Menopause simplified – is HRT a good option for me?
Written by Dr Camilla Janssen - updated March 2023
The menopause is a natural part of ageing that usually occurs between 45 and 55 years of age, as a woman's oestrogen levels decline. In the UK, the average age for a woman to reach the menopause is 51. The perimenopausal stage normally lasts for a few years leading up to this.
You are thought to be “post-menopausal” when you have had a year since your last period. (But you are only able to know this if you are not on any hormones or contraception that may affect your periods).
Symptoms may include some or all of the below and can be intermittent initially
We typically diagnose menopause from symptoms alone and don't need to do blood tests.
When should you start on HRT?
It is beneficial to start HRT when menopausal symptoms impact on your home, work, social or sex life and you deem that the benefits of HRT will outweigh the risks. The symptoms may start a few years before your periods actually stop, so it may be beneficial to start HRT at this time. You don't have to wait until your periods have stopped to start HRT.
If you have had a Surgical Menopause - i.e. your ovaries have been removed surgically, then you should replace the hormones that your body is no longer producing until the time a natural menopause would occur at the earliest -i.e. 51yrs. There are no increased risks related to HRT as you are replacing the hormones that your body would otherwise produce.
Primary Ovarian Insufficiency (POI) also known as Premature Menopause, affects up to 1 in 100 women and this is when your periods stop before the age of 40. It means your ovaries are not working well and the lack of hormones cause many associated troublesome symptoms and health conditions if left untreated. It is important to replace the hormones that your body is no longer producing until the age of natural menopause at the earliest i.e. 51yrs old. There are no increased risks related to HRT before age of natural menopause, as you are replacing the hormones that your body would otherwise produce. Daisy Network is dedicated to providing information and support to women diagnosed with Premature Ovarian Insufficiency.
This advice has fluctuated over the years and has caused considerable confusion. More recently published findings show that although not entirely risk free, it remains that HRT is the most effective solution for the relief of menopausal symptoms, and it also works to prevent future diseases that can be triggered or exacerbated by low hormone levels. Link to Women's Health Concerns Fact Sheet on the Risks and Benefits of HRT.
Other personal characteristics can play a bigger part than HRT in increasing the risk for many conditions such as Breast Cancer, Stroke and Venous Thromboembolic events such as a Deep Vein Thrombosis or Pulmonary Embolus. These include Obesity, Smoking and Alcohol. It is important to manage these risks independently. Click on this infographic to see the comparison of lifestyle risk factors versus Hormone Replacement Therapy (HRT) treatment and the risk of Breast Cancer
Many lifestyle factors can improve the symptoms of the menopause. A lower carbohydrate diet is a good way to stabilise blood sugars and help with menopausal symptoms as well as addressing obesity and hence other risk factors. Sleep, physical exercise, mental wellbeing, with a healthy out look on life, have a huge impact on how we feel. We suggest looking at our lower carbohydrate pages link here as well as all the health and wellbeing resources embedded in this website. It is worth optimising how you are running your body before adding medications.
HRT - what should I take?
Do you still have a uterus? - Do you have a history of Endometriosis? Do you still have a cervix?
If the answer is “NO” to all the above, then you will need Oestrogen only HRT.
If the answer is “YES” to one of the above, then you will need to have a combined HRT containing both Oestrogen and Progesterone.
The oestrogen is the active component of HRT that will help your menopausal symptoms, BUT if you take oestrogen alone, this may cause thickening of your uterus lining. If the oestrogen is used on its own without progesterone, this could increase your chance of endometrial cancer. Progesterone stops the lining of the womb thickening and hence prevents the chances of endometrial cancer. Hence it is very important if you still have a uterus or a cervix, or if you have a history of endometriosis, that you take both Oestrogen and Progesterone.
Cyclical or Continuous Regime?
Depending on your age and when your last period was, you will be advised to either take these hormones cyclically, ie continual oestrogen through the month and adding in the progesterone for 2 weeks out of every 4 weeks of the cycle. A monthly bleed is normal in these circumstances. If you are on cyclical patches, you will have 2 different types of patches in the packet. It is important to put them on in the correct order for this reason.
If you are older or have not had periods for a long time, then you may be advised to take a continuous regime of oestrogen and progesterone, at the same dose daily which doesn’t vary over the month. You should not have any bleeding with this combination, and you should speak to your doctor if you get bleeding 3-6 months after starting a new combination.
Pills or transdermal application (ie Patches, Gel, or spray)?
There are slightly higher risks associated with blood clots if you take your HRT in a pill form.
