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HRT FAQs

HRT stands for hormone replacement therapy. For many women, it’s the most effective way of managing menopause symptoms and it can transform how you feel. Here we answer some of the questions about HRT that we are asked most frequently.

For most women, HRT is an effective way of managing menopause symptoms. It also provides long-term health benefits, reducing the risk of osteoporosis and, for many, heart disease.  The small risks of HRT are generally far outweighed by the benefits.

HRT is an effective way of managing menopause symptoms, such as:

  • Hot flushes and night sweats
  • Low mood and anxiety
  • Brain fog and memory issues
  • Vaginal dryness
  • Painful sex
  • Loss of libido/sex drive
  • Bladder issues
  • Skin, tissue, and joint quality
  • Joint and muscle aches and pains

HRT can help the lesser-known symptoms too, although there may be less published evidence.

We often get asked whether HRT will delay the menopause. Some women believe that it just ‘presses pause’ on their symptoms, worrying that the symptoms will come roaring back as soon as they stop taking it. This isn’t what happens. If you are ‘programmed’ to experience menopause symptoms for, say, 10 years and take HRT for 7 years, you will probably experience 3 more years of symptoms if you decide to stop treatment. So, you will have avoided those years of symptoms altogether.

Breast cancer is the risk that most concerns people in connection with HRT. What we know for certain is that:

  • Every woman has a different background risk of breast cancer before HRT is added into the equation. The lifetime risk of breast cancer is one in eight women[1].
  • Women worry most about dying from breast cancer, but in fact, far more women die of heart disease. This in no way diminishes the importance of breast cancer, but it highlights how important it is to be aware of heart disease.

The risk of breast cancer is likely to increase the longer you take HRT but is still low. This risk slowly reduces when you stop HRT. The longer you have been on it, the longer this ‘tailing off’ time may be.

If you take body-identical progesterone (more on those below), some studies have shown that the risk of breast cancer is lower when compared with older, synthetic progestogens[2].

For more information on how different factors affect your risk of breast cancer, have a look at the summary results from the Women’s Health Initiative Study. It clearly shows that lifestyle factors, such as drinking alcohol and being overweight in particular, have a greater impact on your risk of breast cancer than taking HRT.

Oestrogen-only HRT

Studies show that after five years, there is little or no increase in the risk of breast cancer diagnosis in women who take oestrogen-only HRT[3]. There is likely a very small increase in the risk of breast cancer year on year if you take oestrogen-only HRT.

Combined HRT

There’s a very small increase in the risk of being diagnosed with breast cancer if you take combined HRT (oestrogen and progestogen), but this doesn’t mean there is an increased risk of dying from breast cancer.

Sequential HRT

Sequential HRT is not quite as effective in protecting the womb as continuous combined HRT. This is why after four years, or when you reach 55 years of age (the age at which most women’s periods have stopped), your therapy should be switched to continuous combined HRT.

If you have a womb and take oestrogen-only HRT in a tablet, gel, spray or patch, the risk of cancer of the womb will increase. That’s why it’s important to take a progestogen alongside oestrogen or have an ‘in date’ Mirena™ coil (within five years) to protect your womb.

If you use vaginal oestrogen, you don’t need to add a progestogen as the amount you absorb into your body is tiny.

Some studies have shown a link between HRT and some types of ovarian cancer[4]. The risk is very low. There is no evidence that taking HRT will increase your risk of dying from ovarian cancer.

Before the menopause, your ovaries produce three main types of hormones:

  • Oestrogens (for example, oestradiol)
  • Progestogens (for example, progesterone)
  • Androgens (for example, testosterone)

It’s the loss of oestrogens that results in most menopause symptoms. And while all women’s testosterone levels gradually decline from our 30s, this impacts some of us and not on others. You can find out more about testosterone here.

Put simply, HRT aims to replace the declining levels of oestrogen that your ovaries used to make, and this, in turn, helps to reduce your menopause symptoms. It also has long-term health benefits, more crucial than ever as women’s life expectancy is increasing.

For most women, HRT consists of two hormones – oestrogen and a progestogen. Testosterone can also be an option.

Oestrogen is needed to manage most menopause symptoms. If you still have a womb (you have not had a hysterectomy) and take oestrogen by itself, this can thicken the lining of your womb, increasing your risk of womb cancer. The progestogen hormone is there to protect the lining of the womb.

When considering hormones, there are two types of this HRT:

  • combined HRT contains oestrogen and a progestogen. This can be sequential or continuous.
  • oestrogen-only HRT.

