Hormone Replacement Therapy (HRT)
Information and advice for patients
Gynaecology
What is hormone replacement therapy (HRT)?
Hormone replacement therapy (HRT) is a treatment for the symptoms of the menopause.
As women get older their normal cycle of production of the hormones estrogen and
progesterone declines, resulting in menopausal symptoms. HRT works by replacing the main
hormones that the body is no longer producing naturally.
What are the types of HRT?
Estrogen only
Estrogen is the most effective hormone to relieve menopausal symptoms. Women who have
had a hysterectomy only need to take estrogen. Women who have not had their womb
removed (a hysterectomy) are not suitable for estrogen-only HRT because, if used over
a prolonged period of time, it can cause the lining of the womb to change and become
cancerous. These women will also need to take progestogens as part of their HRT to prevent
this.
Sequential (cyclical)
Sequential HRT involves taking both estrogen to relieve menopausal symptoms, and taking
progestogens for 10-12 days each month to reduce the risk of the estrogen causing abnormal
(possibly cancerous) changes to the lining of the womb. It is suitable for women who have
not had a hysterectomy and who are peri-menopausal. Women who are peri-menopausal
are those who are experiencing menopausal symptoms because of the reduced production
of hormones but are still having periods as their ovaries have not yet completely failed.
Sequential HRT will cause a monthly bleed similar to that of your normal cycle.
Continuous combined HRT
This type of HRT involves taking estrogen and progestogen every day. It is recommended for
women who are postmenopausal (have not had a period in the least 12 months) and who still
have their womb.
How HRT is delivered
There are several ways in which HRT can be administered:
Tablets
Tablets containing the hormone(s) can be taken daily. This method is the most common form
of HRT and usually does not cause any problems with other prescribed medications. The
tablets often come in a calendar pack to help you to remember to take them.
Patches
Hormone patches can be applied to the skin anywhere below the waist and the hormone(s)
diffuse through the skin into the fat cells underneath and then into the blood. Patches are
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Hormone Replacement Therapy (HRT)
Information and advice for patients
Gynaecology
available in different sizes and can contain estrogen only or both estrogen and progestogen.
It is the glue of the patch that contains the hormone(s).
Some patches need to be changed twice weekly while others can be left on for a full week.
They usually stick well and stay put when bathing, showering or swimming but will not stick
well if body lotions or treatments are used shortly before applying the patch.
Gels (Estrogen only)
Estrogen contained in a gel can be applied to the inner thigh, backs of the arms or shoulders.
The estrogen diffuses through the skin into the fat cells underneath and then into the blood.
The gel comes in a dispensing system that delivers a measured dose of the estrogen. The gel
can be applied to the skin daily and doesn’t leave any trace of having been administered. If
you still have your womb you will also need to take separate progestogens.
Mirena
The Mirena is an intrauterine system (‘coil’ placed inside the womb) that delivers
progestogen into the womb. It can be used as the progestogen component of HRT for 4
years, so women will need to take estrogen in addition to this. The Mirena can minimise the
unwanted effects of the PMS-type symptoms of the menopause. It is also a contraceptive and
can reduce blood loss from heavy periods, sometimes stopping periods altogether. Fore more
information on Mirena please see the leaflet ‘Mirena’.
Hormone Implants
Hormone implants are small pellets which are inserted into the fat under the skin (usually
the tummy) where they slowly become absorbed releasing the hormones slowly over 4 – 6
months. They are suitable for women who need higher doses of HRT to give adequate relief
from symptoms. For more information please see the ‘Hormone implants’ leaflet.
Vaginal Estrogens
Vaginal estrogens are delivered in small tablets, creams or pessaries and give very small
doses of estrogen to the surface of the vagina. They are used to provide vaginal lubrication,
treat vaginal dryness and can be used along side other HRT treatments or on their own. The
hormone does not transfer into the rest of the body in sufficient quantity to relieve any
other symptoms.
Nasal spray (Estrogen only)
This form of HRT is not currently available but has previously been used and is likely to be
available again in the near future. It delivers the estrogen in a fine spray which is applied
into your nose daily. The estrogen is quickly transferred into your blood from there. If you
still have your womb you will also need to take separate progestogens.
