need to be considered on an individual basis.

Guidelines suggest an annual reassessment of HRT in order to provide safe prescribing and to discuss the risks and benefits of taking HRT for you personally.

What are the side effects from HRT?2022-12-02T16:44:42+00:00

Some women experience mild side effects when treatment begins including, breast tenderness, nausea, bloating, skin irritation, irregular bleeding. These side effects will usually disappear within 6-8 weeks of starting HRT. If they do not improve then a change in your type or dose of HRT may be necessary. Your doctor will be able to offer advice regarding this.

How long does HRT take to work?2022-12-01T09:47:26+00:00

 

It can take several months to see the full benefits of HRT; however, most women feel the initial benefits after just a few weeks.

What is the difference between body identical/ regulated bioidentical and compounded bioidentical hormones?2022-12-01T09:47:05+00:00

Body identical HRT or regulated bioidentical HRT is the safest form of HRT, with the lowest risk of adverse effects. This is what we prescribe at Chelvey Menopause. These hormones are structurally identical to the natural hormones we produce in our bodies.

The British Menopause Society and NHS do not recommend compounded bioidentical hormones. These hormones are not regulated and there is not enough medical evidence to support the safe use of this type of HRT.

What type of HRT do you prescribe?2022-12-01T09:46:41+00:00

We only prescribe regulated HRT as recommended by the British Menopause Society.

We do not prescribe compounded bioidentical hormones.

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