Are there different types of HRT?
Medically, the choice of type and administration route of HRT is dependent upon a woman’s menopausal status and uterine status. Practically, there may be other specific reasons why a particular form of HRT is chosen, e.g. ease of taking tablets, side effects experienced.
There are 4 main forms of estrogen:
- Oral Estrogen
- Transdermal Estrogen – in the form of a patch or gel directly on the skin
- Subcutaneous Estrogen – implanted pellets
- Vaginal estrogen cream / tablet
Women with a uterus must also use progesterone to protect the uterine lining.
Women should also be counselled about the possibility of using testosterone which can be of benefit if libido and/or energy levels are low.
How to get the right HRT treatment?
Creating the right HRT requires careful consideration of the symptoms and health factors of the individual.
Oral treatment regimens may be sequential or combined.
- Sequential HRT mimics the natural cycle with continuous estrogen and sequential progesterone i.e. only for part of the month. The length of time progesterone is used varies between individuals, but is usually anything from one to two weeks of the cycle. Continuous Combined HRT is when both estrogen and progesterone taken together every day of the cycle, continuously
Transdermal estrogen is particularly useful when taking oral tablets is not possible or desired. In addition, it is the preferred route if there are any cardiovascular risk factors involved.
HRT implants (estrogen and/or testosterone) are generally recommended when other methods have failed or if using the treatment routinely is problematic. As they last for at least 6 months, close monitoring of estrogen/testosterone levels is recommended to ensure correct dosing.
HRT is also available in a vaginal cream / vaginal tablet. These are recommended for the treatment of local symptoms, such as vaginal atrophy, dry / sore vagina and pain on intercourse.
How long to take HRT for?
The recommendation is that the duration of HRT usage is individualised. This will obviously be dependent on each woman’s circumstances. The discussion within a menopause clinic will involve the following factors:
- What benefits have been achieved.
- Level of side-effects (if any)
- Any risk factors that may increase with continued use
- Age of woman when HRT started
Women with ongoing symptoms may need to continue HRT long term.
Stopping using HRT after the menopause transition
When HRT is first started, the doctor may recommend gradually lowering the dose to reduce side effects, such as breast tenderness or bleeding problems.
After a mutually agreed duration of treatment, an attempt may be made to reduce the dose with a view to assessing whether menopause symptoms are continuing. If symptoms do not return / worsen an attempt can then be made to stop treatment.
Recent data suggest that there may be increased cardiovascular risks when HRT is stopped; it is not clear whether the risks are mitigated if the dose is tapered rather than stopped abruptly, but the former seems the logical strategy.