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Hormone Replacement Therapy (HRT)
Information and advice for patients
Gynaecology
What are the benefits of HRT?
The estrogen used in most HRT treatments is the same as that which occurs naturally in the
body and low dosages are usually sufficient to gain symptom control without raising the
hormone levels in the blood above normal. The benefits of hormone replacement therapy
are:
Symptom relief
The main benefit of HRT is that it provides relief from menopausal symptoms which can be
disruptive to your quality of life and can last for a few years. These symptoms include hot
flushes, night sweats, tiredness and skin and vaginal dryness.
Prevention of disease
• HRT can delay the onset of cardiovascular disease, osteoporosis and dementia in young
women who have an early menopause. It is therefore recommended that women under
50 years of age who have had a spontaneous or surgical menopause should use HRT.
• If you are under 60 years of age and are at risk of developing or have osteoporosis then
HRT can be used both to prevent and treat osteoporosis.
• Starting HRT in the early years of the post menopause can reduce your risk and delay the
onset of cardiovascular disease and alzheimers. However taking HRT when you have these
conditions will not help and may be detrimental.
• HRT can also reduction your risk of developing diabetes and colon cancer.
What are the risks of HRT?
Blood clots
Starting HRT when the levels of your hormones are low can result in an increased risk of
developing blood clots. This risk is mostly seen in the first 12 months after starting HRT. If you
are overweight, smoke, have had a previous clot or do not exercise your risk of developing a
blood clot is increased. You would therefore be advised to have HRT in the form of patches,
as this gives a lower risk of developing blood clots than other forms.
Breast cancer
There is a very small increase in the risk of developing breast cancer if you take HRT. Estrogen
only HRT account for an extra 2 cases of breast cancer in 1000 women when it is used for
5 years. Estrogen and progestogen HRT account for 6 extra cases of breast cancer in 1000
women when it is used for 5 years. Women over 50 yrs should consider using HRT for at least
3-4 years and then gradually withdrawing. This then gives the benefit without increasing the
risk significantly.
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Hormone Replacement Therapy (HRT)
Information and advice for patients
Gynaecology
There appears to be no increase in the risk of breast cancer when HRT is used for less than
3 years. Most women only need HRT for a few years and the additional risk caused by using
HRT declines rapidly after stopping it. However a background population risk will still remain
and you should still attend for breast screening when requested.
Studies on the use of HRT after the age of 50 suggest there is a small increased risk in breast
cancer with the length of time it is used. Other studies would suggest that this risk is only
associated with some forms of HRT, not all.
Mammogram results
Breast cancers can appear on a mammogram as an area of increased breast density. Some
HRT preparations can increase the breast density seen on mammograms which could cause an
abnormal result from the mammogram which needs further assessment (see ‘Assessment at
the breast unit’ leaflet). 1 in 4 women who use combined HRT (estrogens and progestogens)
show this increase in density. Estrogen on its own does not appear to affect the density.
There is no evidence that women taking HRT find mammograms more painful than those
who do not take HRT.
Gallstones
Using HRT can also lead to an increased risk of gallstones, and/or can bring to light gallstones
that were already there but not causing any symptoms. A gallstone is a hard mass made up
of bile pigment and can cause pain and indigestion.
Ovarian cancer
HRT causes a very small increase in the risk of developing ovarian cancer in women who have
had a hysterectomy and use estrogen-only HRT for more than 10 years.
Heart attack and stroke
HRT causes a small increase in the risk of having a heart attack or stroke in women who use it
over the age of 60. It does not appear to cause this increase in risk in women who start HRT
in the early post-menopausal phase.
What are the side effects of HRT?
Side effects of HRT are short lived and include headaches, breast tenderness, and abdominal
bloating. Patients on the period-free HRT can have some vaginal spotting for a few weeks or
months.
Weight gain is not a side effect of HRT although some women may have fluid retention
which may increase their weight by 5lbs. Menopausal women are predisposed to gaining
weight at this time and diet and exercise are important to counteract this.
Some women are sensitive to the progestogens and these can be altered to a different one
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Hormone Replacement Therapy (HRT)
Information and advice for patients
Gynaecology
and trialled for 3 months if this is the case.
It is important to speak to your doctor or practice nurse if you have abnormal bleeding or
other side effects which worry you.
