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9 Minute ReadEducation by Jo Waters
15.10.21 (Updated 23.01.23)
HRT is a health category in itself and thankfully there are lots of different treatments available to suit your individual menopause symptoms. Moreover, these different types of HRT are also delivered in different ways, including pills, patches, gels, sprays, and pessaries.
Also HRT has moved on in the last twenty years. HRT used to involve artificial hormones, but newer types, such as body identical HRT, is made from yams and root vegetables. These are natural, and can be given through the skin as a gel, patch or spray.
So do your research and talk through your symptoms with your GP to find the most appropriate for you.
Your set of symptoms will define what type of treatment is going to be most effective. “If your only symptoms are vaginal dryness and urogenital symptoms then you may only need local oestrogen which can be applied via a pessary, cream or ring,” said Dr Nighat Arif, GP and women’s health expert. “Whereas if you have multiple symptoms such as hot flushes, night sweats and brain fog, then a treatment that supplies oestrogen to hormone receptors all over the body may be a better solution for you.”
While your local GP might well be able to help you, it’s important to specify you need to speak to one who specialises in menopause and women’s health. “Menopause is still not a compulsory part of GP training,” explained Dr Arif. “Don’t forget you can also ask to be referred to a menopause clinic at a local hospital if you think you need more specialist expertise.”
Pills, patches, spays and gels: HRT comes in pill forms (either oestrogen-only or combined with progestogen), transdermal/skin patches (oestrogen only or combined), oestrogen gels, implants (which release oestrogen under the skin), and oestrogen sprays (containing estrodiol and known as Lenzetto), applied to the inner part of the arm between the wrist and the elbow.
IUS implants: Intra-uterine systems such as Mirena deliver progestogen directly into the womb for 3-5 years and function as a contraceptive too (you can still get pregnant when you are perimenopausal).
Synthetic oestrogen and progestogen: These are the older types of HRT made of synthetic chemicals, some of which are derived from horse urine. They are not regarded as being as safe as the newer body identical HRT (see below). Synthetic HRT comes in tablets or patches which combine both oestrogen and progestogen or contain only one.
Bioidentical oestrogens: This type of natural HRT is made from plant chemicals and is the safest form of HRT when delivered transdermally (aka through the skin). Bioidentical oestrogens don’t raise the risks of breast cancer or blood clots as it doesn’t go through the liver. It’s available as gels, (e.g., Oestrogel and Sandrena) a spray (Lenzetto) and tablets (containing estradiol, such as Elleste Solo). The safest type is the sort available on NHS prescription – more on that later - which has been regulated by the Medicines and Healthcare products Regulatory Agency (MHRA).
Bioidentical progestogen: Micronised progesterone (Utrogestan) tablets, are the only body identical form of progestogen currently available. It is chemically identical to human hormones and made from plant sources. It’s used in conjunction with body identical oestrogen for women who have an intact uterus.
Testosterone gel: Although testosterone is better known as being a male hormone, women make it too, and most of it is produced in the ovaries. Young women normally make approximately 100 to 400 mcg per day (3-4 times the amount of oestrogen produced by the ovaries). If you don’t have enough testosterone, symptoms can include low sex drive, sexual arousal and orgasm problems, plus memory and concentration issues, fatigue and loss of muscle strength. Testosterone gel is not available routinely on NHS prescription for women with menopausal symptoms, but it can be prescribed if other types of HRT don’t restore sexual function. The NICE Menopause Guideline says that testosterone gel can be prescribed if the prescriber is familiar with it and is willing to prescribe it ‘off licence.’ Some GPs prefer not to take this responsibility though, and will refer you to a menopause specialist for advice before prescribing. Other GPs will have prescribing restrictions which mean they are not able to offer it. It can also be prescribed privately. Possible side-effects include body hair growth and acne.
Local vaginal oestrogen: This can be delivered into the vagina via pessaries and vaginal rings, creams, and gel containing estradiol. Products include Vagifem, Vagirux and Estring.
It’s a treatment used for urogenital atrophy - the medical name for thinning and shrinking of the tissues of the vulva, vagina, urethra and bladder - which is caused by oestrogen deficiency. This results in vaginal dryness, vaginal irritation, a frequent need to urinate and urinary tract infection.
It can be used alongside other forms of HRT or on its own and can also be considered as a treatment option if standard HRT is contraindicated (in women who have had breast cancer for instance, or have a history of blood clots).
Let's delve a little deeper into body identical HRT and bio identical HRT because yes, they're different.
Confusingly there are two types of bioidentical hormones: those that are regulated and prescribed by GPs, and compounded bioidentical HRT - available from private clinics or ‘specials’ from pharmacies - which are not regulated in the same way as medicines by the Medicines and Healthcare products Regulatory Agency (MHRA).
