We constantly talk about Hormone Replacement Therapy (HRT) and for good reason…
…it can be an extremely effective treatment. The problem is there are many confusing myths and a lot of misinformation out there. Sometimes, it’s best to take a second, take a step back, and go back to 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?
HRT is a treatment you can take to manage your menopausal symptoms. There are two main hormone types of HRT: estrogen-only and combined HRT (which is a combination of estrogen and progesterone). Combination HRT is the most common form of HRT, since taking estrogen on its own is associated with a higher risk of developing endometrial (womb) cancer. Nonetheless, estrogen-only HRT is usually recommended for surgically induced menopause (a hysterectomy, for example).
- How do you take HRT?
There are FOUR ways to take HRT:
- Tablets. Both types of HRT are available in tablet form, which involves taking one small tablet a day. This, for many women, is most convenient, though it is associated with a slightly higher risk of blood clots.
- Skin patches. Likewise, both types of HRT are available as a skin patch, which are placed on the skin and replaced every few days.
- Gels. While it’s not the most common, the gel form is increasing in popularity and is applied daily 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).
- Estrogen implants. Implants exists and they consist of a small pellet-sized implant put under the skin which releases estrogen, though it’s not very common or widely available. It only needs to be replaced every few months (as opposed to taking a tablet every day or replacing a patch every few days), but like the gel, only contains estrogen so progestogen needs to be taken separately.
- Vaginal estrogen. Finally, you can insert estrogen directly into the vagina in the form of a pessary, cream, or ring, which 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 schedule of HRT look like?
HRT regiments differ depending on what stage you are in your menopausal transition (perimenopause, menopause, postmenopause). There are two treatment schedules for HRT: cyclical (or sequential) and continuous. Cyclical is typically recommended for perimenopausal women taking combined HRT. There are two types of cyclical HRT:
- 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 HRT is recommended for post-menopausal and menopausal women. As per its name, continuous HRT is taken continuously, taking estrogen and progestogen every day without a break (or estrogen-only HRT every day without break).
- What is bioidentical HRT 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 HRT?
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 HRT 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 HRT?
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 estrogen and progesterone in the body. It makes sense that replacing those hormones would treat the symptoms!
- What are the risks of HRT?
The risks of HRT are not as large as some would assert. Nonetheless, as with any other medical treatment, there are some risks. According to the NICE Guidelines, risks include blood clots (with oral HRT), strokes (with oral HRT, but this is VERY rare) and cardiovascular disease (only for women taking HRT above the age of 60. Even then, HRT 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 HRT 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 (HRT) 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: HRT causes weight gain, HRT delays the menopause, and natural, alternative treatments to HRT are safer. For a full list, see Dr Newson’s article on 8 Myths About HRT.
- For how long should you take HRT?
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 HRT (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 HRT 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.
- How do you stop HRT? Will symptoms return?
It is possible that your symptoms return after coming off HRT. Because of this, it is advised to come off HRT gradually. Your body may have become dependent on the additional supply of hormones provided by the HRT, and if you stop taking them suddenly you may go into an ‘overnight menopause.’ There is no ‘right time’ to come off HRT, though many doctors prefer not to prescribe HRT after 5 years of usage. While your risk of heart disease and cancer does not increase the longer you take HRT, it does increase with age; therefore, many doctors do not like to prescribe HRT for too long into one’s life. Of course, the length will vary depending on at what age you start taking HRT.