All about HRT (Hormone Replacement Therapy)

It is estimated that there are around 13 million women who are currently perimenopausal or menopausal in the UK, which is equivalent to about a third of the entire UK female population (Source: Wellbeing of Women).

The menopause is an inevitable stage in a woman’s life course. The average age for menopause is 51 years; however, around 1 in 100 women experience the menopause before the age of 40 years. Most women go through it between the ages of 45 and 55, but symptoms can begin months before periods stop, and can last for a few years afterwards.

The majority of women experience at least some menopause symptoms. These symptoms can vary from mild to severe and some symptoms can affect a woman’s everyday life, seriously impacting her quality of life.

Although every woman’s experience will differ, common menopause symptoms include:

• Hot flushes.
• Night sweats.
• Mood swings and anxiety.
• Vaginal dryness.
• Bladder issues.
• Difficulty sleeping.
• Headaches.
• Losing interest in sex.
• Difficulty remembering things and concentrating (brain fog).
• Joint and muscle aches and pains.

During the perimenopause and into the menopause, a woman’s production of oestrogen and progesterone decreases. It is the big drop in oestrogen levels that causes most of the symptoms of menopause. There are several therapies that can help to manage menopause symptoms, and these include HRT.

What is HRT?

HRT stands for Hormone Replacement Therapy. It is a prescribed treatment that can help to relieve many of the symptoms of the menopause. For most women, HRT consists of two hormones, oestrogen and a progestogen. Testosterone can also be an option.

How does HRT work?

Before the menopause, a woman’s ovaries produce three main types of hormones:

• Oestrogens such as oestradiol.
• Progestogens such as progesterone.
• Androgens such as testosterone.

It is the loss of oestrogens that results in most menopause symptoms. Oestrogen controls a woman’s reproductive cycle as well as controlling other functions, including bone density, skin temperature and keeping the vagina moist.

As a woman approaches the menopause, her ovaries produce less and less of the hormone oestrogen. As the name Hormone Replacement Therapy (HRT) suggests, HRT replaces the body’s natural supply of the hormone oestrogen which diminishes during menopause and, in turn, helps to reduce some of the menopause symptoms. As oestrogen also stimulates the lining of the womb, those taking HRT will also need to take another hormone, progestogen, at the same time to protect the womb lining; this is known as combined HRT.

A woman doesn’t need to wait until their menopausal symptoms become unmanageable before seeking advice about HRT. HRT is most effective to start when a woman is perimenopausal. This is before the official menopause, which is 12 months after a woman’s last period. There is no maximum length of time for which a woman can take HRT; technically a woman can take it forever.

Types of HRT

There are two main types of HRT: Combined HRT and Oestrogen-only HRT. Combined HRT can be sequential or continuous.

• Sequential combined HRT – It is called this because oestrogen is taken every day, and the progestogen is taken for usually half of the month. HRT taken this way results in a monthly bleed rather like a period.
• Continuous combined HRT – It is called this because the two hormones oestrogen and progestogen are taken together, daily. This approach results in no bleeding.
• Oestrogen-only HRT – Most women who have had a hysterectomy don’t need the progestogen and will take what is known as oestrogen-only HRT. Some women who have had a subtotal hysterectomy where the womb is removed but the cervix is left behind, may need to take combined HRT as some of the womb lining may remain.

HRT is available in the following formats:

• Tablets – These can be oestrogen and progesterone or oestrogen-only and are easy to take every day.
• Patches – These can be oestrogen and progesterone or oestrogen-only. They are stuck to the skin below the waist and are usually changed twice weekly or weekly depending on the brand.
• Gels – These are oestrogen-only. They are applied usually to the back of the arm or inner thigh and used daily.
• Sprays – These are oestrogen-only and are used daily.
• Vaginal oestrogens – These are oestrogen pessaries, creams and gels that are inserted directly into the vagina.
• Implants – These are injected beneath the skin to provide slow release of oestrogen over several months.

