HRT: A Comprehensive Guide to Hormone Replacement Therapy

Menopause can be a challenging phase in a woman's life, often accompanied by bothersome symptoms that affect daily life quality. Fortunately, Hormone Replacement Therapy (HRT) offers an effective form of treatment. HRT replaces the hormones, such as oestrogen, that naturally decrease during menopause, alleviating symptoms and providing various health benefits.

Understanding Hormone Replacement Therapy

All types of HRT contain an oestrogen hormone which replaces the oestrogen that your ovaries no longer make after the menopause. You may sometimes also need other hormones (such as progestogen and testosterone) that your body is no longer producing. It comes in various forms, including oral tablets, skin patches, gels, and sprays. The choice of HRT depends on individual needs, risk factors, and preferences. Ideally, the hormones used in HRT should be identical to those naturally produced by the body, known as body-identical HRT.

Types of Hormones in HRT

Oestrogen: there are different types of oestrogen hormones, but the safest form is 17 beta estradiol. It is safer when oestrogen is absorbed through your skin in patches, gels, or sprays, as this reduces side effects and risks.

Progesterone: Using oestrogen alone can thicken the uterine lining, leading to bleeding and an increased risk of endometrial cancer. Progestogen is often added to counteract this effect. The safest form of progestogen is micronized progesterone, branded as Utrogestan in the UK and available as capsules which can be swallowed or used vaginally.

Testosterone: In some cases, testosterone may be added to HRT after several months of oestrogen use. It can improve mood, energy, stamina, motivation, and libido and is available as a gel or cream.

Vaginal Oestrogen: For localised symptoms like vaginal dryness or bladder issues, oestrogen creams, vaginal tablets, or rings can be used alongside or independently of HRT.

Choosing the Right HRT Regimen

The choice of HRT regimen depends on individual factors. If you have a womb (uterus), combined HRT with both oestrogen and progestogen is recommended to prevent uterine thickening and potential bleeding.

  • If combined HRT is started before you have the menopause or within 12 months of your last period then you will be offered a ‘cyclical’ combined HRT, which should give you regular monthly withdrawal bleeds.
  • If you start combined HRT more than 12 months after your last period (postmenopausal), you may be offered ‘continuous’ combined HRT (bleed-free HRT). You may experience some vaginal bleeding in the first 3 months, but after this it should stop. You may also be offered this regime after a year of being on cyclical HRT.

Women without a uterus (if you have had a hysterectomy) can opt for oestrogen-only HRT.

Benefits of HRT

HRT offers numerous advantages:

Symptom Relief: Most women experience significant improvement in menopausal symptoms. Hot flashes, night sweats, mood swings, and sleep disturbances typically subside. Body aches decrease, and skin and hair quality improve.

Reduced Risk of Chronic Conditions: Importantly, HRT can lower the risk of several chronic conditions that often accelerate during midlife and beyond. These benefits include:

  • Osteoporosis: HRT helps protect bones from weakening due to oestrogen loss, reducing the risk of fractures.
  • Cardiovascular Disease: HRT reduces the likelihood of heart problems, stroke, and vascular dementia.
  • Other Diseases: Women on HRT have a lower future risk of type 2 diabetes, osteoarthritis, bowel cancer, and depression.

Understanding Risks

While HRT is generally safe and effective, there are minor risks to consider:

Breast Cancer: Combined HRT (oestrogen and progestogen) can slightly increase the risk of breast cancer, particularly with extended use. The risk diminishes after stopping HRT and is lower when using micronized progesterone. However, it's essential to consider this risk in the context of individual factors, such as obesity and moderate alcohol consumption - both which increase the risk.

Blood Clots: In rare cases, women with a history of blood clots, liver disease, or migraines may face a small risk of clot formation with oral oestrogen. However, this risk doesn't apply when taken through the skin in patches, gels, or sprays, so is safe for these women.

When to Start HRT

The most effective time to begin HRT is during perimenopause, which occurs before the official onset of menopause, typically 12 months after your last period. You don't need to wait for your periods to cease before starting HRT. Women experiencing bothersome symptoms should consult a healthcare professional to determine the best course of action. While the most significant health benefits are seen in women who start HRT within ten years of menopause, HRT can be initiated at any age.

Hormone Tests Before Treatment

Typically, hormone tests aren't necessary to diagnose menopause in women aged 45 or older who display menopausal symptoms. Treatment decisions are primarily based on symptom assessment.

Final Thoughts

HRT offers a valuable solution for managing menopausal symptoms and reducing the risk of chronic conditions. It's crucial to remember that the benefits of HRT outweigh the risks for most women, especially if started under the age of 60. The decision to begin HRT should be based on individual circumstances and discussed with a healthcare professional. It's also important to note that there is no maximum duration for HRT, and it can be continued indefinitely. HRT does not delay menopause; it simply addresses its symptoms and offers long-term health benefits.

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