Menopause and Hormone Replacement Therapy (HRT)

When you start HRT, the doctor or nurse will discuss your age, symptoms and medical conditions before looking at the risks and benefits of HRT which are specific to you. These can change and will be discussed in your yearly reviews. 

Tests are usually not necessary before starting HRT unless there is a sudden change in menstrual pattern such as persistent heavy/irregular periods, bleeding between periods or after intercourse and postmenopausal bleeding. In these situations, you will be asked to have a pelvic ultrasound scan to assess the lining of the womb and a biopsy of the womb lining may be performed. 

If there is a personal or family history of VTE, a thrombophilia screen (blood test to look for a tendency to develop blood clots easily) may be helpful. If there is a high risk of breast cancer, you will be asked to consider a mammography or MRI scan and referred to familial breast cancer services depending on the level of your risk. A blood test for lipid and glucose profile will be requested if you have risk factors associated with cardiovascular disease.

The choice of delivery route and type of HRT depends on your preference but there are advantages to certain delivery routes. It is recommended that you are prescribed sequential combined HRT (giving monthly periods) if your last menstrual period was less than one year ago. 

You can be prescribed continuous combined HRT (without periods) if you have received sequential combined HRT for at least one year, or if it has been at least one year since your last menstrual period. Local preparations such as vaginal creams and pessaries are highly effective for symptoms of vaginal dryness, painful sex and urinary frequency. Around 10% to 20% of women still have persistent symptoms with local oestrogen so they will require systemic HRT in addition.

HRT is not a contraceptive. You may be potentially fertile for up to two years after your last menstrual period if you are under 50 years of age and for one year if you are over 50 years. You should therefore use appropriate contraception during this time to avoid pregnancy. A progesterone-only pill alongside combined HRT or Mirena coil with oestrogen are common ways of having both HRT and contraception.

Getting the right dose and combination of hormones to work for menopausal symptoms can take time. If your symptoms do not improve or persist despite taking HRT for more than 2-3 months or if you experience significant side effects, a change of dose or type of HRT is needed. This is because the absorption of hormones from different HRT preparations may vary between individuals. Sometimes, your doctor may consider a blood test for oestrogen levels to assess this.

Testosterone levels drop gradually during natural menopausal transition (it is produced by both ovaries and adrenal glands in the body). Some women experience a persistent lack of libido despite taking HRT containing oestrogen. Testosterone can help in this situation. Some women notice improved energy levels, better mood and less brain fogging on testosterone however more research is needed to confirm these benefits. Testosterone is used in small doses and usually does not cause side effects. Excessive use can cause oily skin, excess body hair, scalp hair loss and deepening of voice.

Most commercially available combined HRT preparations contain progestogens — compounds which have progesterone-like actions but are synthetic. Micronised progesterone is natural progesterone devoid of any androgenic as well as glucocorticoid activities and is considered safer than synthetic progestogens. 

This combined with 17-beta oestradiol is regulated body-identical HRT. Bio-identical HRT refers to compounded HRT preparations which are combinations of plant oestrogens and progesterone-like compounds. These are currently not recommended in the UK by the British Menopause Society as long-term safety data is lacking for many of these.

Whether you take HRT or decide not to take it, a healthy diet, good sleep hygiene, regular exercise in some form and stress reduction activities are key for good long-term health. If you are unable to have HRT, other medications or treatments may be prescribed to help control unpleasant menopausal symptoms. For vaginal dryness and painful sex, vaginal lubricants and moisturisers are often effective.

For hot flushes and night sweats, antidepressants or selective noradrenaline and serotonin reuptake inhibitors such as Venlafaxine, Gabapentin and Clonidine (blood pressure lowering agent) are oral medications which are most prescribed. They can be effective for some but do have side effects such as dizziness, dry mouth, low libido and constipation. CBT (cognitive behavioural therapy) can be effective for vasomotor, sleep and mood-related symptoms.

Alternative therapies including homeopathy, hypnotherapy and acupuncture are also offered at specialist clinics although the evidence base for these remains weak. If you wish to consider any of these alternatives, you should talk to your doctor in detail about the risks versus benefits of these treatment options and make an informed choice.

You will generally be asked to come for a follow-up consultation after starting HRT in about three months. Most symptoms are likely to have responded to oestrogen at this time, and any residual symptoms may require adjustment of treatment. If the chosen HRT suits you and appears effective, you may wish to see your GP or the specialist clinic once or twice every year to review the ongoing need for and safety of continuing HRT. Regular blood pressure monitoring is recommended at follow-up visits. Both mammograms and cervical screening as per national guidelines are recommended in postmenopausal women on HRT.