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.
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
- 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
- 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