If you opt for a transdermal method, there is no increased blood clot risk, and it is your choice as to which of these methods is most acceptable. Patches you only have to change twice a week. You can swim and shower with these on. But - dosing is less flexible and some people get an allergy to the glue or find they don’t stick well, particularly if they are “hot” people.
Gels you need to rub on daily, rub onto both inner mid thighs or outer arm and shoulder. Leave for 5 mins to dry before covering with clothes. If you shower or swim within a few hrs of application this may dilute the dose.
Sprays are another good daily option, and dry more quickly than gels. Many GP practices are not allowed to prescribe these at present due to cost implications.
Common Side effects of HRT - These are common in the first 3 months of starting HRT and tend to improve with time.
Bleeding on HRT - Common in first 3 – 6 months of any new HRT regime. It typically does not indicate anything abnormal and usually settles with time. If it persists for more than 3-6 months, then please discuss with a doctor. We can tweak your hormone combination to improve things and we may need to investigate to ensure nothing else is causing the bleeding at this point. For more info click here.
Body Identical vs Bioidentical - Body identical HRT are medicines that have been subjected to safety testing and quality control and are regulated by the Medicines Regulatory Agency. This is the HRT we prescribe in the NHS. It comes as a transdermal preparation (i.e. one that you take via the skin) either as a gel that you rub on daily or as a patch that you change twice a week. Uterogestan is the body identical progesterone. Bioidentical HRT products are unregulated and is a term used for products which are marketed as being "natural" or "individualised" or "customised" for women. These products are unregulated by the Medicines Regulatory Agency and are unlicensed. They have not been subject to the same safety testing or quality control as the regulated HRT products in body identical HRT. The use of bioidentical compounded hormones is not recommended by the British Menopause Society.
Natural Alternatives to HRT - beware, natural doesn't mean safe - arsenic is natural. This Menopause Matters website has wealth of information on menopause, including information on natural alternatives to HRT. Most GPs are not trained in this area and are not able to prescribe these, so you may have to do your own research on these products.
How long should you continue with HRT? - People's menopausal symptoms vary greatly from none at all to lifelong debilitating symptoms. Menopausal symptoms tend to naturally improve with time however the minority will get lifelong flushing and debilitating symptoms. Symptoms are often worse during the perimenopausal years and tend to subside as your body gets used to lower oestrogen levels. As you get older you may need a lower dose of HRT or it may be appropriate to stop all together. HRT should be continued for as long as the benefits of symptom control and improved quality of life outweigh the risks. This balance is directly related to your own personal health and should be assessed on and individual level, typically on an annual basis or if you have a change in your health. The ongoing benefits from HRT with respect to heart disease, bones and brain etc will only continue while you continue to take HRT.
Stopping HRT - You may want to stop HRT and see how your body responds. You can either stop abruptly (expect some initial symptoms) or gradually reduce over time. There are no long-term differences in the outcome between stopping abruptly versus gradually decreasing your dose. If you do stop abruptly, it is normal to have some initial symptoms due to the relative lack of oestrogen, but this should settle over time – over a few weeks to a couple of months, so please do expect this.
Please ensure that you participate in regular breast and cervical screening programmes.
Once started on HRT, we would suggest a follow up with your GP in 3 months’ time with an up-to-date blood pressure reading. Once things are stabilised, an annual review, including and up to date blood pressure, is perfectly appropriate.
If you get new bleeding once established on HRT for more than 6 months, please discuss this with your doctor, as this usually needs investigating.
USEFUL WEBSITES and RESOURCES
Health and Wellbeing - Hampshire and Isle of Wight menopause page. A good source of reliable information on many aspects of health and wellbeing including menopause. You can access one on one support from a menopause advisor, join a virtual menopause support group as well as have access to a variety of exercise videos and live classes.
The British Menopause Society (BMS) is also a good source of reliable information. BMS tools for clinicians has a useful range of resources that summarise the NICE Guideline, provide guidance on HRT prescribing and other treatment options, and to clarify some of the most common myths and misconceptions of menopause.
Newson Health is a private Menopause and Wellbeing Centre. There is a wealth of information on its website including a comprehensive resources page which features fact sheets, booklets and podcasts on many different areas of menopause.
Menopause Matters website has wealth of information on menopause, including information on natural alternatives to HRT.
Primary Care Women's Health Forum has a wealth of information including patient information leaflets as per link.
Balance app allows you to track your symptoms, access personalised expert
content, download a Health Report©, share stories in the community and lots more.