1. Combined HRT

  • Sequential HRT – 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.
  • Continuous combined HRT – So-called because the two hormones (oestrogen and progestogen) are taken together, daily. This approach results in no bleeding.

2. Oestrogen-only HRT

  • 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.

Sequential HRT

If it’s less than 6-12 months since your last period, you’ll need to take sequential HRT. This means you’ll continue to have a (usually) monthly bleed. Most women take this type of HRT for around four years or until they reach 55 (whichever comes first). By 55, most women’s periods have stopped.

Sequential HRT contains oestrogen and progestogen. You take oestrogen every single day, and the progestogen is taken with this for half of the month. This causes a withdrawal bleed rather like a period. Confusingly, medical professionals don’t refer to it as a period since the bleeding is a direct result of the hormones you’re taking.

If you would prefer not to have a monthly bleed and it’s less than 6-12 months since your last period, you could opt to have a Mirena™ intrauterine system (coil) fitted and use this to protect the lining of the womb, alongside oestrogen. This contains a progestogen.

Most women experience no or minimal bleeding with a Mirena™, which lasts for five years. It also provides contraception and is a great option if you’re experiencing heavy periods.

Continuous Combined HRT

If it’s around 12 months since your last period, you can start continuous combined HRT – with no bleed. With this version of HRT, you take oestrogen and a progestogen every day. However, if you begin this treatment too early in the menopause transition while still having periods, you may have irregular, frequent bleeding. A Mirena™ intrauterine system is also a good option here to protect the womb’s lining alongside oestrogen and to provide contraception if needed.

Oestrogen-only HRT

This HRT contains just oestrogen. You can take it if you have had a hysterectomy (you’ve had your womb removed).

There are exceptions to this rule, though. Women who have had a hysterectomy for endometriosis may be advised to take a continuous combined HRT by their gynaecologist.

If you have had a subtotal hysterectomy where the womb is removed, but the cervix is left behind, you may need to take combined HRT as some of the womb lining may remain. Again, you should be guided by your gynaecologist.

If you have had an endometrial ablation procedure where the womb lining is removed – usually for heavy bleeding – you would still need to take combined HRT (oestrogen and progestogen).

HRT is available in the following forms:

TypeWhat you need to knowHormones
TabletsEasy to take every day.
Increase the risk of blood clots, stroke and gall bladder disease.
Oestrogen and progesterone or oestrogen-only.
The oestrogen is usually bioidentical.**
Premarin is a type of oestrogen derived from horse urine.
Tibolone is fully synthetic with oestrogen, progestogen and androgen-like action.
GelsUse daily – usually to the back of the arm or inner thigh.
Do not affect the risk of blood clotting or stroke at standard doses.[2]
A safer option where you are at higher risk of blood clots or stroke (for example smoking, obesity, or are a migraine sufferer).*
Oestrogen only**.
If you have a womb you need a progestogen also.
The oestrogen is bioidentical**.
PatchesStick to the skin below the waist. Usually changed twice weekly (or weekly depending on the brand).
Do not affect the risk of blood clotting or stroke at standard doses.
A safer option where you are at higher risk of blood clots or stroke (for example smoking, obesity, or are a migraine sufferer).*
Can be oestrogen-only.
If you have a womb you need a progestogen also.
Can be oestrogen plus progestogen.
The oestrogen is bioidentical**. The progestogen is not.
SprayUse daily.
Does not affect the risk of blood clotting or stroke at standard doses.
A safer option where you are at higher risk of blood clots or stroke (for example smoking, obesity, or are a migraine sufferer).*
Oestrogen-only.
If you have a womb you also need a progestogen.
The oestrogen is bioidentical**
Micronised progesterone (Utrogestan™)Capsule – swallowed at night.
Can help sleep.
Likely to have a lower risk of breast cancer compared with alternatives.
Unlike synthetic progestogens, it should not affect your risk of heart disease or blood clotting.
Progestogen only.
Used with oestrogen. Prevents the lining of the womb from thickening.
The oestrogen is bioidentical**.
Mirena™ Intrauterine systemA ‘coil’ inserted through the neck of the womb into the cavity of the womb.
Inserted by GPs, family planning clinics, gynaecologists and some menopause clinics.
Lasts for five years for HRT.
Also acts as a contraception.
Progestogen only.
Used with oestrogen.
Very effective at preventing the lining of the womb from thickening.
Vaginal preparationsCreams and pessaries inserted directly into the vagina to help symptoms of oestrogen loss – for example, dryness and irritation.
You
Oestrogen-only.
No need for progestogen if used as advised by your doctor.
May also help some bladder symptoms.
TiboloneTablet.
Helps menopause symptoms.
Small risk of breast cancer.
Risk of stroke over 60.
Protection of bone – like HRT.
Fully synthetic oestrogen, progestogenic and androgenic effects.
Similar to continuous combined HRT – so it’s best started after your periods have stopped.

