Before we dive into the nitty gritty of HRT (hormone replacement therapy), some recommended reading first:
HRT replaces the female hormones women cease to produce due to menopause. Most women start HRT tablets or treatments to combat typical symptoms. However, understanding the risks and the side effects of the various HRT options is essential to deliver the best treatment plan for each individual.
In what ways can I take HRT to alleviate menopausal symptoms?
Menopausal symptoms can include hot flushes, mood swings, night sweats, irregular bleeding and periods, incontinence, sleep problems, painful intercourse, and a range of other physical and emotional symptoms.
There are a number of different ways HRT can be taken to manage menopause symptoms:
Oral – By mouth (in tablet form)
Transdermal – Via the skin (gels, patches, sprays)
Vaginal/Topical – Into the vagina/around the vulva and vaginal area (pessaries, creams, vaginal rings)
Subcutaneous – Into the fatty tissues of the skin (implants)
Different regimens for taking hormone replacement therapy (HRT)
Continuous combined HRT
This is when both oestrogen and progestogen (a synthetic version of the hormone progesterone)/progesterone are taken together as a daily HRT dose. Taking continuous combined HRT hormones is usually for post-menopausal women, i.e., have not had a period for more than one year.
This is when HRT is given in a way to induce a bleed. Usually, oestrogen is taken for the first two weeks of the menstrual cycle. Then a combination of oestrogen and progestogen/progesterone is taken in the last two weeks of the cycle. This regimen is for women who are not yet post-menopausal.
This is when only oestrogen is given every day. This is only given to women that do not have a uterus (have had a hysterectomy).
Otherwise known as Mirena coil. This is an intrauterine system, containing levonorgestrel (synthetic progesterone). This is a great option for women who need contraception and/or have heavy periods/heavy withdrawal bleeds from HRT or for those who have adverse effects from a tablet or patch containing progestogen. The Mirena coil can be used for up to 5 years for HRT.
As with any medication, there can be risks associated with taking HRT, and there are reasons why certain routes are recommended for some people. These are explained below.
Risks Associated with Taking HRT
HRT treatments often have their own side effects. These can include fluid retention, breast tenderness, headaches, indigestion, depression, vaginal dryness, and bleeding. It's essential to consult your GP or menopause specialist before starting HRT to discuss the best option for you. They will consider your medical history, lifestyle, and symptoms before suggesting your most suitable option.
Oral HRT and risk of blood clots
Venous Thromboembolism (VTE), Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)
With oral HRT use, there is a slightly increased risk of having a blood clot, mainly linked to age. This risk of blood clots is thought to be greater within the first year of use; older women with an increased body mass index are at higher risk of having a blood clot.
Women with a blood clot or a family history of blood clots may be denied HRT due to the increased risk. Usually, these women are seen by a specialist menopause service; sometimes, they may be prescribed transdermal HRT if it is considered safe.
Oral HRT will usually have the cycle days printed on the pack. All the tablets in the pack are the same with continuous combined therapy. If you are prescribed sequential therapy, there are two different coloured tablets; again, the pack will have the days of the cycle printed so you know when to take them.
There is little or no increased risk of having a blood clot with transdermal HRT. The risk of blood clots increases in older women and women who are very overweight. Special consideration is given when prescribing HRT, and a transdermal preparation is usually recommended in this group.
Women with coeliac disease or digestive problems should avoid oral HRT as it passes through the gut and will not be absorbed effectively. Transdermal HRT should be recommended in this group of women as it is absorbed through the skin.
When using HRT patches, the skin must be clean, dry and free from creams, etc., so the patch can adhere to the skin effectively. Skin patches release a measured dose of hormones in a 24-hour period, so changing the patch more frequently than prescribed will not give you more hormones.
Gels are usually rubbed into the skin using the fingertips; again, keeping the skin clean and dry is important to ensure the gel is adequately absorbed. Do not shower within an hour of application, as you will wash away the treatment. You must ensure you do not touch anyone with gel on your hands and thoroughly wash and dry your hands after application.
Always follow the manufacturer's guidance regarding where to apply the treatment, as they vary.
Vaginal or Topical Oestrogen
These are a very low dose of oestrogen and can be used in isolation to treat urogenital (vaginal and/or bladder) symptoms (vaginal dryness/soreness/frequency of urine/recurrent urine infections). They can also be used with oral/transdermal HRT if required.
Pessaries and vaginal creams come with an applicator to effectively insert the medication into the vagina. When starting treatment, it is usually applied daily for the first two weeks, then a maintenance dose twice weekly thereafter. This can be used long-term, as symptoms usually return when treatment is stopped.
Vaginal rings are flexible rings around the size of a 50-pence piece that are inserted into the vagina. The ring should be changed every three months and can only be used for up to 2 years.
Vaginal oestrogen creams and pessaries don't carry many of the usual HRT risks. It does not increase the risk of breast cancer, although it might slightly increase the risk of ovarian cancer when used without progesterone/progestogen.
Oestradiol Implants are used as a last resort, usually when all other routes of Oestrogen therapy have not worked. You will need to be seen by a specialist menopause service to have an implant. Implants are inserted into the fatty tissues of the abdomen or buttock by making a small incision and burrowing the implant into the fat. Sutures or steri-strips seal the incision. Regular blood tests need to be taken when having implants, and they usually last 6-12 months.
Mirena LNG-IUS: Needs to be fitted by a healthcare professional; some GPs/practice nurses will fit them. Contraception services will fit them if it is being used for contraception. Some women experience abnormal bleeding, such as spotting for a few months after having the Mirena coil fitted. Many women do not have periods with the Mirena coil, which is a blessing for many women, especially if they suffer from heavy periods. If you are considering a Mirena IUS, taking some pain relief before inserting it is advisable. Ensure you have not had unprotected intercourse in the cycle leading up to your appointment. If you are having a Mirena IUS replaced, you should not have any intercourse in the seven days before your appointment. The Mirena IUS cannot be inserted if there is any risk of pregnancy.
Not everyone needs hormone replacement therapy
A gentle reminder, however, that you do not necessarily need to take HRT for menopause. HRT is designed to restore female hormone levels and treat menopausal symptoms, yet it isn't always required. Many lifestyle factors affect how you experience menopause, and there are also non-HRT alternatives. For many, a healthy diet, exercise, and improved physical and mindful habits can help to relieve symptoms.
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