HRT: which type is right for you?

Why take HRT?

Some women sail through the menopause, barely noticing any difference. For others, though, the menopause brings changes that can make daily life an obstacle course, with symptoms including:

• hot flushes
• low mood
• forgetfulness
• urinary infections
• night sweats
• low libido
• vaginal dryness
• painful sex

Read more about the challenging symptoms of menopause

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Why do women have menopausal symptoms?

It’s all linked to your hormones. Women produce oestrogen and progestogen in their ovaries, but this process slows down, and eventually stops at the menopause, resulting in dramatic changes in some cases.

HRT helps relieve these symptoms by replacing the oestrogen your body has stopped producing.

Read more about how to ease menopause symptoms

What’s in HRT?

HRT contains both oestrogen and progestogen hormones, or oestrogen only, depending on which type you need.

“When you go on HRT, generally at around the age of 50, you need to be on oestrogen and progestogen if you still have a uterus (womb),” explains Dr Jane Woyka, GP, women’s health and menopause expert at the Harrow Health Care Centre, and member of the British Menopause Society Medical Advisory Council.

By replacing the missing oestrogen, HRT reduces menopausal symptoms, and helps preserve your bone density, reducing the risk of osteoporosis.

Read more about preventing osteoporosis

Types of HRT

Oestrogen-only HRT

“If you do not have a uterus you do not need to take a progestogen. However, if you do still have a womb, you must take progestogen as well, in order to protect you from a condition called endometrial hyperplasia, which can lead to severe bleeding and cancer of the endometrium, ” explains Dr Woyka.

“When we choose HRT we might pick different progestogens for different reasons,” says Dr Woyka. “Some are more powerful at controlling bleeding, other have less side effects, so we choose different drugs for different people.”

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Sequential or cyclical HRT – what’s the difference?

“If you are peri-menopausal (in the early stages of your menopause), your GP will probably prescribe sequential combined HRT for you,” explains Dr Woyka. This means that you are likely to have a bleed – like a period – each month. 

“If you are over 55, or your last period was at least two years ago, your GP will probably prescribe continuous combined HRT.” You won’t have a bleed while taking these.

Is it the menopause? Read more about the perimenopause – the period of time leading up to menopause

How to take HRT

Choosing how you’d like to have HRT is usually a matter of personal preference, unless your GP has a particular reason for suggesting a particular form of HRT.

HRT pills or tablets

Taking HRT in pill form is pretty straightforward. Once you and your GP have decided on the best HRT drugs for you to take, you’ll have a prescription, and then just need to remember to take your pill daily.

HRT patches

HRT patches are simple to use. You simply peel the backing off the patch and then put the patch on a hairless area of skin, such as your hip or upper leg.

“HRT patches deliver pretty constant absorption of the hormones,” says Dr Woyka. “We prefer the patch because it doesn’t go through the liver, so it’s ok to give to people with liver problems. And it doesn’t have any effect on venous thromboembolism disorders (VTE - blood clots in the vein).”

HRT oestrogen gel

HRT oestrogen gels are also simple to use – keeping to the prescribed amount, you simply apply this to your skin.

HRT coil

The Mirena Intrauterine system (IUS) contains levonorgestrel, a form of progesterone. This device works locally – in the area of your womb – the progesterone doesn’t affect the rest of your body. If you still have your womb, your GP may suggest this if you want to take oestrogen only through other forms of HRT

HRT pessaries

You can also take oestrogen in the form of pessaries, which you put in your vagina, or a vaginal ring, which you use in a similar way.

HRT implants

These come in the form of small pellets that your doctor will insert just under your skin, after giving you a local anaesthetic. “There aren’t very many of these around,” says Dr Woyka. “So we’re trying not to start anybody on implants because they may have to stop taking them.

Local oestrogen therapy

“This will help with symptoms such as vaginal dryness and painful sex (vaginal atrophy) and may be right for you if you can’t or don’t want to take systemic HRT,” says Dr Woyka.

“You can use an intra-vaginal tablet, such as Vagifem, or a cream such as Ovestin or Gynest. They are very low-dose therapies – the equivalent of having one HRT tablet every six months.”

Testosterone treatment for menopause

“Very occasionally we might additionally prescribe the male hormone testosterone, if a patient does not respond to oestrogen replacement,” says Dr Woyka. “This can improve energy and libido. However, the only gel currently available is one meant for treating men, so you will have to talk to your GP about this.

Find out more about how testosterone affects health

Is HRT safe to take?

The debate about whether Hormone Replacement Therapy (HRT) is safe to take has been going on for years. In 2002, a major study linked taking HRT to a raised risk of breast cancer. As a result the number of women talking HRT dropped by about 50%.

In 2015 a small study on HRT from New York University said that it’s safe for women to take HRT, after all. However, the size of the study brought criticism about how reliable the results could be from some experts.

So what had seemed good news for women who struggle with menopausal symptoms, such as hot flushes, poor sleep, night sweats, forgetfulness, depression and more, was left with a question mark hanging over it.

Now, with the National Institute for Health and Care Excellence’s (NICE) guideline on the menopause, women who are going through it, and the doctors caring for them have a blueprint to work from.

The guideline gives recommendations to those working in the NHS on how to advise patients who are going through the menopause.

Inevitably, some of these women will have minor symptoms that don’t affect them very much. However, other women will be struggling with debilitating symptoms that affect their health and quality of life.

Currently only one in ten women going through the menopause is prescribed HRT, even though it is an effective treatment for helping with symptoms caused by a drop in the levels of the hormone oestrogen.

This means that about 1.5 million women have some menopausal symptoms that last for around four years after their last period.

However, in about 10% of women the symptoms can last for up to 12 years, which can be a long time to cope with hot flushes, night sweats and poor sleep.

NICE’s recommendations should make it clearer and simpler for doctors and women going through the menopause to make decisions about treatment. Read the NICE HRT guidelines here.

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