Hormone replacement therapy (HRT)

Introduction

What is HRT?

Hormone Replacement Therapy or HRT is a treatment used to relieve the symptoms experienced during the menopause. Symptom diary (PDF, 149KB). The symptoms of menopause are caused by a significant change in the amount of the hormone, estrogen, released by the body.

Hormone levels in the body are delicately balanced; they are the chemical messengers that travel throughout the body controlling complex processes such as growth, metabolism and fertility. They have wide ranging effects on the body including influencing the immune system and even mood and behaviour.

The change in estrogen levels can have a knock-on effect on other hormones causing wide ranging symptoms of varying severity. HRT replaces the hormones affected by the menopause helping to restore hormonal balance in the body.

How does HRT work?

The main hormone in HRT is estrogen. This is because it replaces the deficiency of estrogen caused by the menopause. In addition, some HRT preparations will also include progesterone or progestogen (synthetic progesterone). Progesterone naturally occurs in the body and is mainly responsible for maintaining the health of the lining of the uterus.

If a woman with a uterus uses HRT, then progesterone / progestogen will help protect the lining against over-stimulation by estrogen. Consequently, if HRT is recommended then a combined HRT treatment is used with estrogen and either cyclical progesterone/progestogen or continuous progesterone/progestogen (no bleed HRT).

The wide range of types and routes of oestrogen and progestogen allows flexibility and enables treatment to be personalised.

Why take HRT?

The symptoms experienced during the menopause are unique to each individual and can include night sweats, hot flushes, mood swings, memory problems, aches and pains, reduced libido and vaginal dryness. Each woman will have different issues and experience them to differing levels of severity, therefore finding the right treatment programme is essential.

HRT is proven to relieve these symptoms, so it is the treatment of choice if these symptoms are troublesome. If HRT does not work, is contra-indicated (ie medically inappropriate) or is not an individual’s preference, there are still other ways to manage these symptoms.

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 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.

Benefits and Risks of HRT

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 </h5

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.

HRT side affects / Who can take 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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