What type of HRT can I have?
If you have had your uterus (womb) removed you only need oestrogen HRT.
If you still have your uterus you need both oestrogen and a progestogen (combined HRT) to stop the lining of the uterus building up and in rare cases developing endometrial cancer. This is divided into continuous combined or sequential combined HRT. Which one you start with will depend on when your last period was.
Some women may also benefit from the addition of testosterone.
HRT can be delivered by patches, gels, spray or tablets and we can discuss the most suitable option for you. We prefer to prescribe oestrogen through the skin as this doesn’t increase the risk of blood clots and is safer in women with other medical issues.
What are the side-effects and risks of HRT?
There are so many myths about HRT that are still being perpetuated and many doctors are still very cautious about prescribing it despite the proven benefits. Typical misconceptions are that it makes you put on weight, that you can’t have it if you get migraine or blood clots or have a family history of breast cancer, that it just delays your menopause and that you should only be on it it for the shortest possible time.
The biggest worry for most women is the risk of breast cancer but this does not apply to all types of HRT and for the types it does apply to the risk is much smaller than we had been led to believe. The Women’s Health Concern website has excellent information on this, including an infographic looking at the lifestyle risk factors for breast cancer.
There is a small increased risk of blood clots and ischaemic strokes with the tablet forms of oestrogen but not with the patch and gel forms of HRT.
What are the long term benefits of HRT?
If you start HRT before the age of 60 or within 10 years (but ideally sooner) of your last period, you have a significantly reduced risk of developing heart disease in the future. Long-term HRT can also protect against osteoporosis. Women on continuous combined HRT have a lower risk of endometrial cancer than those on no HRT at all.
What about testosterone?
Many people don’t realise that testosterone is a really important hormone for women as well as men. We produce it both in our ovaries and via our adrenal glands and production naturally declines with age. Our levels reduce more dramatically if our ovaries are removed or stop functioning at a young age. Testosterone may be indicated to help libido but in some women it can also improve sleep, motivation, mood, cognition, concentration, muscle strength and energy levels. You would normally have a trial of an adequate dose of oestrogen (with progestogen if you still have a uterus) for at least 6 months before considering whether testosterone is also needed to help with your symptoms. Younger women with a surgical menopause are most likely to need testosterone supplementation.
Does HRT also act as contraception?
No. If contraception is still needed, the Mirena (IUS) is a good option. This can act as the progestogen part of HRT, contraception and reduce heavy bleeding so many doctors recommend it. Other women may decide to take the progestogen only pill as well as their HRT.
How can I improve my vaginal symptoms?
As we lose oestrogen we all develop thinning of the tissues of the vagina, vulva and bladder. This is not something that settles after the menopause but steadily gets worse without treatment, often leading to vaginal burning and itching, painful sex, urinary frequency and recurrent urinary tract infections. Some women find that having a smear becomes more uncomfortable as they get older because of this. All these symptoms can be helped by the regular, long term use of vaginal oestrogen which is very safe and effective. It does not increase the risk of breast cancer and those still with their uterus do not need to have a progestogen as well. Only women on an aromatase inhibitor are not able to have local oestrogen.
Most women on HRT find their vaginal symptoms are greatly improved but about 20% find they need to add in long term vaginal oestrogen.