HRT

Introduction

Hormone Replacement Therapy (HRT) aims to correct the deficiency of oestrogen and progesterone (the female hormones) that occurs at menopause. HRT is the generic name given to a group of drugs, which are prescribed in a variety of preparations.

The body makes many hormones and, in general, when a hormone is lacking it needs to be replaced. For example, an under-active thyroid gland is treated with thyroid hormone and diabetes is treated with insulin.

The ovary makes oestrogen, progesterone and some of the ‘male’ hormone, testosterone and the amount of all three produced after menopause declines dramatically. Oestrogen and progesterone are prescribed in a variety of combinations tailored to suit the needs of the woman to alleviate her particular symptoms and to protect bone density.

It may be necessary to work through several different types of HRT, before you find the one that is right for you, so be prepared to make changes with time. It is also possible to prescribe each component of HRT separately and thus to tailor the mix of oestrogen, progesterone and testosterone to the individual’s requirements.

Why Oestrogen And Progesterone?

Oestrogens are used in HRT to alleviate menopausal symptoms such as hot flushes, night sweats and vaginal dryness. As regards osteoporosis, oestrogen can improve bone density and prevent bone loss, although how far the bone is strengthened varies greatly.

Progesterone has a very clearly defined role and must be given to all women receiving oestrogen who have a uterus or womb. The reason for this is that oestrogen used on its own can cause cancer of the endometrium and this danger disappears when progesterone is given.

Progesterone is usually given at monthly intervals to bring on a menstrual withdrawal bleed. For women who have not had a hysterectomy, any oestrogen treatment must be combined with progesterone, either in tablet form or with a second patch, in order to provide a menstrual bleed.

Some new HRT preparations use progesterone only once every three months. Alternatively, progesterone and oestrogen can be given together continuously so that no periods occur.

Do I Need Testosterone?

The ovary makes about half of the supply of testosterone – the other half comes from the adrenal gland. Some women find that lower testosterone levels reduce their sex drive and their energy levels. Up to half of the women with premature menopause may benefit from testosterone therapy. Testosterone replacement is available in the form of implants, tablets, gel, injections or patches. Testosterone treatment only causes excess hair growth and acne if used in too high a dose; for this reason its use needs to be monitored so that it is merely replacing what would have normally been produced by the ovaries. It is something to discuss with your specialist if you are suffering from a low libido.

Different Types Of HRT

Combined HRT

Tablets and patches are forms of combined (oestrogen and progesterone together) HRT. Using combined HRT usually involves taking a form of oestrogen continuously and progestogen for 10-14 days of every month, these may be in a calendar pack similar to the pill. When the progestogen is finished a period or withdrawal bleed will occur, however these are often lighter than previously experienced.

Continuous Combined HRT

Continuous combined HRT involves taking both hormones everyday without breaks. In theory, therefore, no monthly bleeds should occur. However, it may be 2-3 months before they disappear and, in younger women, spotting or bleeding may be a persistent problem and regular withdrawal bleeds may be preferable.

Natural And Synthetic

A lot of literature about HRT talks about the difference between natural and synthetic forms of oestrogens. The term ‘natural’ is somewhat misleading as you are not putting fresh human oestrogen into your body whichever formula you take.

A simplistic analogy is orange juice on sale in supermarkets – whatever we buy whether it is fresh, from concentrates etc - is it actually the same as squeezing the oranges yourself? No!

Natural

The following are a few examples of ingredients that may be listed in the contents of your HRT:

Tablets containing oestradiol, oestriol, and oestrone are often called ‘natural’ oestrogens as they contain or give rise to chemicals that are the same as the oestrogens found naturally in women; as before they enter the blood stream they pass through the gut and the liver and have been converted to oestrone. See Hormones .

Conjugated equine oestrogens are contained in the two preparations listed below:

These are also described as ‘natural’ as the oestrogen in the urine of pregnant mares is very similar to that in women. Is the way that this is farmed natural? This is something that you need to make up your own mind about.

Synthetic

The following substances are so-called synthetic hormones:

These are known to be more potent than natural oestrogens. They are largely used in the contraceptive pill as they are strong enough to stop pregnancy which HRT is not.

Progestogen

Progestogens are usually made from plant sources and resemble progesterone, which is produced by the ovary in the second half of the menstrual cycle. The two main types of progestogen used in HRT are those which more closely resemble progesterone C21 e.g. dydrogesterone and medroxyprogesterone acetate and those derived from testosterone C19 e.g. norethisterone, norgestrel and levnorgestrel.

