Find the HRT that’s best for YOU: Tablets, sprays or gels? Natural or synthetic hormones? Our vital series will help you, and your GP, make the right choice of treatment
Not every woman will want to have hormone replacement therapy (HRT) but there are many who do — and as we reported last week in the first part of our essential guide, they struggle to get it.
But even those who do can face an apparently bewildering choice, with a wide range of formulations and combinations of the treatment — from tablets and gels to patches and implants.
Each form has its own merits; while a once-a-day tablet or pessary may be convenient, a patch or implant can be applied and then forgotten about. A gel, cream or spray applied to the skin will reduce the potential side-effects of tablets.
Some formulations contain ‘body identical’ hormones, where the oestrogen or progesterone is derived from yams or other plant sources — this type of oestrogen (known as 17 beta oestradiol) and progesterone (‘micronised progesterone’), are ‘the safest types in HRT’, says Dr Vikram Talaulikar, a menopause expert at University College London Hospital, who trains GPs and nurses in treating menopause symptoms.
Each form has its own merits; while a once-a-day tablet or pessary may be convenient, a patch or implant can be applied and then forgotten about. A gel, cream or spray applied to the skin will reduce the potential side-effects of tablets
Other formulations contain synthetic versions, made in a lab.
There is also ‘bioidentical’ HRT, available privately — these are essentially bespoke combinations of different plant-based hormones tailored to the individual woman’s blood or saliva test results.
These products are not regulated by the watchdog, the Medicines and Healthcare products Regulatory Agency (MHRA) unlike conventional HRT. Dr Talaulikar explains: ‘The problem is that these formulae may be effective but there’s not enough long-term safety data from randomised controlled scientific studies.’
This route can also prove expensive (around £100 a month).
To help you decide what’s best for you, we spoke to some of the country’s leading menopause experts about the options.
Combined HRT
The most common form of HRT, this is a combination of oestrogen (to reduce symptoms such as hot flushes, low mood, reduced sex drive) and progesterone (to thin the lining of the womb and reduce the risk of womb cancer).
It can be taken in two ways: oestrogen and a low-dose of progesterone taken every day (in this case, a woman will have no periods — this is mainly for post-menopausal women) or daily oestrogen and progesterone for the last ten to 14 days of the month, after which the woman will have a bleed, like a period (this option is often used by perimenopausal women who are suffering menopausal symptoms).
Although it can be taken in one treatment, such as a tablet, you can also take ‘combined’ HRT in separate oestrogen and progesterone form — for example, as a progesterone pill or via the contraceptive coil and an oestrogen gel or patch.
Exactly how it is prescribed i.e. the formulation and frequency will be down to personal preference. It is also based on whether a woman is perimenopausal and still having periods, in which case a cycle of progesterone may be recommended; or through the menopause, in which case a continuous, combined daily dose is more likely.
Types of formulations available: Tablets, patch, gel, spray, implants and the coil. Some will contain both oestrogen and progesterone, others will be separate products.
Brands: Pills — Combined oestrogen and progesterone: Femoston, Kliovance, Clinorette, Elleste-Duet, Kliofem, Novofem, Trisequens (these all contain the natural/body identical oestrogen but synthetic progesterone).
Progesterone only: Utrogestan (body identical).
Gel: Estrogel (oestrogen only, body identical) — usually applied once a day to the arm, belly or thigh for convenience.
Patch: Estradot, Evorel (oestrogen only, body identical), usually worn on the buttock or thigh. Implants: Small pellets of oestrogen (body identical) are placed in the skin in the stomach area, slowly emitting the hormone before being replaced every 6-8 months (implants are not widely used).
Spray: Lenzetto (oestrogen only, body identical) — usually used on the arm, belly or thigh.
Coil: Mirena (progesterone only, synthetic) — the coil is a contraceptive implant fitted into the womb, which releases the hormone over three to five years.
