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What is hormone replacement therapy (HRT)?

During menopause, the level of oestrogen produced by the ovaries declines, leading to symptoms such as hot flushes and night sweats, irregular periods, mood swings and vaginal dryness. Hormone replacement therapy (HRT) is a type of hormonal treatment used to relieve these symptoms. All HRT contains oestrogen, with combined formulations also containing progestogen. HRT can also be used to prevent osteoporosis (weakening of the bones) in postmenopausal women which is more likely to occur as oestrogen levels drop during the menopause.

How does HRT work?

HRT works by supplementing the body’s natural hormones, which are in short supply during the menopause, relieving symptoms and, in some cases, preventing the onset of osteoporosis. Oestrogen-only HRT is suitable for women who have had a hysterectomy or who have certain intrauterine contraception fitted. Women who have not had a hysterectomy, or who do not have an appropriate intrauterine contraceptive fitted, will need to take a combined form of HRT containing progestogen, which counters the thickening effect of oestrogen on the womb lining.

When should you start HRT?

The onset of menopause usually occurs between the ages of 45 and 55 but can occur anywhere between the ages of 30 and 60. HRT is indicated in women who experience troublesome menopausal symptoms such as hot flashes, mood changes or vaginal dryness, and who do not have any contraindications. If you are experiencing these symptoms, it’s recommended to see your doctor for an evaluation of your reproductive health and to check your suitability for HRT. Women who are under the age of 60 and within 10 years of the onset of menopause are most likely to experience the full benefits of HRT.

What are the benefits of HRT?

HRT is considered the most effective treatment for managing the symptoms of menopause, which can greatly impact women’s lives. By supplementing the body’s natural hormones, HRT can relieve symptoms such as night sweats and hot flushes, mood swings, irregular periods and vaginal dryness. It is also an effective treatment for delaying the onset of osteoporosis, and many women continue to use HRT for many years with successful results.

What are the different types of HRT?

All HRT contains oestrogen, as it is the declining levels of this hormone that cause the classic menopausal symptoms. Oestrogen is also the hormone responsible for maintaining bone health and preventing osteoporosis. HRT is broadly divided into oestrogen-only HRT and combined HRT. 

Oestrogen-only HRT, as the name suggests, only contains the oestrogen hormone. This is only suitable for selected women who have had a hysterectomy (removal of the womb). This is because when oestrogen is used alone, it can cause thickening of the lining of the womb, which can lead to troublesome bleeding, or a condition called endometrial hyperplasia. In some cases, this thickening of the womb lining can predispose you to endometrial cancer. If you have had a hysterectomy, you do not need to worry about this as that tissue has been removed. 
Oestrogen-only forms of HRT can be taken orally (e.g. Elleste Solo, Premarin), applied to the skin as transdermal patches (e.g. Elleste Solo MX80, Elleste Solo MX40, Evorel), or applied to the skin as a gel. 

Most people, therefore, use a combined form of HRT, which contains both oestrogen and progestogen. The oestrogen component functions to relieve troublesome menopausal symptoms and keep your bones strong. The progestogen component stops the womb lining from becoming thickened. The oestrogen component can be taken orally or transdermally (via the skin) and the progestogen component can be taken either orally, transdermally, or can be obtained via a Mirena intrauterine system (IUS or coil). 

Women who are experiencing menopausal symptoms but still experience regular periods (or have experienced a natural period within the past 12 months) are recommended to start with a cyclical form of HRT which allows for a regular bleed (e.g. Prempak-C, Trisequens, Elleste Duet). Post-menopausal women (women who have not had a natural period for over a year) can use a continuous combined HRT, which involves taking the same dose of oestrogen and progesterone every day without a break for a bleed (Kliovance, Climesse, Elleste Duet Conti).

HRT patches vs. pills

Oral tablets are the most commonly used form of HRT. It is important to be aware that oral HRT carries a slightly higher risk of blood clots than other forms. Transdermal patches are an alternative for people who struggle to remember to take a tablet each day, or who struggle with side effects of oral medication such as indigestion. Patches are typically changed twice weekly. Oestrogen is also available as a gel, which is applied to the skin, usually every day.

Alternatives to HRT

HRT is widely considered to be the most effective and popular treatment for the symptoms of menopause and is available online at Dr Felix. Some women choose to try herbal supplements and remedies such as St. John’s Wort for the relief of symptoms such as hot flushes and mood swings, although their effectiveness is unknown. Make sure to speak to a pharmacist for advice about herbal supplements before purchasing them. 

