This is the sixth part of our series about the menopause based on our booklet “Fast Facts for Patients: Menopause”, which is freely available online. This article focuses on hormone replacement therapy.
Hormone replacement therapy (HRT) replaces the oestrogen that you lose during the menopause transition, either alone or in combination with a progestogen. It helps to alleviate menopausal symptoms and also reduces the long-term consequences of the menopause.
HRT is recommended as the best treatment for menopausal symptoms – based on all the available evidence.
There are many products and delivery options for HRT, including tablets, patches, gels, a spray and implants. This allows your HRT to be tailored to your needs. A patch, gel, spray or implant may be more suitable than tablets for some women, including those at risk of blood clots. You may need to try more than one type of HRT to find the one that suits you.
HRT helps many women through their menopause transition, but it is not suitable for everyone.
Some women are concerned about the apparent risks of HRT reported in the media. The benefits and risks of HRT are explained in another post to help you decide whether you want to try HRT, and to help discussions with your doctor.
Combined Oestrogen And Progestogen HRT
Women who have a womb and are still having periods (even if they are irregular) need HRT that contains a progestogen. This balances the effects of variable levels of oestrogen (as occurs during the menopause transition), as unopposed oestrogen can cause the lining of the womb to become too thick.
Many women start on a sequential preparation, which includes a progestogen for 12–14 days of each 28-day cycle, so that there is a monthly withdrawal bleed (as with the contraceptive pill). Sequential HRT can be delivered as tablets or through the skin (transdermally).
Preparations with less progestogen can be used, but bleeding may be heavy (although infrequent).
Women then move on to a continuous combined oestrogen/progestogen product at about age 54. A progestogen is taken every day, so there is no monthly bleed. This “bleed-free” HRT provides the best protection for the lining of the uterus in the long term. (It isn’t used earlier in the menopause transition because it can cause irregular bleeding.) Continuous combined HRT is also delivered as tablets or through the skin.
This is suitable for women who:
- have had a total hysterectomy (removal of the womb and cervix)
- have had a Mirena IUS fitted within the last 5 years – Mirena contains the progestogen levonorgestrel which is released into the cavity of the womb, protecting the lining.
Phytoestrogens and Other Alternative Therapies
Phytoestrogens are plant proteins that are similar to oestrogen, and they may help with symptoms during the menopause transition. They include soy products and isoflavones (red clover).
Evidence for the benefits of phytoestrogens in the menopause is mixed.
Red clover is more potent and better researched than soy, and some small studies have shown that it improves some symptoms in some women.
Red clover capsules are best taken at the time of day when symptoms are most troubling. They should not be taken by women with a risk or history of venous thromboembolism or hormone-sensitive cancers.
The use of black cohosh during the menopause is more controversial. It is approved for use in Germany as a non-prescription drug, but its effectiveness has not been proven. There are some concerns about its effects on the liver.
When considering any form of alternative therapy, it is important to think about both the risks and the benefits, as you would for a medicine prescribed by a doctor. If you don’t know whether something is likely to be beneficial, you may not want to expose yourself to even a low level of potential risk.
Testosterone is usually thought of as a male hormone; however, women also produce testosterone, but at much lower levels. Testosterone affects energy levels, sex drive (libido), muscles and joints. A woman’s testosterone level decreases significantly as she gets older.
Testosterone can be used during the menopause transition to improve libido (interest in sex). A small amount of a testosterone gel (one-tenth of the dose used for men) is applied to the skin. It is best applied to areas of skin where there is no hair, such as the inner forearm. (Testosterone can cause hair growth if applied to areas of skin with hair follicles.)
There are currently no licensed products containing testosterone available on the NHS. Some general practitioners are reluctant to prescribe testosterone out of licence.
Please check out the previous and the next post of our series here:
- Long-Term Consequences of the Menopause
- Menopause: Weighing Up the Benefits and Risks of Hormone Replacement Therapy
Information based on Fast Facts for Patients: Menopause (Karger, 2021).