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Hormone replacement therapy (HRT) - explained

Hormone replacement therapy (HRT) is the most common medical treatment of menopause. It comes in many different forms, but it will always have a form of the hormone estrogen in it. There's a lot of confusion about the risks and benefits of HRT - and it can to understand whether it might help you. This article explains what HRT is, the different forms and it's pros and cons.

What is HRT?

HRT is a type of estrogen which you can take to help ease symptoms of menopause. If you've had a hysterectomy in the past, you'll be given estrogens alone. If you haven't had a hysterectomy, estrogen will be combined with progestogen. HRT with both estrogen and progestogen is commonly called 'combined' HRT. The type of HRT recommended for you will also depend on your symptoms and age.

More about estrogens...

There are synthetic (man made) and natural estrogens available. Synthetic estrogens are not commonly used as HRT, unless you are under 40 and have been diagnosed with premature ovarian insufficiency (POI).

Natural estrogens are from plants or animals - but always found in natural living things rather than from chemicals. Natural estrogens used in HRT include estradiol, estrone and estriol - from soybeans or yams mostly. Premarin, a well known form of HRT, uses estrogen from horses.

More about Progestogens...

Using oestrogen only HRT in women with uteruses increases the risk of some diseases - so combined HRT is now recommended. The progestogens used for HRT are mostly synthetic. They are taken as tablets, though there are different ways to take HRT.

The progestogen will often be used cyclically in perimenopausal women - this means taken for a cycle and then taking a break from it. When on a break there will be a withdrawal bleed.

For *post menopausal * women continuous progestogens use is recommended.

Tablet/orally taken HRT

Taking tablets is the most common way to take HRT. This doesn't necessarily mean it's the best way to take it though. There have been developments with patches and gels that work make them a viable alternative.

The main reason not to take HRT as tablets is avoid the impact on the gut and liver. When you take pills they are digested through our normal system, meaning that they'll pass through the gut and the liver. Estrogens taken through the mouth leave also leave the chemical estrone circulating in the body. Estrogens taken non-orally leave the hormone estradiol in the body. These two hormones have slightly different effects.

To get the best effects women may need to take different forms and doses of HRT - mixing tablets, patches and/or gels in many cases.

Patches and gels

Both estrogens and some progestogens (specifically norethisterone and LNG) can be absorbed through the skin. This means that these forms of HRT can be taken into the body when they are applied to the skin directly. There are two main ways to do this - via patches and gels.

Patches can be cut into different sizes, to control dosing. They need to be replaced once or twice a week. The specific advice will depend on the brand of HRT you are taking, and the instructions on the packet. Patches can be applied cyclically or continuously - meaning that they are suitable for peri and post menopausal women.

Gel is only available for estrogen HRT. This means for women who still have a womb, they would need a tablet form of progesterone to accompany the gel.

Implants

Implants are inserted under the skin and release the hormones estradiol gradually into the body. They need to be inserted and replaced every c.6 months. Implants give a higher dose of estradiol than other forms of HRT - which some women find helpful. They also have the advantage of women not having to remember to take tablets or re-apply patches.

Something to consider with implants is that it's harder to control the dose of estrogen - because they are just inserted and start releasing hormones at a set level. For some women, the dose of hormones from an implant will not be enough to cause their symptoms to stop. Implants are also likely to leave a small amount of estradiol circulating after they have run out. The risks attached to this residual hormone are not yet well understood.

When to start HRT?

You don't have to wait until your periods stop to start HRT. If your having symptoms which are causing you trouble and you are open to hormonal therapy you should speak to your GP.

If you choose to start HRT you may have to try out different forms and doses over a few months to get those pesky symptoms under control. There may also be some additional side effects treatment before you find the right dose for you. Stick at it with advice from a doctor until you work out the right treatment for you.

What are some of the common side effects of HRT?

Estrogens can cause:

  • bloating/water retention
  • breast tenderness
  • nausea
  • headaches
  • leg cramps

Progestogens can cause:

  • bloating/water retention
  • breast tenderness
  • mood swings
  • Depression
  • Back pain
  • headaches

For vaginal symptoms only...

There are different types of HRT if you are looking for relief from vaginal symptoms only e.g. dryness, pain during sex, or recurring infections. You can take low dose creams or tablets applied to the vagina. For these symptoms you take estradiol only - the low dose is considered safe for all women without the need for any additional progestogens.

And finally, a little note on testosterone...

It's normal for testosterone levels to drop with age - but for some women (especially those who have their ovaries removed) they can lose a huge amount. Symptoms of low testosterone include loss of libido, mood issues, fatigue and headaches. So they're pretty unpleasant. Testosterone replacement therapy may help women, but currently there are not any testosterone products licensed for women in the UK. This is something we're hopeful will change quickly.

For women with low testosterone some doctors will recommend testosterone gels, produced for men. Women can use these in small amounts to help get relief from symptoms. Often, this would be with a estrogen based therapy.

Overall some of the pros of HRT are:

  • It can help women with horrible symptoms. It is the most effective way to reduce many menopausal symptoms at the moment, but therapy based approaches (CBT) can also be very effective.
  • The highest quality research (Cochrane Systematic reviews) show that HRT started within 10 years of menopause can reduce the risk of CHD and all cause mortaility [1].
  • Treating vaginal symptoms with low dose HRT directly applied to the area is an effective way to help with vaginal dryness and low sex drive (both very common symptoms).

Some considerations are:

  • There may be a slight increase some cancers when estrogen and proestogen combined are used. It's a small but significant increase in risk - but each person should weight these up against the benefits of HRT.
  • There's no one size fit all approach to HRT. It can be quite labour intensive to get the right combination of HRT for you.
  • Treatment always needs to be specific to the indivdual, and once the right HRT is found a doctor should still review it annually.

References:

1 Gabriel Sanchez R, Sanchez Gomez LM, Carmona L, Roqué i Figuls M, Bonfill Cosp X. Hormone replacement therapy for preventing cardiovascular disease in post‐menopausal women. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD002229. DOI: 10.1002/14651858.CD002229.pub2.

2 Hillard T., et al. (2017). Management of the menopause. 6th edn. British Menopause Society. UK.

3 National Health Services Website (2018). *Treatment - menopause * Retrieved 16 October 2019 from [https://www.nhs.uk/conditions/hormone-replacement-therapy-hrt/].