Who can use HRT?

HRT is a suitable option for the vast majority of perimenopausal and menopausal women. Around 15% of women aged 45 to 64 in England are currently prescribed HRT, which has increased rapidly in the last 2 years from around 11% and continues to increase.

There are some medical conditions where HRT may be too risky to prescribe.

These include but are not limited to:

• Uncontrolled high blood pressure.
• Active liver disease.
• Active medical conditions where the risk of blood clotting is very high.
• After certain, but not all, cancers such as endometrial (womb) cancer or breast cancer.
• Abnormal vaginal bleeding that has not been investigated.
• A condition called endometrial hyperplasia, which is a thickening of the inner lining of the womb and it hasn’t been treated.

Your GP will check your medical history to see if HRT is right for you and discuss what your options are.

Some men with unnaturally low levels of testosterone can benefit from hormone therapy, for example, the condition hypogonadism can cause unnaturally low levels of testosterone. It is a dysfunction of the testicles that prevents the body from producing the right amount of testosterone. HRT is also needed when both testicles have been removed or, rarely, when the remaining testicle does not produce sufficient testosterone.

What are the benefits of HRT?

HRT has long-term health benefits, which are more crucial than ever as women’s life expectancy is increasing. HRT can help to alleviate many of the common menopause symptoms that are listed above. As menopause symptoms improve, most women feel a return of their old self within 3–6 months of starting HRT.

A woman’s bones will be protected from weakening due to lack of oestrogen through taking HRT and this will reduce the risk of developing osteoporosis.

The risk of cardiovascular disease will also reduce and a woman will be less likely to develop heart problems, stroke or vascular dementia.

Women taking HRT will also have a lower future risk of developing other diseases such as type 2 diabetes, osteoarthritis, bowel cancer and depression.

After taking oestrogen for a few months, taking testosterone in addition to taking oestrogen can be beneficial to women who still experience menopausal symptoms such as fatigue, brain fog and lack of libido. This, however, needs to be prescribed by a specialist.

There is some evidence to suggest that HRT started early in the menopause may help prevent dementia. However, the evidence for HRT and the prevention of dementia is not clear; what is certain is that starting HRT when a woman is under 60 will not increase the risk of dementia.

The most health benefits from taking HRT are seen in women who start taking HRT within 10 years of their menopause, but usually women of any age can start taking HRT.

Experiencing the menopause before reaching the age of 40, that is early menopause, has significant health risks of its own, such as:

• Cardiovascular disease.
• Osteoporosis.
• Loss of cognitive function.

Taking HRT can significantly decrease these risks by replacing the oestrogen your body would produce naturally at that age. However, it is important to take HRT until you are 51 years, the average age for reaching the menopause in the UK.

What are the risks of HRT?

Side effects with HRT are uncommon but might include breast tenderness or bleeding. If they do occur, they usually happen within the first few months of taking HRT and then settle with time as the body adjusts to taking the hormones. These side effects will vary from woman to woman, and usually settle down within 3 months of taking HRT. However, anyone worried about the side effects after 3 months should consult their GP.

The HRT side effects are often referred to as the 4 Bs, that is:

• Bleeding – This could be brown discharge, light spotting or sometimes more like a heavy period and may come and go or last for a few weeks. Any bleeding usually settles after a few weeks. Contact your GP if it has been more than 3 months and you are still bleeding.
• Breasts – They may become tender, be quite painful, and be more sensitive around the nipples. This can last for several weeks but usually settles with time. Wearing a good-fitting and supportive bra can usually help.
• Bloating – Some women may feel bloated and uncomfortable similar to having trapped wind. This can be due to the progesterone and usually settles with time.
• Blues – Some women might feel lower, or more emotional, in the first few weeks if they are taking progesterone.

It is common for some women to put weight on as they approach the menopause but there is no evidence that HRT itself causes this.

