To start with, we need to distinguish between different HRT treatments; the 2 most common types of HRT are oestrogen-only and combined (oestrogen plus progestogen). There is also a third type of HRT called Tibolone. It is a synthetic steroid that acts like oestrogen and progesterone.
The 2 main hormones used in HRT are:
- Oestrogen – including estradiol, estrone and estriol
- Progestogen – a synthetic version of the hormone progesterone, for example dydrogesterone, medroxyprogesterone, norethisterone and levonorgestrel.
In consultation with your GP, you will need to find out which types of HRT are the best for you. This may involve some adjustments along the way to find the optimum balance for you personally.
There are many different types of HRT formulations including tablets, skin patches, creams and gels. However, there are very few specific studies on the effects or efficacy of different formulations. Most of the studies are based on HRT treatment via tablets and patches.
Tablets are one of the most common forms of HRT. The usual intake is one tablet per day. Both oestrogen-only and combined HRT tablets are available as tablets. For some women, this is the simplest way of having treatment. It’s important to be aware that some of the risks associated with HRT. Risk of blood clots, are higher with tablets than with other forms of HRT (although the overall risk is still small).
Skin patches are also a common way of taking HRT. You stick them to your skin and replace them every few days. Both oestrogen-only and combined HRT patches are available. Skin patches may be a better option than tablets if you find it inconvenient to take a tablet every day. Using patches can also help avoid some side effects of HRT, such as indigestion. Unlike tablets, they do not increase your risk of blood clots.
Oestrogen gel is an increasingly popular form of HRT. It’s rubbed onto your skin once a day. Like skin patches, the gel can be a convenient way of taking HRT and does not increase your risk of blood clots and other risks associated with tablets. But if you still have your womb, you’ll need to take some form of progestogen separately too, to reduce your risk of womb cancer.
HRT also comes as small pellet-like implants that are inserted under your skin (usually the most chosen place is in the tummy area) after your skin has been numbed with a local anaesthetic. The implant releases oestrogen gradually and lasts for several months before needing to be replaced. This may be a convenient option if you do not want to worry about taking your treatment every day or every few days. Again, if you still have your womb, you’ll need to take progestogen separately too. It has to be said though, that implants of HRT are not widely available and are not used very often.
A more common implant option is the intrauterine system (IUS or coil). An IUS releases a progestogen hormone directly into the womb. It can stay in place for 3 to 5 years and also acts as a contraceptive, and it can be an advantage for peri-menopausal women experiencing symptoms but still having a period.
Oestrogen is also available in other forms such as a cream, pessary or ring that is placed inside your vagina. This can help relieve a very common symptom which is vaginal dryness, but will not help with other symptoms such as hot flushes. It does not carry the usual risks of HRT and does not increase your risk of breast cancer, so you can use it without taking progestogen, even if you still have a womb.
Testosterone is available as a gel that you rub onto your skin. It is usually only recommended for women whose low sex drive (libido) does not improve after using other HRT options. It is used alongside another type of HRT. Current testosterone products available in the UK (such as Tostran and Testogel) are currently unlicensed for the treatment of low sex drive. This means the manufacturers of these products have not specified that they can be used in this way. Despite this, there is evidence that testosterone can be effective. Ask your GP for more information on testosterone products.
HRT treatment routines
Your treatment routine for HRT will depend on whether you’re in the early stages of the menopause or have had menopausal symptoms for some time.
The 2 types of routines are cyclical (or sequential) HRT and continuous combined HRT.
Cyclical HRT is often recommended for women taking combined HRT who have menopausal symptoms but still have their periods. It is also known as sequential HRT.
There are 2 types of cyclical HRT:
- Monthly HRT – you take oestrogen and progestogen alongside it for the last 14 days of your menstrual cycle. Monthly HRT is usually recommended for women having regular periods.
- 3-monthly HRT – you take oestrogen every day, and take progestogen alongside it for around 14 days every 3 months. This protocol is usually recommended for women having irregular periods. You should have a period every 3 months.
It’s useful to maintain regular periods so you know when your periods naturally stop. This shows you when you’re likely to progress to the last stage of the menopause.
Continuous combined HRT
This type of HRT is usually recommended for postmenopausal women. A woman is usually said to be postmenopausal if she has not had a period for 1 year. Continuous combined HRT involves taking oestrogen and progestogen every day without a break. Oestrogen-only HRT is also usually taken every day without a break.