*You’re at higher risk of blood clots if you smoke, have a higher body weight in relation to your height (body mass index), or suffer from certain medical conditions that put you at greater risk of blood clots or stroke. Migraine sufferers can take HRT, even though they can’t take the combined oral contraceptive pill. It’s safer to use oestrogen through the skin as a patch, gel, or spray than as tablets which may further increase the risk of stroke.

**Bioidentical means that the hormone is the same as that made by your body. Bioidentical progesterone has been shown to have a lower risk of breast cancer than synthetic alternatives. It may be better tolerated, it doesn’t affect blood clotting or cholesterol and other blood fats. We go into more detail on bioidentical hormones below.

HRT replaces the oestrogen in your body. This helps keep your bones healthy, reducing your risk of osteoporosis and preventing fractures.

HRT is the most important way to prevent and treat osteoporosis in women with premature ovarian insufficiency (POI) and menopausal women below 60 years of age, particularly those experiencing symptoms of the menopause.

Heart disease is important. Women worry most about dying from breast cancer, but in actual fact, more women die of heart disease[5]. This in no way diminishes the importance of breast cancer, but it does highlight how important it is to be aware of heart disease too.

There’s a lot of conflicting and sometimes worrying advice on the internet connecting HRT with heart disease. Here’s what we know for certain:

  • If HRT is started within ten years of the menopause or before the age of 60, HRT can help prevent cardiovascular disease and reduce the risk of dying from cardiovascular disease[6]. So, even if you have risk factors for cardiovascular disease like high blood pressure or high cholesterol, it doesn’t mean that you can’t take HRT.
  • If you start HRT more than ten years after the menopause – HRT may not prevent heart disease, but there is no evidence of an increase in cardiovascular illnesses, such as heart attacks or strokes.

The evidence for HRT and the prevention of dementia is not clear. There is some evidence to suggest that HRT started early in the menopause may help prevent dementia. What is certain is that starting HRT when you’re under 60 will not increase the risk of dementia.

There is evidence to suggest that the risk of bowel cancer is reduced in women who take HRT. HRT may protect against or help osteoarthritis, and joint pains can improve along with glucose control in type 2 diabetes.

The media often focuses heavily on HRT risks, yet the reality of the scientific data shows that the risks are very low for most women[7].

The risks of HRT vary from woman to woman and the type they take. The following factors can affect your long-term health and may affect the risks of HRT for you:

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

It’s essential that HRT is tailored to suit you by an experienced healthcare professional, as menopause management is not one-size-fits-all. A healthy diet and regular exercise will help you reduce the risks and reap the maximum benefit from HRT.

Read our article on HRT for more detail on the following risks of HRT: breast cancer, other cancers, blood clots, stroke, and gallbladder disease.

If you choose not to take HRT, you may experience many of the symptoms of menopause. Remember, not all women experience every kind of symptom and some women ‘sail through’ menopause with hardly any symptoms at all.

For some women, menopause symptoms are mildly inconvenient, for others they can be quite debilitating. Many menopause symptoms are not a risk to your health – such as hot flushes and forgetfulness. But there are more significant risks too, such as a loss of bone density leading to osteoporosis and an increase in risk of heart disease after the menopause.

You may also experience changes to your libido and sexual response, such as vaginal dryness and reduced sex drive. There are many non-hormonal options to help though.

Oral HRT (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 (transdermal oestrogen) in the form of patches, gels, and sprays does not carry these same risks. Some of the older synthetic types of progestogen can also increase the risk of blood clots by a small amount.

Of course, you may already be at risk of blood clots if you smoke, are overweight or have had a blood clot in the past. If this is the case, transdermal HRT should not add to your risk.

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.

There are some medical conditions where HRT may be too risky. We can’t list all the medical conditions here, but they include 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, where you have abnormal vaginal bleeding that has not been investigated.

The benefits and risks of HRT are different for everybody, and it is important that you talk through your situation with a menopause specialist. It’s also important to discuss your medical history in full before thinking about starting HRT.