The benefits of taking HRT have to be balanced against any risks. NICE guidelines for HRT shows that the risks are very low for most women. The risks from HRT vary from woman to woman and the type they take. A healthy diet and regular exercise will help reduce the risks and reap the maximum benefit from HRT. The following factors can affect long-term health and may affect the risks of taking HRT.

Your GP will consider these when deciding whether to prescribe HRT and which type they prescribe:

• Your age.
• Your weight.
• Whether you smoke.
• How much alcohol you drink.
• Other existing medical conditions.
• Your family history.

Breast cancer is the risk that most concerns people in connection with HRT. The risk of breast cancer is likely to increase the longer a woman takes HRT, but is still low. This risk slowly reduces when a woman stops HRT. The longer they have been on it, the longer this ‘tailing off’ time may take. Summary results from the Women’s Health Initiative Study clearly shows that lifestyle factors, such as drinking alcohol and being overweight, in particular, have a greater impact on a woman’s risk of breast cancer than taking HRT.

The risk of cancer of the womb will increase for women taking oestrogen-only HRT, which is why it is important to take a progestogen alongside oestrogen to protect the womb. Women taking vaginal oestrogen don’t need to add a progestogen as the amount absorbed into the body is tiny.

Oral HRT, that is oestrogen in tablet form, can increase the risk of blood clots in blood vessels, such as deep vein thrombosis in the legs and pulmonary embolism in the lungs. By contrast, oestrogen taken through the skin in the form of patches, gels and sprays does not carry these same risks.

As with the risk of blood clots, HRT tablets increase the risk of stroke. Taking oestrogen through the skin, at normal doses, does not carry the same risk. The risk of stroke increases as you get older, so for younger, healthy women, the blood clot risk for HRT is low.

Alternatives to using HRT

Not every woman chooses to take HRT or can have HRT to help their symptoms of the menopause.

This may be because they:

• Want an alternative treatment that works especially well for one particular symptom.
• Have concerns about the safety and side effects of HRT.
• Would prefer alternative treatments to help alleviate symptoms of the menopause.

There are alternatives to HRT, which can be broadly classified as:

• Herbal medicine – This is a practice based on the use of plants or plant extracts to relieve symptoms, for example, evening primrose oil or St John’s Wort.
• Alternative medicine – This is a range of therapies used instead of conventional medicine, such as acupressure, acupuncture and homeopathy.
• Complementary therapy – These are interventions that tend to be used alongside conventional medicine, for example aromatherapy with HRT.
• Non-hormonal medical treatments – These are treatments prescribed by your doctor, such as antidepressants.

When deciding whether or not to commence HRT you should in the first instance talk to you GP about all the alternatives open to you.

You should try to get answers to three key questions:

• What are my options?
• What are the pros and cons of each option for me?
• How do I get support to help me make a decision that is right for me?

Final thoughts

From 1 April 2023, women in England will be able to access cheaper hormone replacement therapy (HRT) for menopause through a new prescription prepayment certificate (PPC), enabling access to a year’s worth of menopause prescription items for the cost of two single prescription charges which is currently £18.70, reducing HRT costs to less than £20 a year.

Following the announcement, Women’s Health Ambassador, Dame Lesley Regan, said: “The menopause is an inevitable stage in a woman’s life course. As a gynaecologist, I’ve witnessed first-hand the symptoms that women experience, which can have debilitating impacts on their daily lives. Making HRT more affordable will have a hugely beneficial impact on the lives of so many women. This prepayment certificate is a major step forward in prioritising the health and wellbeing of women.”

Dr Ranee Thakar, President of the Royal College of Obstetricians and Gynaecologists, said: “We know that cost can be one of the barriers that women face in accessing treatment to manage their symptoms during menopause, and the introduction of HRT PPCs is a positive step to improve access to HRT. This announcement is an important first step, and we hope that more will be done to address the challenges and inequalities faced in accessing menopause care and treatment.”