Hormone Replacement Therapy & Menopause Symptoms: Types, Side Effects & Deciding If HRT Is for Me

The menopause process is inextricably linked to two key female sex hormones, oestrogen and progesterone.

During the menopause, which usually starts around age 50 for most women, levels of oestrogen and progesterone decline. This imbalance can cause a multitude of uncomfortable, sometimes even debilitating symptoms: hot flushes, fatigue, irregular periods, vaginal dryness, weight gain, mood changes and decreased bone density (osteoporosis).

As the name suggests, hormone replacement therapy (HRT) is a treatment that involves replacing the important female sex hormones that deplete during the menopause process. In doing so, HRT promotes hormonal balance and can alleviate many menopause symptoms.

Let’s explore the different types and methods of HRT.

What are the different types and ways of taking hormones for menopause symptoms?

Different types of hormones used in HRT

HRT is a treatment that replaces oestrogen and progesterone, the two main hormones that we stop producing during the menopause. There are different types of these hormones used in HRT:

• Oestrogen: Treatment can include different forms of oestrogen, usually bioidentical oestrogens (such as estradiol and estriol). Bioidentical refers to a hormone derived from plant oestrogens that is chemically identical to the one our body produces.
• Progesterone: Treatment involves either a bioidentical progesterone (a hormone that is identical to human progesterone) or a synthetic progesterone, also known as progestin (this can include medroxyprogesterone, dydrogesterone, and norgestrel).

What’s the difference between progesterone, progestogen and progestin?

The terms progesterone, progestogen and progestin sometimes cause confusion.

Although they can be seen as interchangeable for the purposes of general discussion, progestin is a synthetic version of the natural female sex hormone, progesterone, and mimics its effects. Progestin is used as part of HRT.

Progestogen is a term that can be used to cover both progestin and progesterone; it means anything that can bind to and activate the progesterone receptor in the body, whether a synthetic or natural hormone.

Combined or oestrogen-only HRT?

Oestrogen and progestogen are usually taken together, a treatment known as combined HRT. Taking oestrogen alone can increase your risk of womb (uterus) cancer; progestogen counteracts oestrogen’s negative effect on the womb.

Some women — usually those who have had their womb removed (a hysterectomy) — are recommended oestrogen-only HRT, since there’s no risk of womb cancer.

Different ways of taking hormones as part of HRT

HRT can be systemic, meaning it travels through the entire body. This includes tablets, patches, gels and implants. Alternatively, HRT can be local. This is for people with vaginal discomfort, taking the form of a cream, ring or pessary.

There are a number of methods of HRT. You may find one way of taking HRT more convenient than another, or one method may be recommended for you based on health factors. A discussion with your doctor will help you to decide which one is best for you.

• Tablets: A once-a-day oral tablet is the most common way of taking HRT, with tablets available for combined and oestrogen-only therapies. Many women find this to be a simple, fairly hassle-free method of taking HRT. There is understood to be a marginally higher risk of blood clots and breast cancer with tablets than other types of HRT. Oral oestrogen has the potential to be taxing on the liver, so those with a damaged liver may want to explore an alternative.
• Skin patches: Another popular way of taking combined or oestrogen-only HRT is a patch that you stick onto a clean, dry, hair-free area of your lower body — such as the buttock or lower stomach. This is usually replaced after several days. This method can be more popular for women who are concerned about the increased risks associated with tablets, or those who may tend to forget to take a daily tablet.
• Oestrogen gels: Increasingly popular are gels that can be applied to a clean, dry part of the body once a day — such as the shoulder, arms or inner thigh. Again, this type of HRT is popular amongst women concerned about the small risks associated with tablets, or find a daily tablet inconvenient. If you still have your uterus intact, you’ll need to also take progestogen to reduce the risk of womb cancer.
• Implants: Although less common and less widely available, HRT is also available as a small, crystalline implant that goes under your skin in the stomach area. This method provides your body with several months’ slow release of oestrogen before requiring replacement. As with the gels, you’ll need to take progestogen to guard against womb cancer if you still have your uterus.
• Vaginal oestrogen: This method of HRT is available as a ring, pessary or cream that is placed inside the vagina. It is known as local HRT. This type does not prevent common symptoms like hot flushes, but is known to help with vaginal dryness. Unlike gels and implants, even if you have your uterus intact, you don’t have to take progestogen with this method.
• Testosterone: Amongst women whose sex drive isn’t restored by HRT, applying a daily testosterone gel may be a useful libido-booster — this is used alongside your HRT treatment. Side effects can include hair growth and acne.

What are the treatment routines for taking HRT?

Your treatment plan usually depends on how long you’ve been in the menopause.

A continuous combined regime of HRT is not usually recommended for women still having periods or those in the early stages of the menopause.

