Hormone Replacement Therapy

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Introduction

Hormone Replacement Therapy (HRT)

Hormone replacement therapy (HRT) is a treatment used to relieve symptoms of the menopause. It replaces hormones that are at a lower level as you approach the menopause.

This page covers:

Benefits of HRT

How to get started

Who can take it

Types of HRT

Stopping HRT

Risks and side effects

Alternatives

Benefits of HRT

The main benefit of HRT is that it can help relieve most of the menopausal symptoms, such as:

Many of these symptoms pass in a few years, but they can be very unpleasant and taking HRT can offer relief for many women.

It can also help prevent weakening of the bones (osteoporosis), which is more common after the menopause.

How to get started on HRT

Speak to your GP if you're interested in starting HRT.

You can normally begin HRT as soon as you start experiencing menopausal symptoms and won't usually need to have any tests first.

Your GP can explain the different types of HRT available and help you choose one that's suitable for you.

You'll usually be started off on a low dose, which can be increased at a later stage. It may take a few weeks to feel the effects of treatment and there may be some side effects at first.

Your GP will normally recommend trying treatment for three months to see if it helps. If it doesn't, they may suggest changing your dose or changing the type of HRT you're taking.

Who can take HRT

Most women can have HRT if they're experiencing symptoms associated with the menopause.

But HRT may not be suitable if you:

  • have a history of breast cancerovarian cancer or womb cancer
  • have a history of blood clots
  • have untreated high blood pressure your blood pressure will need to be controlled before you can start HRT
  • have liver disease
  • are pregnant - it's still possible to get pregnant while on HRT, so you should use contraception until two years after your last period if you're under 50 or for one year after the age of 50

In these circumstances, alternatives to HRT may be recommended instead.

Types of HRT

There are many different types of HRT and finding the right one for you can be tricky.

There are different:

  • HRT hormones - most women take a combination of the hormones oestrogen and progestogen, although women who don't have a womb can take oestrogen on its own 
  • ways of taking HRT - including tablets, skin patches, gels and vaginal creams, pessaries or rings
  • HRT treatment regimens - HRT medication may be taken continuously without a break, or in cycles where you take oestrogen continuously and only take progestogen every few weeks

Your GP can give you advice to help you choose which type is best for you. You may need to try more than one type before you find one that works best.

Read more about the different types of HRT.

Stopping HRT

There's no limit on how long you can take HRT, but talk to your GP about the duration of treatment they recommend.

Most women stop taking it once their menopausal symptoms pass, which is usually after a few years.

When you decide to stop, you can choose to do so suddenly or gradually.

Gradually decreasing your HRT dose is usually recommended because it's less likely to cause your symptoms to come back in the short term.

Contact your GP if you have symptoms that persist for several months after you stop HRT, or if you have particularly severe symptoms. You may need to start HRT again.

Risks and side effects of HRT

As with any medication, HRT can cause side effects. But these will usually pass within three months of starting treatment.

Common side effects include:

Some types of HRT can also cause a small increase in your risk of certain serious problems, such as blood clots and breast cancer.

The benefits of HRT are generally felt to outweigh the risks. But speak to your GP if you have any concerns about taking HRT.

Read more about side effects of HRT and risks of HRT.

Alternatives to HRT

If you're unable to take HRT or decide not to, you may want to consider alternative ways of controlling your menopausal symptoms.

Alternatives to HRT include:

  • lifestyle measures - such as exercising regularly, eating a healthy diet, cutting down on coffee, alcohol and spicy foods, and stopping smoking
  • tibolone - a medication that's similar to combined HRT (oestrogen and progestogen), but may not be as effective and is only suitable for women who had their last period more than a year ago
  • antidepressants - some antidepressants can help with hot flushes and night sweats, although they can also cause unpleasant side effects such as agitation and dizziness
  • clonidine - a non-hormonal medicine that may help reduce hot flushes and night sweats in some women, although any benefits are likely to be small

Several remedies (such as bioidentical hormones) are claimed to help with menopausal symptoms, but these aren't recommended because it's not clear how safe and effective they are.

Read more about alternatives to HRT.


How-it-works

Types

Different types of hormone replacement therapy (HRT) are available.

If you're considering HRT, talk to your GP about the options suitable for you, as well as possible alternatives to HRT.

This page covers the different:

HRT hormones

Ways you can take HRT 

HRT treatment regimens

HRT hormones

HRT replaces the hormones that a woman's body no longer produces because of the menopause.

The two main hormones used in HRT are:

  • oestrogen - types used include estradiol, estrone and estriol
  • progestogen - a synthetic version of the hormone progesterone, such as dydrogesterone, medroxyprogesterone, norethisterone and levonorgestrel

HRT involves either taking both of these hormones (combined HRT) or just taking oestrogen (oestrogen-only HRT).

