HRT/MHT options explained
Fluctuating and declining sex hormone levels as we approach menopause can cause a number of symptoms including hot flushes, night sweats, sleep difficulties, joint aches, mood changes, vaginal dryness and many more.
Hormone replacement therapy (HRT) or menopause hormone therapy (MHT), as it is also known as, is regarded as the most effective medical treatment.
There is some terminology to get your head around:
- Systemic HRT/MHT – this is HRT/MHT that is delivered orally or transdermally, which is via the skin. Systemic HRT/MHT comes in:
- Tablets and capsules
- Patches
- Gels
- Spray
- Creams (testosterone only)
- Mirena intrauterine coil which provides a progestin to the womb lining
- Implants – although these are less commonly used these days.
- Topical – this is usually oestrogen or DHEA that is applied locally in or around the vagina. Topical HRT affects the areas where it is used and has very little absorption into or effects on the rest of the body. (See the Fact sheet 4 on the Genitourinary Syndrome of Menopause).
It comes as a:
- Cream
- Pessary
- Gels
- Slow-release silicon ring.
Here we are talking about systemic HRT/MHT.
The two hormones commonly prescribed in HRT are oestrogen and progesterone or a progestin which is a synthetic version of progesterone. The newer forms of transdermal oestrogen and progesterone available on the NHS are made from wild yams or soy and in the UK are known as body-identical which means they are very similar to those that the body naturally produces. Every individual’s needs and sensitivities to hormones are unique and your healthcare professional will assist you in making a choice of the right type and dose for you.
If you have had your womb and cervix removed you may only be given oestrogen only HRT/MHT (unless you have had endometriosis). If you still have a womb you will need progesterone/a progestin as well as it protects the endometrium or lining of the womb from becoming too thick and increasing your risk of endometrial cancer. Taking both is known as ‘combined HRT’.
There are multiple HRT products with varying strengths which means there are a many different combinations that can be tried when trying to find which one suits you best.
Transdermal HRT does not increase the risk of blood clots or stroke in healthy women (unlike most oral HRT) and it can be used even if one has migraines with aura. There is a slightly higher risk of breast cancer with use of combined HRT/MHT over five years or more depending on the type of progestin/progesterone you are using. Dydrogesterone and micronised natural progesterone are generally regarded to have the lowest risk. The risk is estimated to be about 5/1000 extra cases over 5 years of use. Oestrogen only HRT causes no/minimal increase in risk of breast cancer.
The next thing to consider is ‘cyclic’ or ‘sequential’ versus ‘continuous’ HRT/MHT.
Cyclical HRT/MHT means taking the progesterone component for around 10-14 days a month. This will mimic a natural cycle and give you a bleed each month.
Continuous, as the name suggests, involves taking a progesterone component every day so there is no ‘period’.
Many women in perimenopause opt for cyclical HRT and then swap to continuous HRT when they reach the age of the average menopause, around 51.
Another option is Tibolone which is not a hormone per se but binds to oestrogen, progesterone and testosterone receptors in the body and acts like a continuous combined HRT. It is available in a tablet form that’s taken daily. It may have some advantages for people with endometriosis and fibroids, and it also has androgenic (i.e. testosterone) effects so may help with low libido.
When starting HRT/MHT there can be initial side effects such as bloating, breast pain, mood changes (low mood/anxiety), nausea, fluid retention and bleeding. These may take a few months to settle. If they do not, see your doctor and discuss changing the type or dose you are using. It can sometimes be a case of trying multiple preparations to find which suits you best.
*In some countries body identical is called bio-identical. In the UK bio-identical often refers to products that are compounded for you by a pharmacy as opposed to those that are available on the NHS. The products that are supplied on the NHS are regulated for safety and efficacy. Compounded products do not have the same rigorous long-term safety and efficacy data as regulated HRT.
Reviewed: September 2024