Vaginal oestrogen

Vaginal oestrogen is available in the form of a cream, pessary or ring, and helps relieve localised symptoms such as vaginal dryness. This form of HRT does not have the risk of blood clots or thickening of the lining of the womb as occurs with other forms and can be taken on its own. Vaginal oestrogen will not help relieve symptoms such as mood swings and hot flushes as it only has local effects.

What are the side effects of HRT?

Like all treatments, HRT can have side effects. Side effects are usually mild and not everyone will experience them. 

The main side effects associated with taking oral or transdermal oestrogen include:

• Breast tenderness
• Bloating
• Swelling
• Nausea
• Indigestion
• Leg cramps
• Headaches
• Vaginal bleeding

The main side effects associated with taking oral or transdermal progestogen include:

• Breast tenderness
• Swelling
• Headaches
• Mood changes including mood swings and depression
• Abdominal pain
• Back pain
• Vaginal bleeding
• Acne

Different types of HRT may be more suitable for different people. If side effects persist and are troubling you, speak to your doctor about trying a different type of HRT.

What are the risks of HRT?

Many women are put off HRT because of the potential risks. While it is important to understand what these risks are, it is also important to understand that they are small and generally outweighed by the benefits.

• Blood clots (venous thromboembolism): Taking oral hormone replacement therapy is associated with an increased risk of developing a blood clot. It is thought that the risk of developing a blood clot is between 2 and 4 times higher for women using HRT, although this is heavily dependent on lifestyle and other risk factors. For every 100 women taking HRT tablets for 7 years, it is estimated that less than 2 will develop a blood clot. HRT patches and gels have no link to an increased risk of blood clots.
• Heart disease and stroke (cardiovascular disease): When started under the age of 60, HRT is not associated with a significant risk of cardiovascular diseases, such as heart disease or stroke. 
• Breast cancer: As a hormonal treatment, HRT has been linked to oestrogen-sensitive cancers such as breast cancer. Taking HRT for more than one year has been found to slightly increase your risk of breast cancer. This depends on the formulation you are taking, and there is no increased risk when using vaginal oestrogen alone. For women of average weight aged between the ages of 50 and 69, the chance of developing breast cancer is 6.3%. This rises to 6.8% if oestrogen-only HRT is used for a period of 5 years, and to 8.3% if continuous combined HRT is used for a period of 5 years. The risk is greater the longer you use HRT, and your risk remains increased even after you have stopped taking HRT. This increased risk is small, and the benefits are still likely to outweigh this potential risk. 
• Ovarian cancer: The link between HRT and ovarian cancer is less clear, however, the most recent studies suggest that for every 1,000 women using HRT for five years, there is only one extra case of ovarian cancer. 
• Endometrial cancer: Oestrogen-only HRT can increase the risk of endometrial cancer, and for this reason, women with a womb are recommended to take combined HRT, which contains progestogen which mitigates the thickening effects of oestrogen on the womb and actually reduces the risk of developing endometrial cancer overall. 

Your individual risk will vary depending on your genetics, lifestyle, and other medical conditions. If you are worried about the potential risks of HRT, speak to your doctor or nurse for more information.

How does HRT affect your sex life?

Research suggests that HRT can significantly increase interest in sex in postmenopausal women. It often relieves symptoms such as vaginal dryness and clitoral atrophy and has been known to boost libido in postmenopausal women.

Will HRT make you gain weight?

Many women are wary of HRT as they believe it will make them gain weight. However, there is no evidence to support this claim, particularly since women’s bodies react to HRT in different ways. Menopause itself is often a cause of weight gain, which may or may not affect you regardless of whether you are using HRT. Weight gain with menopause can be managed by exercising regularly, eating healthily, and generally maintaining a healthy lifestyle.

Do you get your period when taking HRT?

For women who experience menopausal symptoms, but who have had a natural period in the last 12 months, it is recommended to use a form of cyclical HRT. Cyclical or “sequential” HRT causes a regular bleed, usually every 4 weeks, and is recommended for women experiencing regular periods. Three-monthly cyclical HRT is typically recommended for women experiencing irregular periods, producing a bleed every three months.

Is HRT safe?

HRT is widely considered to be a safe and effective treatment for the symptoms of menopause. Though risks do exist, and it is important to be aware of them, they are small and generally outweighed by the benefits. While using HRT, it is important to go for regular health check-ups, including breast cancer screening and smear tests.

Is HRT for menopause the same as HRT for gender transition?

HRT for menopause is not the same as HRT for gender transition. Both are hormonal treatments, but serve different purposes and are not interchangeable.

Does taking HRT cause diabetes?

Taking HRT in any form does not cause diabetes, nor does it affect your glucose (sugar) control.