What is hormone replacement therapy (HRT)?
Perimenopause and menopause symptoms are wide-ranging, including hot flushes, night sweats, low mood, vaginal dryness, and reduced interest in sex. These symptoms are due to fluctuations in or a lack of oestrogen. HRT, in the form of oestrogen, is the most effective treatment for these symptoms.
HRT comes in many different forms in terms of type, strength, and how it enters the body. Over 50 different combinations are available. The most suitable HRT for each individual woman will depend on many factors, including her stage of perimenopause or menopause, whether she has a uterus, her medical history, and individual preference.
What hormones are replaced?
Oestrogen
Oestradiol, derived from yams, is most commonly used. Its molecular structure is identical to the oestrogen produced by the body and is referred to as ‘body identical’.
Oestradiol can be taken orally as a tablet or through the skin (transdermally) in the form of a patch, gel, or spray. Additionally, local (topical) oestrogen in a vaginal tablet, cream, or vaginal ring can be used to treat vaginal dryness and urinary symptoms.
Progesterone
Progestogens are synthetic forms of progesterone. A progestogen is needed in combination with oestrogen for women who still have a uterus because taking oestrogen alone can stimulate the lining of the uterus (endometrium) to grow and thicken, increasing the risk of uterine cancer.
Taking a progestogen counteracts the effects of oestrogen and protects the endometrium. Several progestogens are available, with micronised progesterone (brand name Utrogestan) being the safest. Micronised progesterone comes in capsule form, taken orally or sometimes inserted into the vagina. It is also ‘body identical’.
Another safe way to replace progesterone is by using the Mirena Intrauterine System-IUS (Mirena coil), which is inserted into the uterus. This releases small amounts of the progestogen levonorgestrel over five years and also provides effective contraception.
Testosterone
Some women continue to experience symptoms of fatigue, lack of sex drive, and difficulty concentrating despite taking oestrogen. For women whose symptoms persist after taking oestrogen for a few months, the addition of testosterone may be helpful.
What type of HRT will be prescribed?
The type of HRT will be tailored to the individual woman and will depend on her stage of menopause and whether or not she has had a hysterectomy. Here is a summary of the main forms:
Oestrogen alone
Oestrogen-alone HRT is suitable for women who have had a total hysterectomy, where the entire uterus, including the cervix (neck of the uterus) is removed.
Oestrogen and progesterone (combined HRT)
For women who still have a uterus, progesterone is prescribed in addition to oestrogen to protect the lining of the uterus (endometrium). This is known as ‘combined HRT’. Combined HRT may also be used in women who have had a partial hysterectomy where the cervix remains, as some of the uterine lining may still be present. Combined HRT is recommended for women who have undergone an endometrial ablation (an operation to treat heavy periods by removing the uterine lining) or for some women with endometriosis who have had a hysterectomy.
Sequential (cyclical) and continuous combined HRT
Oestrogen is the mainstay of HRT. The way in which progestogen is combined with oestrogen depends on the stage of perimenopause or menopause.
- Sequential (cyclical) HRT: For perimenopausal women who are still having periods, or have had a period within the last 12 months, sequential or cyclical HRT is used. Progesterone is added for 14 days a month, which will usually be followed by a bleed, similar to a normal cycle.
- Continuous combined HRT: For women whose last period was over 12 months ago, continuous combined HRT is used. Progestogen is taken every day with oestrogen, and no bleeding occurs.
By understanding the different types of HRT and their benefits, women can make informed decisions about managing their menopause symptoms and improving their overall health and quality of life.
