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Hormone Replacement Therapy (HRT)

  1. When to take hormone replacement therapy (HRT)
  2. When to start HRT
  3. How long to take HRT for
  4. Stopping HRT
  5. HRT hormones
  6. Ways of taking HRT
  7. Testosterone
  8. Tibolone
  9. HRT treatment routines
  10. Risks of HRT
  11. Research into HRT and other conditions

When to take hormone replacement therapy (HRT)

You can take hormone replacement therapy (HRT) if you have menopause symptoms, including during perimenopause and after your periods stop (post-menopause).

Menopause usually affects women between the ages of 45 and 55, but it can happen earlier. It affects anyone who has periods.

HRT helps with symptoms and has other benefits, including helping to prevent osteoporosis.

The type of HRT that’s right for you depends on what stage of menopause you’re at.

When to start HRT

If you have menopause symptoms that are bothering you consider talking to your physician about starting HRT.

It’s your choice whether to take HRT and when to start. You do not need to wait until your symptoms are severe, or until your periods stop completely.

Your physician should explain the benefits and risks and help you decide.

If you’re going through early or premature menopause

If you have premature menopause (before the age of 40) or early menopause (before the age of 45), it’s particularly important to take either HRT or the combined pill.

This increases your level of oestrogen, which helps protect you from conditions such as osteoporosis.

You’ll usually be advised to take HRT until you’re at least 51 years old.

If you take the contraceptive pill

If you take hormonal contraception such as the combined pill or progestogen-only pill, you may not know when you reach perimenopause or menopause, because the contraception can affect your periods.

The combined pill can mask or improve menopause symptoms, as it contains oestrogen, which is also used in HRT.

You cannot take HRT at the same time as the combined pill. A GP may recommend that you keep taking the combined pill until age 50, and then switch to HRT. You may be advised to take the pill continuously rather than stopping for a week in a 4 week cycle.

If you’re taking the progestogen-only pill (mini pill), you can usually take HRT alongside it.

You’ll no longer need contraception after the age of 55 as it’s very rare to get pregnant naturally. You may need to use barrier methods such as condoms to protect you from sexually transmitted infections (STIs).

How long to take HRT for

There’s no fixed limit on how long you can take HRT, but talk to your physician for advice. You’ll usually have a review of your treatment every year.

For symptoms such as hot flushes, you’ll usually need to take HRT for 2 to 5 years, but it can be longer in some cases.

For joint and bone protection, taking HRT between the ages of 50-55 has the most benefit. 

It’s best to only take HRT for as long as the benefits outweigh the risks. This depends on your symptoms, your age and any risk factors you have.

Vaginal oestrogen does not have the same risks as other types of HRT, so you can keep taking it for as long as you need it to control vaginal dryness.

Benefits and risks if you’re older

As you get older, and particularly after the age of 60, the risks of HRT may start to outweigh the benefits.

This is because you’ll usually find that menopause symptoms improve as you get older, so you’re less likely to need HRT to help with symptoms. Meanwhile the risk of breast cancer increases the longer you take combined HRT.

If you want to keep taking HRT or start taking it over the age of 60, a GP may recommend taking a low dose, and using patches or gel rather than tablets, to reduce the risk.

Stopping HRT

Talk to your physician if you’re thinking about stopping HRT.

If you’re over 50 years old and are taking HRT to relieve menopause symptoms, a GP might suggest that you try stopping every 2 to 3 years, to see if you still need it or if your symptoms have improved.

If your menopause symptoms return when you try stopping, and you decide that the benefits of HRT for your symptoms still outweigh the risks, you can keep taking HRT for longer.

What happens when you stop taking HRT

When you decide to stop taking HRT, you can choose to stop suddenly, but it’s usually recommended to reduce your dose gradually over 3 to 6 months.

You may find that symptoms come back for a short time when you stop taking it. This is less likely to happen if you reduce your dose gradually.

If your symptoms come back and do not go away after 3 months, speak to your physician, who may suggest other treatments or restarting a low dose of HRT.

There are different types of hormone replacement therapy (HRT) available.

They can:

  • Contain different hormones – oestrogen, progestogen or both (a specialist doctor may also sometimes prescribe testosterone)
  • Be taken or used in different ways – tablets, patches, gel, spray or vaginal rings, pessaries or cream
  • Be taken or used at different times – routines can be cyclical (sequential) or continuous

The type of HRT that’s best for you depends on different factors, like if you’ve had a hysterectomy, what stage of menopause you’re at and your personal preferences.

If you’re considering taking HRT talk to a your physician about the options suitable for you.

HRT hormones

HRT replaces the hormones that your body produces less of as you go through menopause.

Menopause is when your periods stop due to lower hormone levels. It usually affects women between the ages of 45 and 55 but it can happen earlier. It affects anyone who has periods.