If you go through the menopause before you reach 40 (also known as premature ovarian insufficiency – POI), it’s important to talk to your healthcare professional about HRT. Experiencing the menopause before reaching this age has significant health risks of its own, such as:

  • Cardiovascular disease
  • Osteoporosis
  • Loss of cognitive function

HRT can significantly decrease these risks, and it’s important to take it until you are 51 – the average age for reaching the menopause in the UK.

If you’re concerned that it will mean you have been on HRT for years, it’s worth remembering that all you are doing is replacing the oestrogen your body would produce naturally at that age.

There is no right answer to the question about how long to take HRT for, and there is no arbitrary age cut-off. The benefits and risks will differ for every woman as they enter their 60s and beyond. That’s why it’s essential that you speak to a healthcare professional experienced in treating the menopause and in prescribing HRT – menopause management is not one size fits all!

Benefits

HRT is effective in treating the symptoms of the menopause – important when around 5% of women continue to experience symptoms of the menopause for 15 years and longer. In other words, well into their 60s.

HRT is also beneficial in preventing osteoporosis and continuing the prevention of heart disease (if HRT was started early in the menopause.)

  • If HRT is started within 10 years of the menopause or before the age of 60, there is evidence that it reduces the risk of heart disease.
  • If HRT is started after the age of 60 or after 10 years, the evidence we have suggests that there should not be a significant increase in the risk of heart disease.
  • However, there is also evidence suggesting that starting older oral forms of HRT in older age may increase the risk. It’s always best to discuss your case and your risk factors for heart disease with a doctor.

Risks

The main risks of using HRT to consider are the increase in the risk of breast cancer diagnosis and the increased risk of blood clots and stroke.

The risk of breast cancer increases with age and with the length of time you take HRT. (Other breast cancer risk factors include your weight, your alcohol intake, and whether you smoke. Regular exercise can reduce the risk).

If you have had a hysterectomy, you only need oestrogen-only HRT. This is associated with a lower risk of breast cancer than combined HRT containing oestrogen and progestogen, though the risk of breast cancer is also likely to increase with time if you take oestrogen-only HRT. If you have a womb, you need to take a progestogen to reduce your risk of cancer of the womb.

If you need to take a progestogen, taking Utrogestan with oestradiol, or taking Femoston oral HRT (which contains oestradiol and dydrogesterone) are likely to have a lower risk of breast cancer than synthetic alternative forms of HRT containing norethisterone. Utrogestan, Femoston™, and the Mirena have never gone head-to-head in trials. The amount of progestogen released into the body from the Mirena is low but not zero.

The risk of blood clots – for example, in the leg (deep vein thrombosis), lungs (pulmonary embolism), or brain (stroke) – increases with age. HRT tablets increase the risk further. Having the oestradiol through the skin in the form of a patch, gel or spray will not further increase the risk. If you need to take a progestogen, Utrogestan and the Mirena should not significantly affect the risk of blood clotting. Older synthetic progestogens – such as norethisterone – do. So, heading into your 60s, it’s safer to switch to transdermal oestradiol plus Utrogestan or the Mirena.

Studies have suggested that the risk of ovarian cancer diagnosis increases by a small amount, year on year, though there is no evidence that HRT actually causes this [Beral V, Million Women Study C, Bull D, Green J, Reeves G. Ovarian cancer and hormone replacement therapy in the Million Women Study. Lancet. (2007) 369:1703–10.]

You may experience some of the side effects of HRT listed below when you start it and they generally settle in the first three months. Side effects can vary depending on the type of HRT you take.

Possible oestrogens side effectsPossible progestogens side effects
Rash/itchingBreast tenderness
Feeling sickBloating
Leg crampsHeadaches/migraine
Headaches/migraineLow mood and depression
FatigueAcne/greasy skin
Breast tenderness or breast swellingTummy pains
Vaginal bleedingNausea
Fluid retention – eg ankle swellingBackache
DizzinessVaginal bleeding
Mood changes – low mood or anxietyChange in vaginal discharge
Drowsiness
Dizziness
Itching

Source[8]. Please note, this list is not exhaustive, so if you’ve been prescribed hormones, please read the leaflet that comes with them.

Some women bleed when they start HRT or change their dose. This should settle in three to six months and is usually light. If the bleeding is heavy, happens after sex, or persists for longer than six months, please speak to your doctor as you’ll need an examination and more tests.

Thankfully, for most women, these side effects generally settle after three months.

Progestogen intolerance

Some women can be intolerant of progestogens. They may experience depression, anxiety, feel like their brain isn’t fully functioning, and have severe premenstrual-type symptoms when taking progestogens. This may be limited to a single type of progestogen or may apply to all of them. 