Cyclical HRT

Also known as sequential HRT, this routine is for women who are in the earlier stages of the menopause and are still having periods. The sub-type of cyclical HRT you’ll have depends on whether your periods are regular or irregular.

• Regular periods: You’ll usually be recommended monthly HRT — you’ll take oestrogen every day, then progestogen alongside the treatment for the last 14 days of the cycle.
• Irregular periods: 3-monthly HRT will likely be most suitable. Like monthly HRT, this involves taking oestrogen daily, but differs in that you’ll be taking progestogen alongside it for 14 days only every three months.

Continuous combined HRT

For women who are postmenopausal, continuous combined HRT is most often recommended. This routine consists of taking oestrogen and progestogen every day with no breaks, or just oestrogen if your treatment plan is oestrogen-only.

How long do you take HRT for?

There’s no limit on the length of time HRT can be taken. Most women take HRT for as long as their menopause symptoms persist — on average, around four years after your last period, but this varies for every woman. It’s possible to stop using HRT ‘cold turkey’, but a gradual reduction is usually recommended to prevent menopause symptoms reappearing in the short term.

What are the side effects of taking oestrogen and progesterone for menopause symptoms?

When taking HRT, you may report side effects — these normally subside around three months after treatment starts. Make sure you’re in contact with your doctor if they persist for longer or are causing you particular pain or trouble.

Side effects of taking oestrogen as part of HRT:

• Indigestion, bloating and nausea
• Bloating, swelling and tenderness
• Leg pain or cramps
• Headaches
• Vaginal bleeding
• Skin irritation

Side effects of taking progesterone as part of HRT:

• Fluid retention
• Tenderness (particularly in the breasts)
• Stomach and back pain
• Depression or mood swings
• Headaches
• Back aches
• Acne on the face, back or chest
• Vaginal bleeding

How to treat side effects from HRT

Usually, side effects from taking oestrogen and progestogen disappear within a few weeks, but can sometimes take as long as three months to subside. In the meantime, there are a number of things you can do to minimise the discomfort they may cause.

• Regular exercise: Ensuring you stay active is not only sound health advice in general, but can help with leg cramping, swelling and pains.
• Take HRT at night (and with food): Taking your HRT later in the day with a meal — as opposed to in the morning — has been reported to diminish several side effects resulting from treatment, particularly indigestion, bloating and sickness.
• A healthy diet: A low-fat, high-fruit diet has been associated with reduced breast tenderness during HRT treatment.
• Stay hydrated: Most menopausal women will be familiar with the course of action for a thumping headache or migraine — a good intake of water, a lie down and some paracetamol usually prove helpful.
• Consider a probiotic: Researchers have suggested that pre- and probiotics can be used in conjunction with HRT in order to attenuate any side effects resulting from treatment. In general, these supplements of friendly live bacteria have been clinically shown to have benefits for menopausal women.

Needless to say, if your HRT side effects subsist, make sure to consult your doctor. You may want to explore alternative ways of taking your HRT, such as moving from a tablet routine to a patch-based treatment.

The Medicines and Healthcare products Regulatory Agency (MHRA) runs a Yellow Card Scheme that allows you to report any symptoms you suspect you’re experiencing as part of your HRT.

What are the benefits of HRT for menopause symptoms?

As almost any menopausal woman will be able to tell you, the process can give rise to many uncomfortable symptoms. By replacing the hormones that decline in production during the menopause, the main benefit of HRT is the effective relief of most of these wide-ranging physical, psychological and emotional symptoms.

Let’s take a clear, science-based look at how HRT can benefit women experiencing menopause symptoms.

Here’s the evidence on the benefits of HRT for menopause symptoms:

• Hot flushes and night sweats: Clinical trials clearly show that HRT is highly successful in minimising these common vasomotor symptoms. In one large study, HRT reduced the frequency of symptoms by 75% and their intensity by 87%, with oestrogen-only and combined oral HRT both very successful in treating hot flushes.
• Osteoporosis: In the first five years of the menopause, women can lose up to 10% of their bone mass. Research shows that HRT helps to protect this bone density, significantly reducing the risk of fractures. When used in conjunction with exercise, HRT has been shown to be particularly effective for minimising frailty and boosting our musculoskeletal health.
• Menopause mood swings: Many women experiencing the menopause find that they begin to struggle more with low mood, depression or anxiety. In a randomised clinical trial, HRT was shown to provide clear improvements to menopause-related depression and depressive symptoms.
• Vaginal atrophy and dryness: Vulvar vaginal atrophy (VVA) and the resulting dryness can be painful, affecting over half of all menopausal women. HRT has been clinically shown to reduce vaginal atrophy in 75% of cases, with a local vaginal oestrogen therapy successful in 80–90% of cases. It restores pH, blood flow and vaginal cells.
• Sleeping disorders: Hormone therapy is one treatment that has been shown to improve chronic insomnia in menopausal women.
• Diabetes: Menopause-age women are at increased risk of weight gain and associated diseases like type 2 diabetes — hormone therapy has been shown to provide a protective effect, with some limited evidence even suggesting that it helps to improve body composition by reducing fat accumulation.
• Decreased libido: Hormones are fundamental to our sex drive and sexual responsiveness; HRT has been shown to provide a 44% improvement to sexual desire in menopausal women, with androgen therapy (like testosterone gel) suitable for women who fail to respond to HRT.
• Skin problems and skin aging: There is a role between oestrogen deficiency and skin health — HRT has been shown to improve skin healing and provide a boost to quality of skin.

