Oestrogen Hormone Therapy

What is oestrogen?

Oestrogen is a hormone produced by the ovaries. It has a wide range of important effects including:

Regulates our periods
Maintains the thickness of the vaginal wall and promotes lubrication.
Protects the bones and joints
Helps keep skin and hair healthy
Impacts brain function, including increasing the happy hormone serotonin.

During perimenopause level of oestrogen in our body can swing from high to low. These swings can cause large changes to our periods, mood, joints, hair and skin - and create those pesky perimenopause symptoms.

Our oestrogen levels reduce as we approach menopause and move into post menopause life. This decline can also introduce symptoms.

Who needs to take oestrogen as part of hormone replacement therapy (HRT)?

Everyone. Oestrogen replacement is central to any HRT because oestrogen is the main driver of symptoms.

There are a few different types of oestrogen that can be in hormone therapies. The type of oestrogen with the lowest risk is something called 17 beta-oestradiol. This is the 'body identical' form of oestrogen - meaning it has exactly the same chemical structure as the hormones in your body.

There are older forms of hormone therapy that contain different types of oestrogens. One of these is premarin - quite well know for being from the urine of pregnant horses. Although some suggest this is natural - it is not body identical and a little outdated. We wouldn't expect doctors today to prescribe this form of oestrogen hormone therapy.

What are the different types of oestrogen HRT?

Body identical oestrogen HRT can come as tablets, patches or gels. Each form has some advantages and disadvantages - and ultimately the type for you will depend on your own lifestyle and preferences. A good HRT consultation will take into account your lifestyle, and should explain the risks and benefits of each option.

Oestrogen HRT tablets

Advantages:

If you already take medications or supplements each day, it can be easy to remember to take a daily pill.
Easy to know when you are running out of tablets.
If you are getting HRT privately tablets are often the most cost effective form.

Disadvantages:

Higher risk of blood clots than transdermal forms of HRT (gels and patches). This size of this risk differs depending on the type of oestrogen in the tablet. Body identical oestrogen tablets have the smallest increased risk. Non-body identical forms have a larger risk.
Some women find it difficult to remember to take tablets everyday if this is not part of their normal routine.
Because tablets are absorbed through the digestive system it's more likely that digestive problems might occur.
Women with migraines should not take tablets because there's a small increased risk of stroke with this form of HRT. Women who suffer with migraines are already at an increased risk of stroke, so taking oestrogen as a patch or gel is better for them.
Tablet oestrogen may lower libido. Taking oestrogen tablets can increase levels of Sex Hormone Binding Globulin (SHBG). This hormone binds to the testosterone in your blood - lowering libido. Oestrogen as a patch or gel does not increase SHBG, so does not have this effect.
Tablets are a fixed daily dose of oestrogen. With gels and patches the dose can be adjusted more easily. Finding the right dose for your body may take some adjustments, and this can be easier with gels and patches.

Transdermal Oestrogen HRT as patches and gels

Advantages:

Lower risk of blood clots.
Lower risk of digestive issues.
Lower risk of decreased libido.
Easier to tailor the dosing as you can change patches more or less frequently, and apply more of less of a gel sachet.
Some women find patches very convenient as they stay on the skin for days, meaning you do not have to remember something daily for HRT.

Disadvantages of patches:

Some women who have sensitive skin may react to the adhesive of patches.
Patches are in shorter supply than other forms of HRT at the moment (spring 2020). Shortages are expected to improve over the coming months.
If you are getting your HRT prescription privately patches are often the most expensive.

Disadvantages of gel:

Most women absorb the gel very easily, but a small number of women do not. No other creams should be applied for an hour after applying the gel to support absorbption.
In general, the gel is applied daily which can be harder to remember.
If you are getting your HRT prescription privately gel more cost effective than patches, but still more than tablets.

What are the risks attached to oestrogen HRT?

As outlined above the risks depend on the form of HRT you take. Often women are worried about breast cancer with HRT. This is because of older evidence suggesting HRT made your chances of developing breast cancer much greater. The evidence has really moved on since this famous study.

With breast cancer risk the important things to remember are:

Women under 51 years old do not have an increased risk of getting breast cancer when using HRT, regardless of the length of time they take it for. This is important. Taking HRT when you are younger can reduce your long term risks for osteoporosis, dementia and coronary heart disease.
Women without a womb, taking only oestrogen, do not have an increased risk of breast cancer.
The small increased risk of breast cancer for older women comes from the progesterone part of combined HRT. Body identical progesterone (micronised progesterone) has lower risks. The increased risk is very small for the first 5 years of taking HRT, and increased slightly after 5 years. To put the risk into perspective it is less than being overweight, obese or drinking a couple of glasses of wine a night.
It's also important to note that if you do get breast cancer (which 1 in 8 women do, regardless of HRT) that the chances of survival are not reduced if you take HRT. In fact the survival chances may be better if you take HRT but more evidence is needed to confirm this.

Other risks depend on the form and type of HRT you take. Body identical oestrogen has much lower risks than older forms of oestrogn. As outlined above tablets have a higher risk of clotting than patches or gels.

Do I need to know anything else about HRT?

There are many different types of HRT you can try. If one type doesn't work for you, there's many others you can try before giving up. This is why it's important to track your symptoms as you start to take HRT, and throughout your menopause journey.

If you need combined HRT it can be useful to have the oestrogen and progesterone prescribed separately. This allows the dose of oestrogen to be tweaked without changing the progesterone.

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). *Types - Hormone Replacement Therapy - * Retrieved 16 March 2020 from [https://www.nhs.uk/conditions/hormone-replacement-therapy-hrt/types/].

4 Panay, N., Briggs, P., & Kovacs, G. (Eds.). (2015). Managing the Menopause: 21st Century Solutions. Cambridge: Cambridge University Press.

5 A, Noor et al. (2016). “Progesterone vs. synthetic progestins and the risk of breast cancer: a systematic review and meta-analysis.” Systematic reviews vol. 5,1 121. 26 Jul. 2016, doi:10.1186/s13643-016-0294-5