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Guide to HRT: What is Hormone Replacement Therapy?

Author: Forth

September 26, 2022

Women smile having a cup of tea

What is Hormone Replacement Therapy?

Hormone replacement therapy (HRT) is a body identical hormone treatment that can be prescribed to women experiencing symptoms related to perimenopause and menopause. It is also an effective preventative treatment for longer-term health issues such as cardiovascular disease and osteoporosis. As women go through menopause, the risk of developing these diseases increases due to the drop in oestrogen. But having HRT helps reduce these risks.

According to the National Institute for Health and Care Excellence (NICE) about 1 million women in the UK use hormone replacement therapy to treat the symptoms associated with declining levels of oestrogen and progesterone during perimenopause and post-menopause.

Body identical HRT is the recommended treatment for perimenopause and menopause in the UK. It is the only regulated form of HRT and therefore carries a lower risk than bioidentical HRT.

Contents

“As women are spending an extended part of their lives in the menopausal state, ensuring you empower yourself with up to date information to make informed decisions, will enable you to ensure maintaining quality of life during this phase of your life”

Dr Nicky Keay, Endocrinology Expert, BA, MA (CANTAB), MB, BCHIR, MRCP

Nicky keay

What are the benefits of HRT?

Relief from symptoms

Perimenopause symptoms can have a serious impact on a woman’s life. Forth’s Menopause in the Workplace survey found that 63% of women said that their working life had been negatively affected in some way by their symptoms.

Our perimenopause symptom research found that the top symptoms often experienced by women approaching menopause are changes in mood (87%), changes in memory (81%), and poor sleep (81%).


Benefits of taking hrt

Protection against osteoporosis

The chances of developing osteoporosis and breaking a bone increase as women reach menopausal age. NICE guidelines advise that the risk of fragility bone fractures is decreased in women taking HRT as it restores the body’s level of oestrogen.[1]

The benefit of HRT on bone health lasts only as long as HRT is being taken but may last longer if HRT is taken for a longer period of time.

Benefits of taking hrt

Preventing heart disease

HRT can also help prevent diseases associated with declining hormone levels such as cardiovascular disease. Research has found that women who were using HRT were overall 30% less likely to die from cardiovascular risk factors including diabetes, high blood pressure and high cholesterol than those not on hormone therapy.[2]

Prevention from certain cancers

NICE guidelines advise that overall studies indicated that HRT use was associated with a generally consistent reduced risk of gastrointestinal cancers, including colorectal cancers. Taking combined HRT can minimise the risk of developing endometrial (womb) cancer.[3]

How does HRT work?

HRT works by replacing the hormones oestrogen and progesterone that decline as a woman transitions to the menopause.

Taking HRT upon diagnosis of symptoms that are related to perimenopause can help women better manage this phase in their life by reducing the physical and psychological symptoms caused by changing hormone levels.

Is HRT Safe?

There has been a lot of misleading information in the press on the increased risks of developing breast cancer due to HRT. However, according to a BMJ editorial published in 2019 on HRT and breast cancer the risks of developing breast cancer due to an unhealthy lifestyle – such as being overweight – is six times higher than that posed by taking combined HRT.

Risk of breast cancer 6x higher

“…women should be counselled that other factors, including body weight and alcohol consumption, have a greater effect on breast cancer risk than HRT. For example, the extra risk of breast cancer associated with being overweight or obese is six times higher than the extra risk associated with combined HRT, according to NICE.”

BMJ editorial ‘HRT and breast cancer risk’ published 11 Oct 2019

Side effects of HRT

Like any medicine, the hormones used in hormone replacement therapy can cause side effects. However, these usually improve over time. The NHS advises[4] that side effects can include:

  • Headaches
  • Abnormal pain
  • Tender breasts or swelling
  • Feeling sick
  • Bloating
  • Mood swings
  • Depression
  • Acne

Vaginal bleeding

Although irregular bleeding or spotting can occur during the first 4-6 months of taking continuous combined HRT, you should consult your doctor if you get heavy bleeding, that lasts for more than six months, or if bleeding starts suddenly after some time without bleeding.[5]

If you find that any of these side effects are severe, it is vital you talk to your doctor to discuss this. Changes to HRT dosage and type can often elevate these symptoms.

Breast cancer

Combined HRT can be associated with a small increase in the risk of breast cancer.[6] The increased risk is related to how long you take HRT, and it falls after you stop taking it.

There has been a lot of misleading information in the press on the increased risks of developing breast cancer due to HRT. However, according to a BMJ editorial published in 2019 on HRT and breast cancer the risk of developing breast cancer due to an unhealthy lifestyle – such as being overweight – poses a risk of developing breast cancer that is six times higher than that posed by taking combined HRT.[7]

Furthermore, NICE advice studies have been carried out that show for women of menopausal age who take oestrogen-only HRT there is little or no change in the risk of developing breast cancer.[8]

Womb cancer

As mentioned above, taking combined HRT can reduce womb cancer risk. However, taking oestrogen-only HRT can increase your risk of developing this cancer[9]. This is why oestrogen-only HRT is usually only offered to those who have had a hysterectomy, as they have no risk of womb cancer to begin with.