What are the risks of HRT for menopause symptoms?

Not including side effects that usually subside within a few weeks, there are a number of risks associated with hormone replacement therapy.

HRT is an individual decision — each woman should consult with their doctor on whether they feel the benefits of therapy in terms of reducing menopause symptoms outweigh potential risks, however uncommon they may be.

The risks can depend on the type of HRT you choose, whether you’re taking a combined or oestrogen-only course, your own health status and the length of your treatment.

Let’s have an evidence-based overview of the risks of HRT for menopause symptoms. What does the latest science tell us?

Blood clots

Women who take oral combined HRT tablets have a slightly increased risk of developing blood clots, although such cases are very rare. In a large observational study of almost half a million women, there were an extra nine cases of blood clots per 10,000 women in those who had taken HRT compared to those who hadn’t.

If you have a history of blood clots, you may want to explore an alternative to tablet-based HRT, such as patches or gel, which have been proven to not increase your risk of blood clots.

Heart disease

A recent overview of emerging research has suggested that HRT may actually be beneficial in the prevention of heart disease if started at a younger postmenopausal age (under 60). In older women, there may be an initial slight increase in heart disease risk, but researchers state that ‘overall lifetime occurrence rates’ are not increased by HRT use.

The main risk factors of cardiovascular disease are smoking, high blood pressure, high cholesterol, lack of exercise, obesity, diabetes, ethnic background and family history.

Breast cancer

Long-term combined HRT has been associated with a slightly increased risk of breast cancer. This risk depends on your age and increases the longer you take the treatment, but there is a ‘pronounced decline in risk’ after treatment stops. Women taking an oestrogen-only or short-term combined course of HRT are at no increased risk of breast cancer.

As part of your HRT routine, you’ll usually be invited to attend breast cancer screening appointments and be assessed regularly by your doctor. In order to minimise risks, you’ll usually be prescribed the lowest effective dose possible.

Ovarian cancer

According to one large study, ‘the link between MHT [menopausal hormone therapy] and ovarian cancer remains unproven’. Other research has hinted at there being a slightly increased risk amongst women taking combined HRT, but once treatment is stopped, the risk level reverts to as if HRT had never been taken.

Womb cancer

Oestrogen-only HRT is known to increase a woman’s risk of womb (endometrial) cancer. This is why a combined course of HRT is recommended for women who still have their womb; progestogen counteracts the adverse effects of oestrogen on the endometrium and can even reduce the risk of womb cancer. Since women who’ve had a hysterectomy do not have a womb, oestrogen-only HRT is suitable.

Hormone replacement therapy and weight gain

Since HRT became available in the UK in 1965, there has been a belief that it can cause you to gain weight. Although aging, lifestyle changes and menopause cravings may cause you to put on weight, many studies have shown that there is no evidence whatsoever that hormone therapy causes weight gain.

Hormone replacement therapy and diabetes

Some people associate HRT with increased risk of diabetes. Research has found no evidence of this link; in fact, HRT has even been associated with a statistically significant increase in insulin sensitivity.

Hormone replacement therapy: a relief for many menopausal women

Many women find HRT to be a significant boost to their quality of life, providing much-welcome relief from the menopause’s many, wide-ranging symptoms. The decision to choose HRT is one for each individual woman. It will depend on the impact of your menopause symptoms on your life and your evaluation of the risks of treatment.

Consult with your doctor when deciding whether HRT is right for you. They will be able to advise on the type and length of treatment to achieve the desired effect based on your symptoms.

Despite tablets being the most common way of taking HRT, a different type may be recommended for you, such as one that’s absorbed through the skin. If your symptoms are only vaginal dryness or pain during intercourse, vaginal HRT only may be suitable. Some women may also want to consider alternative therapies to HRT.

Many find that HRT can work excellently in tandem with a specially-formulated, all-in-one daily supplement for perimenopausal or menopausal women, such as Cleanmarine MenoMin. There’s also encouraging emerging evidence that probiotic bacteria can work in partnership with HRT to help relieve side effects of treatment.

If you’d like to explore other insight-packed articles on the menopause, head over to The Menopause Blog.