Hormone replacement therapy (HRT) explained

At one time, hormone replacement therapy (HRT) was routinely used to improve menopause symptoms. But today, it is widely viewed as one of the most controversial medications around. Although 8 in 10 women experience menopause symptoms (with seven symptoms being the average) only a very small proportion of women are currently taking HRT in the UK.

For many women, deciding whether to take HRT despite the bad press it’s received, or to struggle on with their symptoms, can be a difficult decision to make.

To help you gather the facts and make as informed a decision as possible, we’ve taken a closer look at HRT – including what it is, what the risks and benefits are, and why it carries so much stigma.

What is HRT?

During the menopause transition, a woman’s ovaries will produce less estrogen and progesterone, until the body stops producing it all together. Hormone levels will continue to fall, until they remain at a constant low level once menopause is over.

Low estrogen and progesterone levels can have a range of different physical and emotional effects on the body, including hot flushes, aching joints, mood changes, brain fog, and a loss of libido.

To improve menopause symptoms and longer term health, some women might choose to have hormone replacement therapy (HRT). HRT is a medication that replaces the female hormones that a woman’s body is no longer producing. It can come in various different forms, including tablets, patches, creams and gels.

HRT is prescribed by GPs and menopause specialists, and the dose and combination of HRT medications recommended can vary depending on each woman’s specific health needs.

What are the benefits of HRT?

The benefits of HRT are extensive, and it can help to relieve the majority of symptoms that can last several years post-menopause – including hot flushes, mood changes and vaginal dryness.

HRT has also been shown to reduce the risk of conditions such as type 2 diabetes, osteoporosis (brittle bones), bowel cancer, and certain heart diseases. In addition, research suggests that there’s a link between HRT and a reduced risk of dementia.

The overall aim of HRT is to help improve a woman’s quality of life.

Dr Louise Newson on the benefits of HRT

What are the risks of HRT?

A large-scale US clinical trial in 2002 identified some risks of combined HRT (estrogen plus progesterone) that have made it controversial ever since. The Women’s Health Initiative Study (WHI) went on for almost six years until it ended abruptly after researchers found a small increased risk of breast cancer and blood clots in women taking it. This news made headlines and created panic among the general female population – with the takeaway message being that the risks of taking combined HRT outweighed the benefits for all women.

However, a reanalysis of the 2002 study several years later found that the results of the study were overestimated, and that women who took combined HRT between the ages of 50 and 59 actually had fewer fractures, cancers, and deaths, than those that took the placebo drug. It confirmed that women who start HRT after the age of 60 are at a small increased risk of developing breast cancer and/or blood clots – however, HRT is usually started much earlier than 60 in UK clinical practice. The report also suggests that there are ways to minimise the risks of taking HRT, such as by taking a lower dose.

Since the reanalysis on the WHI in 2007 (and since newer and safer forms of HRT have been introduced), health experts today say that the benefits of combined HRT generally outweigh the risks, with the risks for women aged 50-60 years old being rare. It’s thought that the risk of breast cancer for a woman who drinks moderately or is obese, is greater than it would be for a woman who takes HRT.

How has HRT changed over the years?

A common concern over HRT for many women is that they want what they want to put in their body to be as natural and close to their own hormones as possible – which is completely understandable.

In the past, there were fewer HRT medicines to choose from, and two common ones were made from horse urine, so they contained hormones that were identical to a horse’s hormones rather than our own. This meant that women were taking estrogen that was different from that which they would naturally produce or need.

Today, many modern HRT medications are made from plant extracts, such as yams and other root vegetables, and have the exact same molecular structure as our own female hormones. Regulated forms of these HRT medications are called ‘body identical hormones’ and are available on the NHS. These are separate from ‘compounded bioidentical hormones’, which contain synthetic hormones, and do not follow the same regulatory processes.

For the best HRT results with the fewest risks and side effects, health experts generally recommend taking body identical hormones, taking estrogen through the skin rather than in tablet form, and taking progesterone as an oral capsule. However, it’s always best to have a chat with your GP or menopause specialist about what the best course of action for you would be based on your own circumstances.

To find out more about the difference between body identical and compounded bioidentical hormones, you might want to have a listen to the video below from Dr Renee Hoenderkamp.

Who can take HRT?

Though the risks of HRT can greatly outweigh the benefits – it’s still not suitable for everyone. Health professionals might suggest that women who have a history of breast, ovarian or womb cancer use alternative methods to HRT.

Women who have a history of blood clots, high blood pressure, and liver disease might also be at a greater risk of clotting when taking HRT tablets, but these risks can be removed by taking HRT through the skin in the form of a patch, or gel instead.

It’s important to have a thorough discussion with your GP or with a menopause specialist about the pros and cons of HRT, and how HRT could impact you as an individual.

Are there any side effects of HRT?

HRT can cause side effects such as vaginal bleeding, abdominal pain, headaches, and breast tenderness. If side effects do occur, they will usually appear during the ‘breaking in’ period and should settle down within 3-4 months.

Different brands of HRT can cause different side effects, as can the different types. If a particular brand or type isn’t working well for you, then it’s worth asking your doctor whether there’s something else that you could switch to, for example from tablets to patches.

What are the different types of HRT?

The type of HRT you take will usually be determined by your medical history, and your doctor should discuss with you which HRT you are being given and why.

When it comes to hormones, there are two types of HRT:

Combined HRT (containing both estrogen and progesterone)

This type of HRT is recommended for women who haven’t had a hysterectomy. The added progesterone helps to keep the womb lining thin, and reduces the risk of uterine cancer.