If this happens to you, speak to your doctor who may be able to tailor your regime to help. Progestogens are important, and changing from the recommended licensed regime may significantly increase the short-term risk of irregular bleeding or the long-term risk of developing endometrial cancer. 

Therefore, reducing the dose or number of days that the progestogen or progesterone is taken should only be taken under specialist guidance.

You may have come across the terms bioidentical and body-identical hormones. They both refer to hormones that are biochemically the same as the hormones made by your ovaries.

Different menopause clinics use them to mean different things. Here’s a quick guide to help you understand them:

Regulated bioidentical hormones (rBHRT)

Regulated bioidentical hormones (rBHRT) derived from plants are available on a standard, regulated prescription – they can be prescribed by our clinic or your GP/specialist in the NHS. They include oestradiol and micronised progesterone which are commonly prescribed in the UK.

Compounded bioidentical hormones (cBHRT)

These are also derived from plants and are made by private clinics in a process known as compounding. Compounded bioidentical hormones are not regulated and are not available on the NHS. They are marketed as precise duplicates of the hormones from your ovaries after blood test analysis. The hormone combination is then made up by a private pharmacy.

These combinations do not follow the same regulations as conventional HRT and haven’t been through the same strict testing processes for effectiveness and safety.

The blood tests and hormones are also very expensive – significantly more than the cost of a private or NHS prescription. More expensive does not necessarily mean better. We don’t prescribe these.

You may have read about Premarin. This is derived from horse urine (the name comes from PREgnant MARes’ urINe), so it’s ‘natural’ but contains several different types of oestrogen. Available in tablet form, it is not commonly prescribed in the UK.

If you have been advised not to take HRT, or don’t want to, antidepressants are one of the alternatives to HRT. Antidepressants can be an important part of treatment if you suffer clinical depression or anxiety that is made worse by the menopause.

They can lift your mood, help you sleep, and reduce your anxiety. They may also help hot flushes, although HRT is a more effective treatment.

While very useful for many, antidepressants can have side effects such as feeling shaky, anxious, nauseous, indigestion, poor sleep, and a reduction in libido. Always read the leaflet. MIND has more information on anti-depressants here.

As you can see, there’s a wide range of options available when it comes to HRT, so understanding the types, benefits, risks and what’s best for you can feel like a bit of a minefield at first.

What’s most important is finding the right solutions for you and your situation. That’s where a chat with an expert can be really worthwhile.

To talk to a friendly, knowledgeable menopause expert, book a consultation with one of our doctors.

Authored by:

Dr Clare Spencer
Registered menopause specialist, GP and co-founder

Last updated:

07/04/2021

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References

  1. Source: https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/breast-cancer/risk-factors

  2. Source: progestogens Fournier A, Berrino F, Riboli E, Avenel V, Clavel-Chapelon F. Breast cancer risk in relation to different types of hormone replacement therapy in the E3N-EPIC cohort. Int J Cancer. 2005 Apr 10;114(3):448-54.

  3. Source: Anderson GL, Limacher M, Assaf AR, Bassford T, Beresford SA, Black H, Bonds D, Brunner R, Brzyski R, Caan B, Chlebowski R, Curb D, Gass M, Hays J, Heiss G, Hendrix S, Howard BV, Hsia J, Hubbell A, Jackson R, Johnson KC, Judd H, Kotchen JM, Kuller L, LaCroix AZ, Lane D, Langer RD, Lasser N, Lewis CE, Manson J, Margolis K, Ockene J, O’Sullivan MJ, Phillips L, Prentice RL, Ritenbaugh C, Robbins J, Rossouw JE, Sarto G, Stefanick ML, Van Horn L, Wactawski-Wende J, Wallace R, Wassertheil-Smoller S; Women’s Health Initiative Steering Committee. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women’s Health Initiative randomized controlled trial. JAMA. 2004 Apr 14;291(14):1701-12. as well as https://www.nice.org.uk/NG23/

  4. Source: Collaborative Group On Epidemiological Studies Of Ovarian Cancer, Beral V, Gaitskell K, et al. Menopausal hormone use and ovarian cancer risk: individual participant meta-analysis of 52 epidemiological studies. Lancet. 2015;385(9980):1835-1842.

  5. Source: https://www.bhf.org.uk/informationsupport/heart-matters-magazine/medical/women/coronary-heart-disease-kills

  6. Source: https://www.nice.org.uk/guidance/ng23/

  7. Source: https://www.nice.org.uk/guidance/ng23/

  8. Source: https://www.medicines.org.uk/

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