Hormone replacement therapy (HRT)
What is HRT?
Hormone therapy for women, also known as Hormone Replacement Therapy (HRT), is a specialised treatment aimed at alleviating the symptoms that women experience during the menopause phase.
To effectively manage these symptoms, keeping a symptom diary can prove beneficial in tracking and documenting your individual experiences. The menopausal symptoms arise due to the notable fluctuations in oestrogen levels within the body.
Hormones act as messengers to help regulate various essential processes like growth, metabolism and fertility. Hormones have far-reaching effects on the body, including influencing the immune system and even affecting mood and behaviour.
During menopause, the fluctuations in oestrogen levels can disrupt the delicate hormonal balance, leading to a range of symptoms with varying intensities. Hormone Replacement Therapy (HRT), also known as hormone therapy for women, steps in to address these hormonal changes by replacing the hormones that are affected by menopause.
By restoring hormonal balance, HRT aims to alleviate the symptoms and promote overall well-being.
How does HRT work?
Hormone Replacement Therapy (HRT) primarily utilises oestrogen to address the oestrogen deficiency caused by menopause. In some cases, HRT formulations may also include progesterone or progestogen, which is a synthetic form of progesterone. Progesterone naturally occurs in the body and plays a crucial role in maintaining the health of the uterine lining.
In hormone therapy for women with a uterus, the addition of progesterone or progestogen helps protect the uterine lining from excessive stimulation by oestrogen. Therefore, when HRT is recommended, a combined treatment is often used, consisting of oestrogen and either cyclical progesterone/progestogen or continuous progesterone/progestogen (known as no-bleed HRT).
The availability of various types and delivery methods for oestrogen and progestogen offers flexibility in treatment options and allows for personalised approaches tailored to individual needs. If you are searching for HRT specialists near you, we are here to provide expert guidance and support.
Why take HRT?
The timeline for experiencing the benefits of hormone therapy for women can vary, typically taking a few weeks for initial effects to be felt. It may take 6-12 weeks for the full effects to manifest as hormone levels stabilise and symptoms continue to improve. At Hormone Health, we prioritise regular follow-up consultations to monitor your progress. We recommend reviewing patients after 3 months followed by subsequent check-ups every 6-12 months.
During these follow-up consultations, we will request blood tests to assess your hormone levels while on the prescribed medication. This helps us evaluate the effectiveness of your hormone therapy. Based on these results and your symptoms, adjustments to the HRT dosage may be necessary during your consultation to optimise your treatment.
How long does it take to work?
There is no predictable timescale but it will normally take a few weeks until the initial benefits of HRT are felt. The full effects may take 6-12 weeks, as hormone levels settle and symptoms continue to improve. At Hormone Health, we like to review patients after 3 months and then every 6-12 months after this.
We ask that you have blood tests prior to being seen at follow up consultations. This is so that we can see how your hormone levels are on the medication you have been prescribed. The dose of your HRT may need to be adjusted at your consultation, depending on these results and your symptoms.
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 hormone therapy for women is chosen, e.g. ease of taking tablets or 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 regimes may be sequential or combined.
- Sequential HRT mimics the natural cycle with continuous oestrogen 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 oestrogen and progesterone are taken together every day of the cycle.
As they last for at least 6 months, close monitoring of oestrogen/testosterone levels is recommended to ensure correct dosing.
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 for hormone therapy for women is to individualise the duration of usage based on each woman’s circumstances. This decision is made through discussions within a menopause clinic, taking into account 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. – this can be discussed with a Hormone Health associate during your clinic appointment.
What are the benefits of HRT?
The main benefit of HRT is to relieve the symptoms of menopause. For most women, these benefits significantly outweigh the risks associated with HRT.
Alongside helping with hot flushes, night sweats, mood swings and bladder symptoms, the following are benefits of HRT:
- The effect of HRT on bone health is significant. HRT increases bone density, and the benefits are maintained many years after stopping HRT.
- In women with premature menopause [Premature Ovarian Insufficiency (POI)], the use of HRT is recommended as the long term lack of estrogen in a younger age group can increase the risk of developing osteoporosis, cardiovascular disease and cognitive problems. These problems can be reduced with HRT as long as is used at least until the average age of menopause (51 years).
What are the risks of HRT?
Over the past 20 years, there have been a number of studies into the risks of taking various forms of HRT. The risks can vary from one woman to another and can depend on many factors, so it is essential that any treatment is determined on an individualised basis taking into account familial and personal health history.
Guidance from the menopause societies and the National Institute for Health and Care Excellence is that the lowest effective dose is used. The duration of use should be individualised and re evaluated annually according to the benefit / risk balance.
Cancer issues
Breast, endometrial and ovarian cancers are multi-factorial and may involve general health risk factors, such as diet, smoking, alcohol intake and family history. The data concerning risks are complex and vary according to the population studied. Consequently, these risks should be discussed in detail within a menopause clinic to establish the absolute risk for each individual.
Continuous combined HRT appears to reduce the risk of endometrial cancer. The risk of breast cancer does not appear to increase within the first 5 years of usage of HRT and if present, is no greater than 1 extra case per 1000 women per year. The risk ovarian cancer with HRT remains controversial but if present, is no more than 1 extra case per 5000 women per year.
There are no scientific data that show an increased risk of cervical, vaginal and vulval cancer with HRT usage and HRT appears safe after diagnosis of these cancers.
Clotting issues
Oral HRT appears to be associated with an increase in risk of developing a clot, medically known as a Venous Thrombo Embolism (VTE).This risk also increases with age. Therefore long term use needs to be assessed in line with any other clotting risk factors.
Transdermal HRT avoids stimulating clotting factors and can potentially be used with caution even in women with a clotting risk.
The pros and cons of HRT should be carefully weighed up in high risk situations and it may be prudent to work with a haematologist who has knowledge of HRT.
What are the side effects of HRT?
This depends on what has been prescribed, but the most common side effects are:
Estrogen
Bloating, breast tenderness or swelling, nausea, headaches.
Progesterone
Weight gain, fluid retention and swelling (oedema), fatigue, acne, drowsiness or insomnia, breast discomfort or enlargement, premenstrual syndrome (PMS)-like symptoms.
The Hormone Health clinic will try and achieve the best hormone balance possible, which may mean altering the doses/timings of elements of the treatments. Progesterone seems to be the most common cause of unwanted side effects but for instance, using the capsules as a vaginal pessary instead of taking orally, can reduce the side effects significantly
Who can take HRT?
HRT is particularly recommended for women below the age of 60 years. This represents the group of women, where any risks are at their lowest and possible benefits are most likely. Women over 60 years wishing to start HRT should have the benefit risk balance carefully considered with low dose transdermal estrogen preferred with natural progesterone.
HRT should be used in women with Premature Ovarian Insufficiency (POI) or early menopause at least until the age of 51 to protect against osteoporosis, cardiovascular disease and dementia.
Usual contra indications to HRT include:
- Pregnancy
- Undiagnosed abnormal vaginal bleeding
- Active or recent blood clot or myocardial infarction (heart attack)
- Suspected or active breast or endometrial (womb) cancer
- Active liver disease with abnormal liver function tests
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