We constantly talk about Hormone Replacement Therapy and for good reason…
The problem is that there are many confusing myths around hormone replacement therapy (HRT) and a lot of misinformation out there. Let’s go back to the basics: what is it, how do you take it, how do you get it, and what do you need to know about it?
What is HRT?
Hormone replacement therapy is a treatment you can take to manage your menopausal symptoms. There are two main hormone types of treatment:
1. Oestrogen-only and combined HRT (which is a combination of oestrogen and progesterone).
2. Combination HRT is the most common form, since taking oestrogen on its own is associated with a higher risk of developing endometrial (womb) cancer. Nonetheless, oestrogen-only hormone replacement therapy is usually recommended for surgically induced menopause (a hysterectomy, for example).
How do you take it?
- Tablets. Both types of HRT are available in tablet form, which involves taking one small tablet a day. For many women, this is most convenient, though it is associated with a slightly higher risk of blood clots.
- Skin patches. Both types of HRT are available as a skin patch, which are placed on the skin and replaced every few days.
- Gels. This is not the most common method. It is easily applied to the skin. However, it doesn’t come as a combination, so you would need to take progestogen separately (from a progesterone gel or a Mirena coil, for example).
- Oestrogen implants. Implants consist of a small pellet-sized implant put under the skin which releases oestrogen. It’s not very common or widely available. It needs to be replaced every few months as opposed to taking a tablet every day or replacing a patch every few day. Like the gel, implants only contain oestrogen so progestogen needs to be taken separately.
- Vaginal oestrogen. You can insert oestrogen directly into the vagina in the form of a pessary, cream, or ring. This is particularly helpful for vaginal dryness (but not as effective for other symptoms). Even if you still have your womb, progestogen does not need to be taken separately.
What does a typical treatment look like?
Hormone replacement therapy treatments change depending on what stage you are in your menopausal transition (perimenopause, menopause, postmenopause). There are two treatments: cyclical (or sequential) and continuous. Cyclical is typically recommended for perimenopausal women taking combined HRT. There are two types of cyclical hormone replacement therapy:
- Monthly: take estrogen every day, and take progestogen alongside it for the last 14 days of your menstrual cycle
- Three-monthly: take estrogen every day, and take progestogen alongside it for 14 days every three months (mostly recommended for women who experience irregular periods).
Alternatively, continuous hormone replacement therapy is recommended for post-menopausal and menopausal women. It is, of course, taken continuously, taking oestrogen and progestogen every day without a break (or oestrogen-only every day without break).
What is bioidentical and body-identical HRT?
If you’ve seen these buzzwords around, you may be a bit confused as to what they are and what the differences are. Fortunately, our friend Dr Louise Newson put the confusion to rest in her guest article Bioidentical and Bodyidentical HRT.
Where can I get it?
If you’re in the UK, you can get HRT through the NHS or a private clinic. As mentioned in Dr Newson’s article above, be weary of any custom-made hormone replacement therapy given by a private clinic, as they are often not as regulated as NHS-sourced HRT and might not be as effective.
What are the benefits of hormone replacement therapy?
Many, many, many women attribute the relief of their menopausal symptoms to HRT and it’s no surprise why. It’s a very good treatment. Menopausal symptoms are caused by the declining levels of oestrogen and progesterone in the body. It makes sense that replacing those hormones would treat the symptoms!
What are the risks?
The risks of hormone replacement therapy are not as large as some think. Nonetheless, as with any other medical treatment, there are some risks. According to the NICE Guidelines, risks include blood clots and strokes (with oral treatment), and cardiovascular disease (only for women taking treatment above the age of 60. Even then, treatment does not increase your risk of dying of cardiovascular disease). Additionally, and of high concern for many, is the slight risk of cancer, which is outlined in great detailed in our article HRT and Cancer, by Dr Ornella Cappellari.
What are some common myths about HRT and why are there so many myths?
The reason why there are so many myths and misconceptions surrounding hormone replacement therapy could trace back to 2002. According to Richard J Santen, president of the Endocrine Society. After the 2002 findings from the Women’s Health Initiative (WHI), which indicated that hormone replacement therapy was harming women, prescriptions for it fell by 80% worldwide.
On top of that, he explained: ‘medical training programmes began to overlook training new doctors on how to care for menopausal women’. Myths include: hormone replacement therapy causes weight gain, delays the menopause, and natural, alternative treatments are safer. For a full list, see Dr Newson’s article on 8 Myths About HRT.
For how long should you take hormone replacement therapy?
While it may not be the answer you want to hear, it depends on who you are and what you’re experiencing! Due to recent research, it is now recommended to stay on HRT for longer than 5 years; however, this depends on when you start taking treatments (the earlier you’ve started, the longer its suggested you take it). That said, many women take it past their 60s and beyond, especially as a treatment for osteoporosis. The length of time you are on hormone replacement therapy depends on when you started the menopause and how severe your symptoms are. If you use HRT and your health is well regulated, there shouldn’t be a problem with long-term use.
Will symptoms return if you stop?
It is possible that your symptoms return after coming off hormone replacement therapy. Because of this, it is advised to come off it gradually. Your body may have become dependent on the additional supply of hormones provided by the treatment, and if you stop taking them suddenly you may go into an ‘overnight menopause.’ There is no ‘right time’ to come off it though many doctors prefer not to prescribe hormone replacement therapy after 5 years of usage. While your risk of heart disease and cancer does not increase the longer you take hormone replacement therapy, it does increase with age; therefore, many doctors do not like to prescribe treatments for too long into one’s life. Of course, the length will vary depending on at what age you start treatment.