Most women take combined HRT because taking oestrogen on its own can increase your risk of developing womb (endometrial) cancer. Taking progestogen alongside oestrogen minimises this risk.

Oestrogen-only HRT is usually only recommended for women who have had their womb removed during a hysterectomy.

Ways of taking HRT

HRT is available in several preparations that are taken in different ways. Talk to your GP about the pros and cons of each option.

The main forms of HRT are outlined below.

Tablets 

Tablets, which are usually taken once a day, are one of the most common ways of taking HRT.

Oestrogen-only and combined HRT tablets are available. For some women this may be the simplest way of having treatment.

However, it's important to be aware that some of the risks of HRT, such as blood clots, are higher with tablets than with other forms of HRT (although the overall risk is still small).

Skin patches

Skin patches are also a common way of taking HRT. You stick them to your skin and replace them every few days. Oestrogen-only and combined HRT patches are available.

Patches may be a better option than tablets if you think you might find it inconvenient to take a tablet every day.

Using patches can also help avoid some side effects of HRT, such as indigestion, and unlike tablets they don't increase your risk of blood clots.

Oestrogen gel

Oestrogen gel is an increasingly popular form of HRT. It's applied to the skin once a day and is absorbed by the body.

Like skin patches, this can be a convenient way of taking HRT while avoiding an increased risk of blood clots.

But if you still have your womb, you'll need to take some form of progestogen separately too, to reduce your risk of womb cancer.

Implants

HRT can be given using small pellet-like implants inserted under your skin (usually in the tummy area) while your skin is numbed with local anaesthetic, although these aren't widely available and aren't used very often.

The implants release oestrogen gradually over time and can stay in place for several months before needing to be replaced.

This may be a convenient option if you don't want to worry about taking your treatment every day or every few days. But if you still have your womb, you'll need to take progestogen separately too.

If you're taking a different form of oestrogen and need to take progestogen alongside it, another implant option is the intrauterine system (IUS). An IUS releases a progestogen hormone into the womb. It can remain in place for a few years and also acts as a contraceptive.

Vaginal oestrogen

Oestrogen is also available in the form of a cream, pessary or ring that is placed inside your vagina.

This can help relieve vaginal dryness, but won't help with other symptoms such as hot flushes.

It doesn't carry the usual risks of HRT and can be used without taking progestogen even if you still have a womb.

HRT treatment regimens

Different treatment courses of HRT are also available, depending on whether you're still in the early stages of the menopause or have had menopausal symptoms for some time.

The two types are cyclical (or sequential) HRT and continuous HRT.

Cyclical HRT

Cyclical HRT, also known as sequential HRT, is often recommended for women taking combined HRT who have menopausal symptoms but still have their periods.

There are two types of cyclical HRT:

  • monthly HRT you take oestrogen every day, and take progestogen alongside it for the last 14 days of your menstrual cycle
  • three-monthly HRT you take oestrogen every day, and take progestogen alongside it for around 14 days every three months

Monthly HRT is usually recommended for women having regular periods.

Three-monthly HRT is usually recommended for women experiencing irregular periods. You should have a period every three months.

It's useful to maintain regular periods so you know when your periods naturally stop and when you're likely to progress to the last stage of the menopause.

Continuous combined HRT

Continuous combined HRT is usually recommended for women who are post-menopausal. A woman is usually said to be post-menopausal if she has not had a period for a year.

As the name suggests, continuous HRT involves taking oestrogen and progestogen every day without a break.

Oestrogen-only HRT is also usually taken continuously.


Side-effects

Side effects

Like any medication, the hormones used in hormone replacement therapy (HRT) can sometimes have side effects.

Any side effects usually improve over time, so it's a good idea to persevere with treatment for at least three months if possible.

Speak to your GP if you experience severe side effects or they continue for longer than three months.

This page covers:

Side effects of oestrogen

Side effects of progestogen

Weight gain and HRT

More serious risks

Side effects of oestrogen

The main side effects associated with taking oestrogen include:

  • bloating
  • breast tenderness or swelling
  • swelling in other parts of the body
  • nausea
  • leg cramps
  • headaches 
  • indigestion 
  • vaginal bleeding

These side effects will often pass in a few weeks, but the following measures may help relieve some of them in the meantime:

  • taking your oestrogen dose with food may help to reduce nausea and indigestion
  • eating a low-fat, high-carbohydrate diet may reduce breast tenderness
  • regular exercise and stretching may help reduce leg cramps

If side effects persist, your GP may recommend switching to a different way of taking oestrogen (for example, changing from a tablet to a patch), changing the specific medication you're taking, or lowering your dose. 