These hormones are mainly oestrogen and progestogen, which are essential to everything from period cycles, ovulation and pregnancy to bone health.

Testosterone is not currently licensed to treat the symptoms of menopause, but a specialist doctor can prescribe it.

Combined HRT or oestrogen-only HRT

HRT involves either taking oestrogen and progestogen (combined HRT) or just taking oestrogen (oestrogen-only HRT).

If you’ve had a hysterectomy

Oestrogen-only HRT is recommended if you have had your womb removed during a hysterectomy.

If you have not had a hysterectomy

If you still have your womb you’ll need to take both oestrogen and progestogen. Taking both helps to protect against the risk of womb cancer.

You can get your oestrogen from tablets, patches, spray or gel. Your progestogen can come from taking tablets or using an intrauterine system (IUS) such as the Mirena coil. Using 2 separate types of hormone will provide the combined HRT you need.

You can also take or use an HRT that already contains both oestrogen and progestogen.

Ways of taking HRT

HRT comes in several different forms. There are pros and cons for each and you may need to try different brands and methods of taking HRT to find the one that suits you. Talk it through with a GP first.

You’ll usually need to take HRT for 2 to 5 years although it can be longer in some cases. 

Tablets

Tablets are one of the most common forms of HRT. You usually take them once a day. Both oestrogen-only and combined HRT are available as tablets.

Advantages

Taking tablets once a day may be the easiest way of having treatment.

Disadvantages

Some of the risks of HRT, such as blood clots, are higher with tablets than with patches, gel or spray (although the overall risk is still small). Find out more about the benefits and risks of HRT.

Patches

Skin patches are also a common way of taking HRT. They work by sticking onto your skin on the lower part of your body and they gradually release small amounts of hormones into your body.

You’ll usually change your patch every few days, but each brand is different.

Both oestrogen-only and combined HRT are available as skin patches.

Advantages

Patches may be a better option than tablets if you have difficulty swallowing tablets, or are likely to forget to take it.

Using patches can also help to avoid some side effects of HRT, such as indigestion, and unlike tablets, they do not increase your risk of blood clots.

Disadvantages

You might find that skin patches do not always stick well, especially if you moisturise your skin. Patches can also cause redness or irritation or leave a mark on the skin.

Applying the patch to dry, non-moisturised skin, or peeling it off slowly to avoid marks can help.

Oestrogen gel

Oestrogen gel is an increasingly popular form of HRT. You take it by smoothing it onto your skin once a day. Oestrogen is gradually absorbed into your body.

If you have not had a hysterectomy, you must use this gel with a progestogen.

Advantages

Like skin patches, gel can be a good way of taking HRT if you cannot take tablets. Using gel does not increase your risk of blood clots.

Disadvantages

It can take 5 minutes or more for the gel to dry on the skin, so you may have to wait a while before you can do anything else.

Spray

Oestrogen-only HRT also comes as a spray you use once a day. You take it by spraying 1 to 3 sprays onto the inner side of your arm or your inner thigh.

If you have not had a hysterectomy, you must use this spray with a progestogen.

Advantages

This is a good way of taking HRT if you cannot take tablets.

Using the spray does not increase your risk of blood clots.

Disadvantages

Although you can get dressed 2 minutes after using the spray, you need to wait for 1 hour before having a bath or shower.

Intrauterine system (IUS), or Mirena coil

If you have a womb and are taking or using oestrogen tablets, patches, gel or spray, the Mirena coil, an intrauterine system (IUS) may be a suitable way to give you the progestogen you need.

The Mirena coil is inserted into your womb and it gradually releases a form of progestogen (levonorgestrel) into your body.

The Mirena coil is also used as contraception to prevent pregnancy, and to treat heavy periods.

Advantages

The Mirena coil can stay in place for up to 5 years and also acts as contraception.

It can be a good option if you do not want to take or use a medicine every day or have difficulties with other forms of progestogen.

Disadvantages

Implants such as the Mirena coil can cause abdominal pain and bleeding. 

Vaginal oestrogen

Low dose oestrogen is also available as a cream, gel, vaginal tablet, pessary or ring that you put inside your vagina. This can help with menopausal symptoms such as vaginal dryness, a burning sensation or pain during sex.

Advantages

Vaginal oestrogen does not carry the usual risks of HRT and does not increase your risk of breast cancer. You can use it without taking progestogen, even if you still have a womb.

Disadvantages

This form of HRT will not help with other menopausal symptoms such as hot flushes, mood swings or sleeping problems.

Testosterone

Like oestrogen and progestogen, the menopause also causes levels of the sex hormone testosterone to fall, although this happens more gradually. This can make you feel tired, affect your mood and cause a low sex drive (libido). It can also affect bone health.