Available on the NHS? Yes
Expert comment: ‘The majority of women who take HRT are post-menopausal, i.e. more than a year since their last period, and continuous combined HRT is the most commonly used form of HRT in the UK,’ says Dr Edward Morris, a consultant gynaecologist at Norfolk and Norwich University Hospital NHS Trust and president of the Royal College of Obstetricians and Gynaecologists.
‘Oestrogen helps with symptoms while progesterone protects the lining of the womb.’
Taking progesterone can cause symptoms such as mood swings, headaches and bloating — if you’re postmenopausal, taking a low dose each day can reduce hormonal ‘ups and downs’, he adds.
Working out the right combination of these hormones ‘is a decision between the woman and the specialist, and may need to be tailored to the individual woman’s needs’, adds Dr Mike Savvas, a consultant gynaecologist and menopause expert at King’s College Hospital, London.
‘The progesterone in HRT is either a synthetic version of the hormone or the natural, body-identical version called micronised progesterone — the body-identical one is generally better as it is a replica of the hormone a woman produces naturally.’
An example of a continuous combined HRT using micronised progesterone would be oral Utrogestan capsules (100mg daily) at bedtime along with separate oestrogen (tablet, patch, spray or gel), says pharmacist Sid Dajani.
‘Current recommendations advise that the lowest effective dose of oestrogen be used, but this may need to be increased to adequately control symptoms, as every woman’s needs are unique.’
For women who are at high risk of deep vein thrombosis (DVT), either because they are over- weight or have other medical risk factors or they have had a DVT in the past, oestrogen patches, sprays or gels are recommended because this bypasses the liver and reduces the risk of DVT (see below).
Oestrogen-only
Oestrogen-only HRT is generally suitable only for women who have had a hysterectomy. That’s because oestrogen on its own thickens the lining of the womb and increases the risk of womb cancer. It can also be used by women who have a Mirena coil, as it thins the womb’s lining, countering the effect of oestrogen. Fewer than 10 per cent of women use an oestrogen-only form of HRT.
Types of formulations available: Oestrogen is available as a tablet and spray, but it’s most commonly taken via a patch or gel rubbed on the arm or thigh. There are also creams, tablets and rings which can be applied to the vagina to alleviate symptoms of dryness.
Brands: Some of these may be used in a combined HRT regimen.
Patch: Estradot, Evorel (body identical) — changed twice a week
Spray: Lenzetto (body identical)
Pills: Elleste-Solo, Progynova (body identical) — daily tablet.
Gel: Sandrena, Oestrogel (body identical) — rubbed onto the skin once a day.
Pessary: Gina (body identical) — inserted into the vagina to treat dryness and thinning of the skin — one tablet daily for the first two weeks, then twice a week. For women who have gone through the menopause.
Available on the NHS? Yes
Verdict: ‘The best way to give oestrogen is through the skin, most commonly via a patch or gel,’ says Dr Mike Savvas. ‘By mouth increases the risk of blood clots and stroke as the hormone travels to the liver where it can affect production of blood clotting factor. Taking it via the skin circumvents this problem.’
This month, UK medicines watchdog, the MHRA launched a consultation on changing the Gina pessary from a prescription-only medicine to one that is available to buy from pharmacies. Women would still be able to get it on prescription. A decision will be made following the consultation, which ends on February 23.
‘Gina is a form of HRT that contains an extremely low dose of oestrogen and treats only the local area in the vagina rather than circulating around the body, so is very safe,’ says Dr Savvas.
‘It can successfully treat one symptom of the menopause — vaginal dryness — but it won’t help with others.
‘Other forms of HRT will treat vaginal dryness as well as other symptoms. They can also help to prevent recurrent urinary tract infections after the menopause, as oestrogen increases production of natural antimicrobial substances in the bladder and makes the urinary tract tissue stronger.’
Tibolone
Tibolone is a man-made substance that’s been found to have beneficial effects on the brain, vagina and bones. It’s similar to taking combined HRT and mimics the effects of oestrogen and progesterone.