Side effects of progestogen

The main side effects associated with taking progestogen include:

As with side effects of oestrogen, these will usually pass in a few weeks,

If they persist, your GP may recommend switching to a different way of taking progestogen, changing the specific medication you're taking, or lowering your dose. 

Weight gain and HRT

Many women believe that taking HRT will make them put on weight, but there's no evidence to support this claim.

You may gain some weight during the menopause, but this often happens regardless of whether you take HRT.

Exercising regularly and eating a healthy diet should help you to lose any unwanted weight.

More serious risks

HRT has also been associated with some more serious risks, such as an increased risk of blood clots and certain types of cancer.

Read about the risks of HRT for more information.


Disadvantages

Risks

When deciding whether to have hormone replacement therapy (HRT), it's important to understand the risks.

It's also important to consider HRT as only one of a range of interventions to improve your menopausal and post-menopausal health and wellbeing.

Many studies on HRT have been published over the past 15 years that have highlighted the potential risks. As a result, some women and doctors have been reluctant to use HRT.

But more recent evidence and the National Institute for Health and Care Excellence's (NICE) new guidelines say that the risks of HRT are small and are usually outweighed by the benefits.

This page covers HRT and the risks of:

Breast cancer

Ovarian cancer

Womb cancer

Blood clots

Heart disease and strokes

Breast cancer

NICE says:

  • taking combined HRT (oestrogen and progestogen) is associated with a small increased risk of breast cancer - some studies have suggested that for every 1,000 women taking combined HRT, there will be around five extra cases of breast cancer (from a normal risk of 22 cases of breast cancer per 1,000 menopausal women to 27)
  • the risk of breast cancer decreases when you stop taking HRT - estimates suggest the level of risk returns to normal after about five years
  • oestrogen-only HRT is associated with little or no change in the risk of breast cancer

Because of the risk of breast cancer, it's especially important to attend all your breast cancer screening appointments if you're taking combined HRT.

Ovarian cancer

Studies looking at whether HRT can increase your risk of ovarian cancer have so far had conflicting results.

It's thought that if there is any increase in cases of ovarian cancer in women taking HRT, the risk is very small.

A recent study found that for every 1,000 women taking HRT for five years, there will be one extra case of ovarian cancer.

Any risk of ovarian cancer is thought to decrease once you stop taking HRT.

Womb cancer

Oestrogen-only HRT can increase the risk of womb cancer (also called endometrial cancer), which is why it's only used in women who don't have a womb (for example, because they've had a hysterectomy).

Taking combined HRT, particularly a course of continuous HRT (where you take both medications without a regular break), largely eliminates this risk.

If you still have a womb and you're taking HRT, it's important to take both medications as advised by your doctor to avoid increasing your risk of womb cancer.

Blood clots

Blood clots can be serious if they become lodged in a blood vessel and block the flow of blood.

NICE says:

  • taking HRT tablets can increase your risk of blood clots
  • there's no increased risk of blood clots from HRT patches or gels

It's thought the risk of developing a blood clot is about two to four times higher than normal for women taking HRT tablets. But as the risk of menopausal women developing blood clots is normally very low, the overall risk from HRT tablets is still small.

It's estimated that for every 1,000 women taking HRT tablets for 7.5 years, less than two will develop a blood clot.

Heart disease and strokes

NICE says:

  • HRT doesn't significantly increase the risk of cardiovascular disease (including heart disease and strokes) when started before 60 years of age
  • oestrogen-only HRT is associated with no, or reduced, risk of heart disease
  • combined HRT is associated with little or no increase in the risk of heart disease
  • taking oestrogen tablets is associated with a small increase in the risk of stroke, although the normal risk of women under 60 having a stroke is very low, so the overall risk is small

Speak to your GP if you're taking HRT or are considering taking it and are worried about the risk of stroke or heart disease.


Alternatives

Alternatives

If you're unable to take hormone replacement therapy (HRT) or decide not to, you may want to consider alternative ways of controlling your menopausal symptoms.

This page covers the following alternatives to standard HRT:

Lifestyle measures

Tibolone

Antidepressants

Clonidine

Bioidentical or "natural" hormones

Complementary therapies

Lifestyle measures

The following lifestyle measures can help reduce some menopausal symptoms:

  • Take regular exercise - regular activity can reduce hot flushes and improve sleep. It's also a good way of boosting your mood if you feel anxious, irritable or depressed. Weight-bearing exercises can help keep your bones strong.
  • Have a healthy diet - a balanced diet can help ensure you don't put on weight and can keep your bones healthy.
  • Stay cool at night - wear loose clothes and sleep in a cool, well-ventilated room if you experience hot flushes and night sweats.
  • Cut down on caffeine, alcohol and spicy food - as they have all been known to trigger hot flushes.
  • Try to reduce your stress levels - to improve mood swings, make sure you get plenty of rest, as well as getting regular exercise. Activities such as yoga and tai chi may help you relax.
  • Give up smoking - if you smoke, giving up will help reduce hot flushes and your risk of developing serious health conditions, such as heart diseasestroke and cancer.
  • Try vaginal lubricant or moisturiser if you experience vaginal dryness - several different types are available to buy from shops and pharmacies.