Testosterone is not currently licensed to treat symptoms of menopause, but a specialist doctor may be able to prescribe it for you. This is usually only recommended if:

  • You’re post-menopause
  • You have problems with low sex drive
  • HRT alone has not helped

Research is being done on whether testosterone could help with other menopause symptoms, but more evidence is needed.

Testosterone comes as a gel.

Possible side effects of using testosterone include acne, unwanted hair growth and weight gain, but these are not common.

Testosterone gel can also cause side effects in others if they come into contact with it regularly. To avoid this, wash your hands after using it and cover the area with clothing.

Speak to a physician if you think you might benefit from taking testosterone.

Tibolone

Tibolone (brand name Livial) is a prescription medicine that’s similar to taking combined HRT (oestrogen and progestogen) but it also has a testosterone effect. You take it as a tablet once a day.

It can help relieve symptoms such as hot flushes and low mood, although some studies have suggested it may not be as effective as combined HRT.

It’s only suitable if you had your last period more than a year ago (post-menopause).

HRT treatment routines

The way you take HRT depends on different things, such as if you’ve had a hysterectomy, if you’re in the early stages of menopause and still have periods (perimenopause) or if you have not had a period for more than 1 year (post-menopause).

If you’ve had a hysterectomy and take oestrogen-only HRT, you’ll take it every day.

If you need both oestrogen and progestogen, your routine for taking HRT depends on various things, including whether you’re in the earlier stages of the menopause and still having periods (perimenopause) or have not had a period for 1 year or more (post-menopause).

Sequential combined HRT

You’ll usually be recommended to take sequential (cyclical) combined HRT if you have menopause symptoms but still have periods.

It comes as tablets or patches.

There are 2 types:

  • Monthly HRT if you’re having regular periods – you take oestrogen every day, and take progestogen alongside it for the last 10 to 14 days of your menstrual cycle every month
  • 3-monthly HRT if you’re having irregular periods – you take oestrogen every day, and take progestogen alongside it for around 10 to 14 days every 3 months

You should have a period at the end of each progestogen cycle. If there is no bleeding at these times, speak to your doctor.

If you started on sequential HRT during perimenopause your doctor may recommend changing to continuous combined HRT post-menopause.

Find out more about sequential combined HRT

Continuous combined HRT

Continuous combined HRT is usually recommended if you’re post-menopause. This is when you have not had a period for 1 year.

Continuous combined HRT involves taking oestrogen and progestogen every day without a break.

Risks of HRT

The risks of HRT are small and usually outweighed by the benefits.

The benefits of hormone replacement therapy (HRT) usually outweigh the risks. Recent evidence says that the risks of serious side effects from HRT are very low.

Older studies found potential risks of HRT, and made many people reluctant to take or prescribe it. But this view is now seen as out of date because it does not take account of the benefits as well as the risks.

The benefits and risks of taking HRT depend on your age, your menopause symptoms and any risk factors you have.

If you’re under 60 years old, have menopause symptoms, and are not at high risk of breast cancer or blood clots the benefits of HRT are likely to outweigh the risks.

Breast cancer

HRT can slightly increase the risk of breast cancer. If you’ve had breast cancer you’ll usually be advised not to take HRT.

The increased risk is low: there are around 5 extra cases of breast cancer in every 1,000 women who take combined HRT for 5 years.

The risk increases the longer you take it, and the older you are. It falls again after you stop taking it.

There is little or no increase in the risk of breast cancer from oestrogen-only HRT, which you can take if you’ve had a hysterectomy to remove your womb.

You can reduce the risk of breast cancer by not taking HRT for longer than you need it to control your symptoms. Find out more about when to take HRT.

There are also lifestyle changes that can reduce the risk of breast cancer such as losing weight and stopping smoking. 

It’s especially important to attend all your breast screening (mammogram) appointments if you’re taking HRT.

Blood clots

HRT tablets can increase the risk of blood clots, but the risk is still very low.

HRT patches, sprays and gels do not increase the risk of blood clots. This is because oestrogen is safer when it’s absorbed into your body through your skin.

If you’re at risk of blood clots you’ll usually be advised to use HRT patches, spray or gel rather than tablets.

Stroke

HRT tablets (but not patches, gel or spray) slightly increase the risk of stroke. But the risk is still very low, particularly if you’re under 60 years old.

Research into HRT and other conditions

Research has shown that taking HRT has little or no effect on the risk of getting coronary heart disease.

More research is being done to find out how taking HRT affects some other conditions, such as dementia and diabetes. Any increased risk or benefit is likely to be small.

It’s not known whether HRT reduces the risk of dementia.

HRT does not increase the risk of developing type 2 diabetes. Some recent studies have suggested that it may even slightly reduce the risk.

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