Types of Hormone Replacement Therapy (HRT)
Hormone Replacement Therapy (HRT) is not a “one size fits all” treatments – the type and dosage given will vary according to your needs. There are many different combinations available, which can be taken in various ways – oral tablets, skin patches (like plasters), gels or sprays. The optimal type of HRT is body identical HRT – the hormones are the same as the hormones you naturally produce in your body.
There are so many different types of HRT available. This means that the dose and type of HRT can be altered to suit your individual health needs and risk factors for other conditions, for example if you have had a clot in the past or have high blood pressure. Many women want to take ‘natural’ products for their menopause, but how do you define ‘natural’? There are many medicines available that derive from plants, so therefore they are ‘natural’, but these are often unsafe and have been shown to be harmful to your bodies. For example, although black cohosh has been shown to have some benefit in the treatment of hot flushes, some types of black cohosh have been shown to be associated with liver toxicity.
Oestrogen
Levels of oestrogen in your body reduce during the perimenopause and menopause and once you have gone through the menopause, your levels of oestrogen will remain low forever, if you do not take HRT.
The optimal oestrogen in HRT is a type of oestrogen called ‘17 beta oestradiol’. This is a body identical estrogen and has the same molecular structure as the estrogen which decreases in your body during the menopause. It is safer to have the oestrogen as a patch, gel or spray as this is absorbed directly through your skin and has less side effects and risks. These types of oestrogen can be safely given to women with migraines and those with a higher risk of clot, as there is no increased risk of clot using these types of oestrogen. It is also natural because it is derived from a plant chemical that is extracted from yam plants. Some types of older HRT contain a mixture of different types of oestrogens and are made from pregnant mares’ urine. This type of HRT could be described as ‘natural’, but it is not body identical as it contains many types of oestrogens that you do not need in your body. This type of HRT is rarely prescribed by doctors these days.
Progesterone treatments
There are many different types of progestogens (synthetic progesterone) available for women. If you still have a womb (uterus), it is important that a progestogen is prescribed alongside the oestrogen for your HRT. When you take oestrogen, the lining of your womb can build up, which can increase your risk of cancer. However, taking progestogen or progesterone prevents this build-up, which means there is no increased risk of cancer when you take HRT.
The optimal type of progestogen is called ‘micronised’ progesterone (Utrogestan in the UK). This is a “body identical” progesterone as it has the same molecular structure as the progesterone in your body. This means it is usually associated with fewer side effects than other types of progestogens.
Side effects of progestogens can include bloating, spots and mood swings. Micronised progesterone is also made from the yam plant. The additional advantage of micronised progesterone is there is no increased risk of breast cancer for the first five years of taking it. After this time, the risks of breast cancer are very low and are lower than the risk for a woman taking the older types of progestogen.
Testosterone
The other hormone that many women find beneficial to replace is testosterone which is actually produced by your ovaries in greater quantities than oestrogen, before the menopause. Testosterone can improve mood, energy, stamina, motivation and also libido. It is usually given as a gel or cream and this is also body identical.
So in summary, the safest types of HRT are the oestrogen applied through the skin as a patch, gel or spray with body identical micronised progesterone. Many women also benefit from testosterone, which may help if you’re forgetful or having trouble concentrating at work.
Working out the right dose and type of HRT necessitates a very individualised approach. Women often find that it is only when they are given the right balance of hormones for them, that their symptoms really start to improve. It is useful to remember that as well as improving symptoms, HRT lowers your future risk of developing diseases such as osteoporosis, heart disease, type II diabetes and dementia.
When you start taking HRT, you should notice that your symptoms begin to improve within one to three months. If you don’t start to feel better after three months, or your symptoms return, this is usually a sign that you need to adjust your dosage, or even try a different type of HRT.
Preparing for your appointment
If your local surgery offers double appointments it’s a good idea to book one of these so that you’ll have enough time discuss your symptoms and concerns. Before your appointment, take a look at the symptoms list to record the menopausal symptoms that you’re experiencing.
Make a note of any changes to your periods, and bring a list of any medications that you’re taking, including herbal supplements. It’s also wise to jot down any questions or concerns, so that you don’t forget to mention them during your appointment. If you’re feeling anxious, you can bring along a friend or family member for moral support.
Your first appointment
According to the 2015 NICE menopause guidelines, your doctor should discuss the following:
- the stages of menopause
- common symptoms of the menopause
- how the menopause is diagnosed
- lifestyle changes that can help your health and wellbeing
- benefits and risks of treatment
- how the menopause can affect your future health
Your doctor may want to carry out blood tests to check your hormone levels, but this isn’t usually necessary as these can vary by the hour. Most women can start HRT without needing any investigations or blood tests.
Sometimes your doctor may want to carry out blood tests to rule out other underlying issues, such as an underactive thyroid, and they will also check your blood pressure.
If you would like to take HRT and you feel you would benefit from taking it then you should ask at your first appointment for a prescription of HRT. The majority of women benefit from taking HRT and women can start taking HRT during their perimenopause. No women is usually too old to start taking HRT, even if it is many years since your menopause then you should still be able to take HRT.
Try to leave the room with as many questions answered as possible, ask if your doctor has any leaflets or information they can share with you, and check if you need a follow-up appointment. NICE guidelines recommend a review three months after your first appointment, but you should ask for an earlier review if you are experiencing side effects or the treatment doesn’t seem to be working.
A second opinion
Unfortunately, some doctors and healthcare professionals still believe outdated reports that HRT is linked to cancer, blood clots and heart problems, so they may be reluctant to prescribe HRT. If there’s no medical reason why HRT is unsuitable for you, then it’s important to speak up and, if necessary, ask for a second opinion.
You could ask to speak to another healthcare professional at your surgery, or ask to be referred to a specialist. Alternatively, you could refer yourself to a private menopause clinic. In the UK, the British Menopause Society has a register of recognised menopause specialists at thebms.org.uk. If you live outside the UK, you can contact the International Menopause Society.
What happens if my doctor / nurse won’t give me HRT?
- Informing your doctor about what you are wanting to discuss prior to the appointment or at the start of your consultation will help to ensure you get the most out of your consultation.
- Know your rights as a patient. Doctors will be more likely to consider your views if you can show you are fully informed and understand what any risks are and explain clearly why you still wish to have that treatment option because of the benefits to your life and health you believe it would bring.
- Be persistent but polite. If you do not get the desired outcome at the first appointment, try again another time. You can ask to see another doctor within your practice.
In general, your best approach when talking to your doctor about your menopause is to clearly state your reasons for what you would like, explain what information has led you to this decision, and that you know what the associated risks might be but that it is still what you choose to do. This information may need repeating on several occasions, to several doctors or nurses, but persistence often pays off when you can give a clear and rational argument that shows careful consideration of the evidence of the benefits to your health.