C19 progestogens can give rise to more side effects such as mood swings, depression, headaches and breast tenderness.

C21 progestogens convert into progesterone.

Oral Preparations

Tablets

Tablets are the most commonly prescribed form of HRT. Tablets come either as oestrogen alone, if you have had a hysterectomy, or oestrogen and progestogen combined. There are many different preparations available and many different doses. The dose listed on the packet is likely to be in milligrams. Tablets contain higher doses than patches as they have to pass through the gut and the liver which reduce the active amount the body receives. For many of us, tablets are familiar, convenient and discreet. They must be taken daily but are easily kept in your handbag if you travel a lot. For others though, tablets can be a daily reminder of a medical condition they would rather forget about.

Be aware that you may experience breast tenderness and nausea. If you forget to take a pill, there could be breakthrough bleeding.

The Contraceptive Pill

All oral contraceptive pills contain ethinyloestradiol, a strong synthetic oestrogen designed to prevent ovulation, and so they have often been used as HRT in young women. Oral contraceptive pills are, however, stronger than natural oestrogens and probably carry a higher risk of blood clotting (thrombosis) than occurs with oestradiol valerate or conjugated oestrogens. For many women with an oestrogen-deficiency, oral contraceptives may be unnecessarily strong for use as HRT. More importantly, oral contraceptives provide oestrogen for only three weeks in every four – the fourth week being ‘pill-free’. For women who are oestrogen-deficient, the lack of oestrogen during this pill-free week can cause symptoms and it seems more appropriate to provide oestrogen continuously as with most forms of HRT.

The Pill can be obtained free of prescription charges. Psychologically for teenage girls the pill may be a more acceptable form of replacing oestrogen as it doesn’t have the stigma of old age that HRT may have. For women in their teens and early twenties, taking the Pill may make them feel more in touch with their peer group. On the flip side, taking the Pill for women in their 30’s could be a stark reminder of their loss of fertility.

Non-oral Preparations

Non-oral preparations (also known as Parenteral Systems) do not have to be broken down by the liver, a process known as first pass metabolism. These preparations are, therefore, often favoured for women with diabetes, epilepsy, gallstones or kidney disease.

Patches

Patches are clear plastic squares that are applied from below the waist to the top of the thigh. Generally speaking, the higher the dose the larger the patch. They are changed once or twice a week on regular days.

Patches allow oestrogen to be slowly absorbed through the skin providing a more gradual and, therefore, natural release than a tablet.

Patches are particularly useful for women with liver disease or raised triglyceride levels which are associated with diabetes. They also have fewer side effects than the tablets, so if you have problems with tablets you may want to give patches a try.

Be aware using patches may lead to an allergic reaction to the adhesive or to skin irritation.

Gel

Not commonly prescribed for women who have experienced a premature menopause. Oestrogel works in the same way as patches, through the skin. The gel is rubbed onto the underside of the upper arms or legs or lower body. It must be allowed to dry and the area must not be washed or have other lotions applied to it for at least an hour. Skin contact must also be avoided during that time so applying at night while lying next to your partner is not advisable.

Implants

Implants involve a minor surgical procedure, whereby the implant is inserted beneath the skin of the abdomen or buttock approximately once every six months. However, if you decide to stop taking HRT or the dose is incorrect, implants can be difficult to remove. On the positive side, once implanted you can pretty much forget you are on HRT. If you decide to have implants, you should ensure that blood tests are taken before a new one is inserted. This is due to the fact that the take up of the oestrogen in the blood stream varies from woman to woman and over prescription may lead to tachyphylaxis, a form of oestrogen dependence or addiction. Progestogen tablets will also be needed.

Creams And Pessaries

These are not usually used alone for premature menopause, they are used primarily to relieve vaginal dryness and itchiness. They do not, however, protect against osteoporosis nor do they help alleviate hot flushes and night sweats. A plastic applicator, a bit like a syringe, delivers a measured dose of oestrogen cream into the vagina.

These preparations raise the levels of hormones locally and do not affect the whole body. They are useful for women who can not take systemic HRT.

Vaginal Ring

This is a synthetic ring impregnated with oestrogen which is inserted into the upper third of the vagina and worn for 3 months at a time. This can cause discomfort.