Consultant Gynaecologist

What is HRT?

Hormone replacement therapy (HRT) refers to the use of oestrogen or a combination of oestrogen and progestogen medication for menopausal and post-menopausal women. HRT replaces the body’s lost oestrogen and often brings great relief of vasomotor symptoms (night sweats and hot flushes) and vaginal atrophy, and reduces the risk of osteoporosis. HRT will not correct any deformity that may have occurred in established osteoporosis.

Different kinds of HRT might be prescribed. There is no “one size fits all” treatment. HRT has varying doses of oestrogen and progestogen, and these can be altered to maximise the efficacy of treatment. A combination of oestrogen and progestogen is generally prescribed except for women who have had a hysterectomy who normally need no other hormone but oestrogen on its own, unless any other coexistent medical problem that require combined therapy.

Further, women who have had a hysterectomy and bilateral salpingo-oophorectomy (removal of the uterus, both tubes and ovaries) may suffer symptoms of “female androgen deficiency syndrome — FADS” which includes loss of libido, loss of energy, loss of self confidence, anxiety and headache. These women may benefit from a combined therapy with oestrogen and low dose testosterone, which may be in the form of tablets or implants. Testosterone will replace the missing ovarian androgens, which are produced during the normal reproductive life and until the menopause, either physiological or surgical.

There are preparations of HRT that combine the effects of oestrogen and progestogen in a single tablet without the need for monthly period (period-free HRT), and forms of HRT where a short course of progestogen is taken each month and periods start after the progestogen is stopped (monthly-bleed HRT). It is recommended that period-free HRT is given only to women who have not had a period for at least 12 months or who are aged over 54 and currently on a monthly-bleed HRT.

Absolute contraindications to HRT are: active deep-venous thrombosis (DVT), active liver disease, recent cardio-vascular event, endometrial cancer and breast cancer.

Different types of HRT

• Tablets (taken orally)
• Implants (a small pellet of oestrogen inserted under the skin and replaced at regular intervals)
• Patches (applied to the skin and allow a smaller dose to be given than by tablets)
• Gel (a daily measure of oestrogen is rubbed on to the skin)
• Vaginal preparations (oestrogen is placed directly into the vagina in the form of cream, tablet or ring device)
• Nasal sprays (delivery of oestrogen in a measured dose via an inhaler)

Potential side effects of HRT

When a woman first starts taking HRT she can complain of some minor transitory side effects such as bloating, headache, vaginal spotting, breast tenderness, leg cramps and nausea. They generally tend to disappear within a couple of months.

Thrombosis (blood clots) — there is a slight increase in the risk of blood clots in women who receive HRT. The risk in the general population is 1:10,000, while in women taking HRT it increases to 2:10,000.

Breast cancer — as suggested by some studies, long-term exposure to HRT increases the risk of developing breast cancer. The estimated increase in risk differs according to the type of HRT taken. Postmenopausal women taking HRT for more than 5 years should be advised to have a mammogram every 18-24 months.