Combined HRT can be taken in two ways:

  • Cyclical HRT – which is usually offered to women who are still having periods and is designed to mimic your menstrual cycle. Estrogen is taken every day, and progesterone is added for 10 to 14 days a month. Bleeding might occur at the end of each course of progesterone.

  • Continuous HRT – which is generally recommended for women who are post-menopause and are no longer having periods. Estrogen and progesterone are both taken every day, and while there might be some light bleeding for the first few weeks, this should settle down until you eventually have no bleeding at all.

Estrogen-only HRT

This type of HRT is generally recommended for women who have had a hysterectomy and no longer have a womb – as there is no need to add progesterone to protect the womb lining.

Testosterone

Some women might be prescribed testosterone if estrogen or combined HRT are not effective on their own. GPs or menopause specialists might suggest testosterone for women who are still experiencing symptoms like a lower sex drive, brain fog, or fatigue.

Testerone is usually given to women as a gel or cream to apply to the skin – and though it is not yet licensed in the UK for use by women in the UK, it’s still considered safe by menopause specialists and GPs who can prescribe it.

How do I take HRT?

HRT comes in many forms:

  • HRT tablets. So far, tablets have been a popular way to prescribe combined HRT. However, some doctors are now starting to prescribe estrogen as a patch or gel, along with progesterone capsules or tablets.

  • HRT gels. These are applied directly to the skin every day, though shouldn’t be used near your eyes, vagina, or on your breasts. Most women apply them to the upper arms, thighs, or lower back. It’s important not to let these areas come into contact with anyone else for at least an hour afterwards – especially males.

  • HRT patches. Patches are stuck on an area of skin below the waist and will provide a constant flow of hormones. Doctors will often recommend patches (or gels) to women who have a history of blood clots or liver disease, instead of tablets. Patches cannot be reused and a new one must be applied once or twice a week. Patches might be more likely to irritate skin than gels, and should not be placed near the breasts or under the waistband of your clothes.

  • Vaginal estrogens. HRT is often taken orally, but some women might be given HRT that can be taken vaginally in the form of creams, rings, or pessaries. Women who regularly use condoms (safe sex is still important post-menopause), should steer clear of vaginal creams as they can damage condoms.

When is the best time to start taking HRT?

HRT can begin as soon as you start experiencing menopausal symptoms. You don’t need to wait until you’re post-menopausal – or until your symptoms are unbearable – to approach your GP or menopause specialist and ask for help.

Many women will start cyclical HRT while they are still having periods, and move to continuous HRT once their periods stop altogether. HRT will also not delay or disrupt your menopause, and any symptoms you have when you come off HRT will be ones that you’d still be experiencing whether you’d ever taken HRT or not.

Women will generally be at a lower risk of breast cancer or clotting if they start taking HRT between the ages of 50 and 60.

How long do people take HRT for?

Women can take HRT for various different lengths of time – and how long you take it for should you choose to, will be determined by you and your doctor. Most women who go on HRT usually don’t know how long they will be on it for, but they might take it for a couple of years to start with. Then, if symptoms carry on when they come off it, they may choose to continue taking it.

While some women might take HRT for many years (because they enjoy how it makes them feel, and want to continue to minimise the risk of conditions like osteoporosis, type 2 diabetes, and heart disease), it’s worth noting that there is an increased risk of breast cancer when taking HRT long term.

When a doctor or menopause specialist prescribes HRT, they should invite you for regular reviews to check your health and to make sure that the type of HRT you’re taking is right for you. It’s also important to make sure that you attend all your breast cancer screening appointments.

HRT alternatives

If you can’t take HRT for medical reasons, or if you’d prefer to take control of your symptoms by using alternative methods, then you could try:

  • Adding foods that are high in phytoestrogens to your diet. Phytoestrogens have an estrogen-like effect on the body and are found in food such as tofu, edamame beans, sesame seeds, and garlic.

  • Cutting out triggers that could make menopause symptoms worse. Things like smoking and drinking can trigger hot flushes, and can also increase your risk of developing heart disease and cancer. For tips on how to break unhelpful habits, you might want to have a read of our article here. Spicy food and caffeine can also trigger hot flushes, so it might be best to avoid if this happens.

  • Eating a healthy, balanced diet to make sure that your heart and bones stay as healthy as possible. Check out the diet and nutrition section of our site for tips, advice, and inspiration.

  • Getting regular exercise. Staying active can help to improve everything from sleep problems, through to hot flushes and mood changes. It can also improve cardiovascular and bone health, and decrease your risk of things like heart disease and osteoporosis.

Final thoughts…

Every woman’s menopause journey will be different, and there’s really no right or wrong way to manage your symptoms – it’s about doing what’s best for you. Your GP or a menopause specialist will be best placed to talk you through your options, and help you make a choice that is well suited to your individual circumstances.

Remember that you can start HRT as soon as you start experiencing menopause symptoms (and health professionals will typically recommend this) – you don’t need to wait until you’re at your wits end and can no longer cope.

For more tips and advice on menopause matters, you might want to read our article, Managing your menopause journey. You can also find your nearest GP on the NHS website – or if you’d rather make an appointment with a menopause specialist, you can find a list of specialists approved by the British Menopause Society (BMS) here.

Are you taking HRT? Or are you thinking about taking it? What have your experiences of HRT been like so far? Join the conversation on the women’s health section of the community forum, or leave a comment below.

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