Hormone Replacement Therapy (HRT)

What is Hormone Replacement Therapy (HRT)?

The menopause can cause some unpleasant symptoms, including:

• Hot flushes

• Mood swings 

• Night sweats

• Reduced sex drive (low libido)

• Sleeping difficulties

HRT can help – severe menopausal symptoms can interrupt with everyday life, so it is important to seek treatment, so you can carry on with your daily activities. The symptoms which women mostly complain about are hot flushes and sweating, improvements in these can help to improve their quality of life.

HRT involves replacing natural hormones – most women take a combination of the oestrogen and progestogen hormones, while women who have had a hysterectomy and have no womb can take oestrogen on its own. The primary aim of HRT is to ‘top-up’ the body’s natural supply of hormones which stop being produced during the menopause.

The two main types of HRT are:

• Oestrogen-only HRT:

• For most forms of HRT – it is normally used in women who have had their womb removed don’t need progestogen, a hormone which protects the lining of the womb

• For vaginal HRT – it can be used by women with a womb and doesn’t include progesterone because it is applied locally to the vagina

• Combined HRT

• Involves a combination of oestrogen and progesterone

• Continuous combined HRT – includes taking the hormones together once-daily for 28 days continuously, doesn't include a withdrawal bleed

• Sequential combined HRT – includes taking oestrogen for 14 days, then both hormones for a further 14 days, results in a monthly withdrawal bleed

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How can I get HRT?

You can reorder HRT from our online prescription service – to do this, you will need to visit your GP first to be initiated on HRT and then have a follow up appointment with them a few months later to review your treatment.

Your GP will discuss the different treatment options available to you. HRT comes in different forms, including:

• Tablets

• Skin patches

• Gels

• Vaginal creams, pessaries and rings

HRT is not right for everyone – you may not be suitable for HRT if:

• You have a history of the following cancers:

• Breast

• Ovarian

• Womb

• You have a history of blood clots

• You have high blood pressure which you do not receive treatment for

• You have liver disease

• You are pregnant

If you are not suitable for HRT – there are alternative available including:

• Lifestyle changes, including:

• Regular exercise

• Eating a balanced diet

• Cutting down on coffee, alcohol, and spicy foods

• Trying to quit smoking

• Herbal remedies – it's not clear whether herbal treatments for HRT are safe or effective

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What different types of HRT can I choose from?

Combination HRT tablets – these contain both oestrogen and progesterone. There are a variety of different tablets available, they are taken once-a-day and are effective at treating the short-term side effects of the menopause. Long-term complications may also be treated through the long-term use of HRT including reducing the risk of osteoporosis.

Combined oestrogen and progestogen patches – these are applied once or twice a week on any area below the waist. The patches are effective at treating the short-term side effects of the menopause. Long-term complications may also be treated through the long-term use of HRT including reducing the risk of osteoporosis.

Vaginal oestrogen – also known as 'local HRT'. It can come in several forms including:

• Creams

• Tablets

• Rings

• Pessaries

All of which contain a small amount of oestrogen and are used to treat the specific symptoms where they are applied such as vaginal dryness or urinary symptoms.

Local HRT will not help with symptoms such as hot flushes or protect against long-term symptoms such as osteoporosis. However, unlike other forms of HRT, local HRT doesn’t have the same increased risks and so can be used by most women. 

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Is HRT the right choice for me?

In most cases, the benefits of HRT far outweigh the negatives – you can talk through any concerns you have with your GP. They will be able to advise you on the different types and forms of HRT. It will probably be your personal choice as to which type to try first.

HRT is the most effective treatment for menopausal symptoms – particularly hot flushes. Large studies have shown that HRT can significantly reduce the risk of fractures, improve vaginal dryness, sexual function, sleep patterns and improves aches and pains.

However, some of the clinical data shows downsides – some studies confirm the increased risk of cancer and cardiovascular health. Some studies have shown there may be an increased risk of stroke, whereas other studies state there may be heart health protective benefits of HRT.

There is evidence which shows HRT increases the risk of breast and ovarian cancer which still means HRT is controversial. The NHS advises that each woman should discuss these risks alongside the benefits of HRT to establish what course of treatment will be best for them. Women who are already at an increased risk of cancer will be advised against taking HRT. The Medicines and Healthcare Products Regulatory Agency (MHRA), also advise that healthcare professionals should carefully consider the benefits and risks for every woman considering taking HRT.

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What are the side effects of HRT?

Side effects are possible – women can experience side effects when they first start taking HRT, these effects can last a few months. Individuals react differently to HRT, so one form is not better than another, it will just depend on how your body reacts to it. 

The common side effects of HRT include:

• Headaches

• Nausea

• Breast tenderness

• Stomach pain

• Indigestion

• Vaginal bleeding

• Small increase in the risk of blood clots and breast cancer

If you are experiencing side effects, you should consult your GP for advice.

HRT may also increase the risk of other medical conditions. 

Endometrial cancer – women who have not had a hysterectomy and are postmenopausal are at an increased risk of endometrial cancer if they take oestrogen-only HRT. 

Ovarian cancer – women taking HRT are also at a slightly increased risk of ovarian cancer. Studies, including one which monitored 948, 576 postmenopausal women on a five year follow up, have confirmed this. For every 1000 women taking HRT 2.6 developed ovarian cancer over a five-year period, compared to 2.2 women who do not take HRT.

Blood clots – HRT tablets, not patches or gels, have been linked to an increased risk of developing blood clots. 

Breast cancer – studies have shown that oestrogen-only HRT causes little or no increased risk of breast cancer. However, combination HRT may increase the risk of breast cancer, but if you stop taking HRT, your risk will reduce.

If you or someone you know is experiencing side effects, or there is an emergency, for example, breathing problems or chest pain you should seek medical attention immediately.

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Sources

Boseley, S. (2017). HRT won’t kill you – but menopausal women still face a difficult decision. The Guardian. [online] Available at: https://www.theguardian.com/society/2017/sep/15/hrt-hormone-replacement-therapy-wont-kill-you-but-menopausal-women-still-face-a-difficult-decision [accessed 13th March 2018].

Guy’s and St Thomas’ NHS Foundation Trust. (2012). Hormone replacement therapy (HRT). NHS. [online] Available at: https://www.guysandstthomas.nhs.uk/resources/patient-information/gynaecology/HRT.pdf [accessed 13th March 2018].

Hickey, M., Elliot, J and Davison, S, L. (2012). Hormone Replacement Therapy. British Medical Journal; 344: e763. 

Jyotsna, V, P. (2013). Postmenopausal Hormonal Therapy: Current Status. Indian Journal of Endocrinology and Metabolism; 17: S45-S49.

Medicines and Healthcare Product Regulatory Agency. (2014). Hormone-replacement therapy: updated advice. gov.uk. [online] Available at: https://www.gov.uk/drug-safety-update/hormone-replacement-therapy-updated-advice [accessed 13th March 2018].

NICE Guidelines. (2015). Menopause: diagnosis and management. NICE. [online] Available at: https://www.nice.org.uk/guidance/ng23/ifp/chapter/benefits-and-risks-of-hrt [accessed 13th March 2018].

Ortmann, O., Dӧren, M and Windler, E. (2011). Hormone Therapy in perimenopause and postmenopause (HT). Arch Gynecol Obstet; 284: 343-355.

Warren, M, P. (2004). Hormone Replacement Therapy: Controversies, Pros and Cons. Clinical Endocrinology and Metabolism; 18(2): 317-332.

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