Tibolone

Tibolone (brand name Livial) is a prescription medication that is similar to taking combined HRT (oestrogen and progestogen). It's taken as a tablet once a day.

It can help relieve symptoms such as hot flushes, low mood and reduced sex drive, although some studies have suggested it may not be as effective as combined HRT.

It's only suitable for women who had their last period more than a year ago (known as the post-menopause).

Side effects of tibolone can include tummy (abdominal) pain, pelvic pain, breast tenderness, itching and vaginal discharge.

Risks of tibolone are similar to the risks of HRT, and include an increased risk of breast cancer and strokes. Talk to your GP about the risks and benefits of tibolone if you're considering taking it.

Antidepressants

Two types of antidepressants - called selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) - can help with hot flushes caused by the menopause, although they're not licensed for this use.

This means they haven't undergone clinical trials for this use, but many experts believe they're likely to be effective and your doctor will discuss the possible benefits and risks with you.

Side effects of SSRIs and SNRIs can include feeling agitated, shaky or anxious, feeling sick, dizziness and a reduced sex drive.

Any side effects will usually improve over time, but you should visit your GP if they don't.

Clonidine

Clonidine is a prescription medicine that can help reduce hot flushes and night sweats in some menopausal women. It's taken as tablets two or three times a day.

It doesn't affect hormone levels, so unlike HRT it doesn't carry an increased risk of problems such as breast cancer. But research suggests it only has a very small effect on menopausal symptoms.

Clonidine can also cause some unpleasant side effects, including dry mouth, drowsiness, depression and constipation.

It may take two to four weeks to notice the effects of clonidine. Speak to your GP if your symptoms don't improve or you experience any troublesome side effects.

Bioidentical or "natural" hormones

Bioidentical hormones are hormone preparations made from plant sources that are promoted as being similar or identical to human hormones.

Practitioners claim these hormones are a "natural" and safer alternative to standard HRT preparations.

However, bioidentical preparations aren't recommended because:

  • they aren't regulated and it's not clear how safe they are - there's no good evidence to suggest they're safer than standard HRT
  • it's not known how effective they are in reducing menopausal symptoms
  • the balance of hormones used in bioidentical preparations is usually based on the hormone levels in your saliva, but there's no evidence that these levels are related to your symptoms

Many standard HRT hormones are made from natural sources, but unlike bioidentical hormones they're closely regulated and have been well researched to ensure they're as effective and safe as possible.

Complementary therapies

Several products are sold in health shops for treating menopausal symptoms, including herbal remedies such as evening primrose oil, black cohosh, angelica, ginseng and St John's Wort.

There's evidence to suggest that some of these remedies, including black cohosh and St John's Wort, may help reduce hot flushes, but generally, many complementary therapies aren't supported by scientific evidence.

Even when there is some supporting evidence, there's uncertainty about the appropriate doses to use and whether the health benefits are sustained. Some of these remedies (especially St John's wort) may also cause serious effects if taken with other medicines.

These products are often marketed as "natural", but this doesn't necessarily mean they're safe. The quality, purity and ingredients can't always be guaranteed, and they can cause unpleasant side effects.

It's a good idea to ask your GP or pharmacist for advice if you're thinking about using a complementary therapy.


"The night sweats really got me"

"The night sweats really got me"

Barbara Hunt, a retired civil servant from Canterbury, Kent, has had a rollercoaster ride with the menopause and HRT.

"I was 51 when I had my first hot flush. My periods had been erratic for six months, so I realised I was approaching the menopause. Then the flushes started with a vengeance.

"My GP immediately suggested HRT. This was when it was being hailed as the wonder drug. I started off with patches. I still had periods, but at least the flushes went away.

"After four years, I heard about its possible side effects and decided to stop taking it. The flushes returned and I got night sweats, too. Heat would suddenly engulf me, then disappear just as quickly. The night sweats were really hard. I was waking up every half-hour and got so little sleep that going back on HRT seemed my only option.

"I started taking it again. To my relief, the flushes and sweats are a thing of the past. I'm now trying to wean myself off the patches by cutting a third off them each time. Having gone on HRT, it seems to be such a tough job to get off it. I sometimes wonder whether, if I'd never taken it, the flushes might be over by now."