What are the risks of not having HRT?
The risk of choosing not to have HRT is that you will not experience the benefits of symptom-
relief and protection against osteoporosis and cardiovascular disease it can give.
Are there any alternatives to HRT?
Some other medications can help to reduce some of the symptoms of the menopause.
Clonidine is a medication which was initially used as a treatment for high blood pressure but
it can also be used to reduce flushing in the skin. Some low dose antidepressants can also
reduce hot flushes by 60%, but if they are taken at the dose for depression can actually cause
hot flushes. Another medication used to control epilepsy is also used to reduce hot flushes.
You can discuss the benefits and risks of each of these with your doctor who will tell you if
any are suitable for you.
Before starting HRT
Most women will be unable to decide if HRT is helpful to them without trying it. Before
taking HRT long-term you will be offered 3 month trial course. This will allow you and your
doctor to see if HRT benefits you and improves your quality of life. This short trial will not
increase your risk of developing breast cancer.
If the trial improves your symptoms then you can discuss with your doctor how long you
should use it for.
Other implications
Contraception
HRT is not a contraceptive (with the exception of the mirena).
• If you are younger than 50 when you have your last period: continue with contraception
for the next 2 years.
• If you are older than 50 when you have your last period: continue with contraception for
the next year.
• If you begin taking HRT when you are still having some periods: continue using
contraception discuss the length of time you will need it for with your doctor.
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Hormone Replacement Therapy (HRT)
Information and advice for patients
Gynaecology
Mammograms
Provided you have no symptoms of breast problems, there is no need to have a mammogram
before starting HRT and it is not necessary to have more frequent mammograms while
taking HRT however it is still advisable to attend for breast screening. This is offered to every
woman every 3 years once over 50yrs.
Blood pressure checks
HRT does not increase your blood pressure (BP) and there is no need for you to have
additional blood pressure checks with every prescription of HRT, but your BP should be
checked annually by your doctor or nurse.
How long should I take HRT for?
Some women will suffer menopausal symptoms for longer than others and there is no strict
time limit to the use of HRT because of this. If you need HRT for symptom relief for more
than 5 years after age 50 then you should discuss the benefits and risks of this with your
doctor. You are the best judge of your quality of life and best suited to making the decision
for yourself, with the guidance of your doctor.
As HRT simply replaces natural hormones, you will not need to have regular monitoring,
however your GP may like to see you once a year to check your response to the treatment
and in case there has been any new research which may influence it.
Contact details
If you have any questions or concerns please contact the menopause clinic or your GP.
Menopause clinic
0121 507 4042
Thursday 2pm – 5pm
Further information
For more information about our hospitals and services please see our website:
Sandwell and West Birmingham Hospitals NHS Trust
www.swbh.nhs.uk
The following related information leaflets are also available; please ask your nurse or doctor
if you would like one:
• The menopause
• Helping yourself through the menopause
• Hormone implants
• Mirena Page 6
Hormone Replacement Therapy (HRT)
Information and advice for patients
Gynaecology
Sources used for the information in this leaflet
• NHS Evidence Clinical Knowledge Summaries, ‘Menopause management’, January 2008
• British National Formulary 62, section 6.4.1: ‘Female sex hormones’, September 2011
• Medicines and Healthcare products Regulatory Agency, drug safety update, September
2007
• Royal College of Obstetricians and Gynaecologists, ‘Menopause and Hormone
Replacement – study group statement’, December 2004
• ‘Management of the menopause: The handbook of the British Menopause Society’, 5th
edition, May 2009
• International Menopause Society, current position papers and consensus statements,
various dates, www.imsociety.org
• Endocrine Society, ‘Postmenopausal hormone therapy: An endocrine society scientific
statement’, July 2010
• National Osteoporosis Society position statement, ‘Hormone replacement therapy for the
treatment and prevention of osteoporosis’, December 2010
If you would like to suggest any amendments or improvements to this leaflet please contact the
communications department on 0121 507 5420 or email: swb-tr.swbh-gm-patient-information@nhs.net
A Teaching Trust of The University of Birmingham
Incorporating City, Sandwell and Rowley Regis Hospitals
© Sandwell and West Birmingham Hospitals NHS Trust
ML3606
Issue Date: February 2012
Review Date: February 2014
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