It also has a testosterone-like effect, mimicking the male hormone which women also produce and which declines during the menopause since some of it is produced by the ovaries.
Tibolone is suitable only for women who haven’t had a period for 12 months. This is because if they’re still ovulating, they may have bursts of naturally occurring hormones. These could upset the delicate balance of the lining of the womb that tibolone and any other continuous, combined HRT require, resulting in irregular bleeding.
Types of formulations available: In tablet form.
Brand: Livial (synthetic)
Available on the NHS? Yes
Verdict: ‘This can be really good for helping mild menopausal symptoms but as the oestrogen isn’t as potent as other forms of HRT, it doesn’t always work,’ says Dr Savvas. ‘It was very popular in the 1990s and 2000s, but less so now.’
Testosterone
This male sex hormone is very important for women, too, as it affects libido, energy levels, mood and sleep and can also help to keep bones healthy.
It is produced by the ovaries and the adrenal glands in women, so when a woman goes through the menopause, testosterone levels will fall. This can lead to low sex drive and if HRT doesn’t alleviate this problem, testosterone may then be prescribed.
Types of formulations available: As a gel.
BRAND: Tostran, Testogel (body identical) — which is rubbed on to the skin daily.
AVAILABLE ON THE NHS? Only on an off-licence basis, supervised by a specialist and prescribed by a GP either on the NHS or privately.
Verdict: ‘Although testosterone isn’t one of the core elements of HRT, it is approved by the National Institute for Health and Care Excellence for women with low libido, although not for other symptoms,’ says Dr Morris.
‘But there currently isn’t a licensed testosterone product for women in the UK. There is a licensed testosterone gel for men, so women can be prescribed it by a specialist “off-label”.
However, this means access to testosterone for women is not a level playing field, with some GPs unprepared to prescribe it. We desperately need a testosterone product for women in the UK.’
Additional reporting THEA JOURDAN
Having been a GP for more than 30 years, I have seen the popularity of HRT come and go. But it is clear to me that with the right combination of medication, and in women for whom it’s suitable, it can transform their lives as their natural hormone levels wane.
I, too, have benefited from HRT. In fact, it would be the one thing I would take to my desert island.
I started to get hot flushes at 53, and my nights were spent tossing and turning — hot, then cold; duvet off, duvet on. I was exhausted. Brain fog swirled and sapped my energy. At times it felt like wading through treacle. My flaky hormones were letting me down, leaving me irritable and forgetful.
I lose my keys at the best of times, but even managed to leave them on the top shelf in the fridge once.
For me, HRT was transformative. I was back to sleeping like a baby.
The other battle was more of an inconvenience — irregular bleeding.
I opted to take a form of combined HRT where, rather than the traditional pill containing both oestrogen and progesterone, I take these hormones separately to suit my needs.
The irregular bleeding settled as soon as I had a Mirena coil inserted — this delivers the hormone progesterone straight to the lining of the uterus, stopping the random periods. More importantly, progesterone is needed to protect the lining of the womb from the slightly increased risk of cancer with oestrogen therapy.
With that risk covered, I was able to have the oestrogen the safest way — through the skin. I use a gel, but patches work, too. For many women this is a winning combination, although there are other options.
For decades there has been a lack of clarity and confidence in many health professionals when it comes to prescribing HRT.
Overly fearful of the risks (HRT is, of course, not suitable for everyone), some are reluctant to prescribe it, and women are left to soldier on, struggling, and often with needless fall-out at work and at home.
The menopausal body is a bit like a car that’s done a good mileage, but the engine is running low on oil — top it up, and it should be good to go for some time yet.
I’ve been on HRT for seven years, and plan to remain on it for as long as my doctor says it’s all right for me to do so.
I was lucky to have an interest in women’s health and a well-informed GP, as well as access to research and up-to-date advice.
So, with the right combination of progesterone and oestrogen, life for me returned to normal — probably with a little sigh of relief all round!
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