Blood Clots

There is an increased risk of developing venous thromboembolism (blood clots) for women who take oral combined HRT. A study in the BMJ found that most HRT tablets were found to be associated with increased VTE risk, with 9 extra cases per 10,000 women per year, compared with no HRT.[10]

Transdermal preparations such as patches or gels given at a standard therapeutic dose do not increase the risk of blood clots.[11]

HRT and Weight Gain

There is a common misconception that HRT can cause weight gain however there is no proven link between HRT according to the NHS[12]. It is common to gain some weight during menopause and this is often regardless of whether you take any type of HRT or not.

When to start taking HRT

The NHS advises you can begin HRT as soon as you start experiencing symptoms associated with perimenopause. Women can also start taking HRT when they are post-menopausal as symptoms can continue after menopause.

Studies have shown that taking HRT earlier in the transition to menopause can help reduce the risks of long-term health issues, such as osteoporosis, coronary heart disease and cardiovascular disease.

When you first start taking HRT your GP will want a follow up review after 3 months to check your tolerability of your treatment. After that, an annual check up will be carried out to check if the dosage is still working for you. If you have any side effects from starting HRT, then you should speak to your GP prior to the annual check up.

How long does HRT take to work?

The NHS advises that it can take a few weeks to begin to feel the effects of the HRT treatment and you should begin to see a noticeable difference at 3 months depending on the dosage and type of HRT you are on.

How long can you keep taking HRT?

There is no clear length of time you should take HRT and it is crucial that you talk to your doctor to devise a plan which is right for you.

How to come off HRT

The right time to come off HRT is very dependent on your own personal journey through menopause. Women tend to stop once their symptoms have finished, but some women will continue into post-menopause or maybe not start their HRT until there are in post-menopause.

It’s recommended that you discuss coming off HRT with your GP and agree on the best way to do it. It’s generally advised that you reduce your dosage gradually to see how you adjust and if your symptoms come back.

You may experience the return of your symptoms after coming off HRT, but these tend to be short lived.

Does your HRT dosage change over time?

As you progress through perimenopause you may find that your dosage of HRT will need to change in line with your declining levels of oestrogen and progesterone.

Some women find that their HRT stops working because their dosage requirement needs to change, if this happens, talk to your GP about increasing the dose.

Types of HRT

The two main hormones used in HRT are:

HRT usually involves taking both of these hormones (combined HRT) as taking oestrogen on its own can increase your risk of developing endometrial (womb) cancer. Taking progestogen alongside oestrogen minimises the risk of developing endometrial cancer.

Oestrogen-only HRT is only recommended for women who have had a hysterectomy.

HRT treatments come in different preparations depending on the type of treatment prescribed. The most common forms are:

  • Transdermal preparations – This is absorbed by the skin in the form of gels and skin patches. This is a recommended treatment path for HRT and is the preferred treatment option.
  • Tablets – Tablets are a common form of HRT. However, studies have shown that they can have a harmful effect on the liver compared to transdermal preparations, causing a higher risk of blood clots.[13]
  • Creams – HRT creams are often prescribed in addition to HRT treatment to be applied locally for symptoms such as vaginal dryness. Creams would not treat other symptoms such as hot flushes, as it only increases local oestrogen, not the whole body’s levels.[14]

Types of hrt

Treatment regimes

There are two different types of HRT treatment regimes, these are sequential and continuous.

Sequential HRT

Sequential HRT is recommended for women taking both oestrogen and progesterone. It consists of taking oestrogen daily alongside progesterone for 12 days of the calendar month.

Continuous HRT

Continuous combined HRT simply means taking oestrogen and progesterone together each day without a break. It is usually recommended for women who are 5 years postmenopausal.

How to get started on HRT

The decision whether to take HRT, the dose of HRT used, and the duration of its use should be made on an individualised basis, ensuring it is the right option for you and your long-term health. Speak to your doctor if you are interested in starting HRT.

They will ask you a number of questions about your symptoms, your age, and if you have any family history of blood clots, high blood pressure or cancers. If you do not have any contraindications, then your GP will discuss with you the different preparations and which one would be right for you.

Questions to ask your doctor

It can be hard to know where to start when you’re considering taking HRT to help with menopausal symptoms, below are questions that could be beneficial to ask your doctor to help you form your decision:

  • Is HRT right for me based on my medical history?
  • How can HRT help me manage my symptoms?
  • What are the long-term health risks?
  • What types of HRT are there?
  • What dosages can be prescribed?

What if HRT isn’t for you?

There are several non-hormonal alternatives to HRT, such as ‘natural remedies’ like Black Cohosh and St John’s Wort. It’s worth remembering that HRT is natural too, as it helps boosts naturally occurring hormones in your body.

Summary

It’s important for women to learn about HRT treatments and how it can help them with their perimenopause symptoms. Being informed and prepared ahead of starting perimenopause on what treatment is best for you will help you have a more informed discussion with your healthcare practitioner to help you get the treatment you need.

“As women are spending an extended part of their lives in the menopausal state, ensuring you empower yourself with up to date information to make informed decisions, will enable you to ensure maintaining quality of life during this phase of your life”

Dr Nicky Keay, Endocrinology Expert, BA, MA (CANTAB), MB, BCHIR, MRCP

Nicky keay