The British Menopause Society has tried to clear up some of the confusion by defining the two types as conventionally prescribed ‘regulated’ bioidentical hormone replacement therapy (rBHRT) or ‘compounded’ bioidentical hormone replacement therapy (cBHRT).
Both types are made from plant sources such as yams, but rBHRT is a regulated medicine and has been assessed for safety and efficacy. Meanwhile cBHRT is not subject to the same regulatory pathways of evaluation by the MHRA as conventional pharmaceutical products. For these reasons, the BMS does not recommend cBHRT products .
Mr Hamoda says: “You don’t know what you are getting with cBHRT – it’s potentially made from the same raw materials, but the purity hasn’t been followed up. There was one report from the States, where cBHRT samples from the 10 main outlets selling them were analysed and some had more oestrogen than was needed and others had less progestogen - which would be of concern because there would be a higher risk of endometrial cancer.”
The BMS also expressed concerns about individualised serum and saliva tests offered by private practitioners and used to make up treatments tailored for individual hormone profiles, saying there was insufficient evidence to back up the claims.
Bioidentical hormones are also sometimes prescribed by health care practitioners who don’t have expertise in menopause. To find a BMS recognised menopause specialist follow this link.
The NICE Guideline on Menopause says HRT should be offered to women as a first-line treatment for menopause. Women in England must pay £9.35 NHS prescription charges for HRT (per item), although there is currently a campaign to get these charges waived as they have been in Scotland and Wales. Labour MP Carolyn Harris, chair of the newly-formed All-Party Parliamentary Group on Menopause, backed a Private Members’ Bill calling for the scrapping of the charges which is due to have its second reading on 29 October.
The type of HRT you are prescribed will depend on factors such as whether you are peri or post-menopausal, if you have a history of breast or endometrial cancer or blood clots, your weight, what your symptoms are and your own personal preference for how it is delivered (e.g., pills, gel, spray, pessaries, or patches).
If you are still having periods and are in the perimenopause, you will be prescribed cyclical HRT. This will mean you take oestrogen daily, and then progestogen with it for the last 14 days of your cycle. This can also be done on a three-monthly basis with progestogen taken for 14 days every three months.
If your periods stopped a year or more ago, you are classed as post-menopausal and can take combined oestrogen and progestogen HRT continuously.
Women who have had hysterectomies to remove their womb only need oestrogen HRT. This is because progestogen is there to protect the womb against endometrial cancer.
As for hair and skin, according to Dr. Moy, thyroid hormone deficiency can cause dry skin and hair loss and getting patients to balanced hormonal levels, through HRT or, best, dietary supplements can improve skin and hair, as well as lower weight.
There’s no evidence that HRT causes weight gain, although weight gain is common around the time of the menopause. This is because the body attempts to expand fat cells to produce more oestrogen and compensate for the ovaries producing less.
Supplemented oestrogen side effects can include bloating, breast tenderness, swelling, leg cramps, nausea, headaches, and vaginal bleeding. These normally settle after a few weeks, however. Side effects of progestogen include mood swings, depression, acne, back and tummy pain, breast tenderness and vaginal bleeding, but these are usually short term.
The best type of HRT for you will depend on your symptoms, medical history, and background risk factors for your age. Dr Arif recommends the newer bioidentical hormones - sometimes called body identical hormones - which are made from yams and other plants, as they are the closest to those produced naturally by the body. “These can be delivered through the skin and are the safest way to take HRT,” said Dr Arif. “The NICE Menopause Guideline has said bio identical HRT does not raise the risk of breast cancer or heart diseases if given through the skin.”
Dr Arif prefers to prescribe gels like Oestrogel or Sandrena, or the spray Lenzetto, “as it gives women more flexibility to control their symptoms than patches do. But I also prescribe patches and the oral version. Although the risks with the oral pill are slightly higher, they are still small.”
Mr Haitham Hamoda, a consultant gynaecologist, clinical lead of London’s King’s College Hospital menopause service and chairman of the British Menopause Society, says bioidentical hormones are safest when administered through the skin. “Then there is no added risk of blood clots or stroke.”
Women can be prescribed bioidentical forms of both oestrogen and progesterone on the NHS, so if you decide this is the type of HRT you want, make sure you are specific when you have your GP consultation and mention the NICE Menopause Guideline.
Unfortunately, women are still experiencing difficulties obtaining HRT products due to shortages and problems in the supply chain, caused by Covid-19-related factory shutdowns and other disruptions. The BMS has issued the following helpful guidance about what to do if women can’t get their usual prescription.
Everything you need to know about the menopause
The truth about HRT and menopause pharmaceuticals
The psychological fallout of the menopause, and how to treat it
The truth about menopause supplements