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How do I take HRT?

There are many different ways to take HRT and many different combinations and dosages, all of which means that there are more options for women.

Tablets

Oestrogen is taken alone if a woman has had a hysterectomy (removal of the womb). It can also be taken with progestogen for a number of days each month, if she still has her womb (see bleed-free products).

When a progestogen is included, the treatment is called ‘opposed’ because progestogen opposes the effect of oestrogen on the womb lining. Oestrogen on its own can cause the lining of the womb to build up in thickness and so increase the risk of cancer. Progestogens prevent this build-up by causing the lining to be lost each month in the form of a bleed. This does not mean that fertility has been restored if you have stopped ovulating.

A disadvantage of tablets is that you have to remember to take them correctly. Another disadvantage common to all drugs taken by mouth is that a higher dosage must be taken to compensate for the loss which occurs as the drugs pass through the digestive tract. The high dose may lead to side effects such as nausea. Hormones taken by mouth also pass through the liver and so carry a greater risk of causing liver damage and gallstones.

Mirena for the progestogen part of HRT

This is an intrauterine system (a type of IUD) which contains a small amount of progestogen that thins the womb lining. It is a contraceptive which is also used for the relief of heavy periods. But it is likely to get a licence for HRT use because it can provide another way of getting the progestogen part of HRT. It works just inside the womb rather than affecting the whole body and may be a safer way of getting progestogen, see HRT Risks. It also has fewer side effects but it may not be suitable for everyone.

Patches

These are small plasters which are applied to the skin, they are available as single patches which contain oestrogen alone. The hormones pass directly from the patch across the skin into the bloodstream. The patch has to be changed once or twice weekly and a new one applied to clean, dry, hairless skin. If a woman has not had a hysterectomy, she will need progestogen in some form e.g. by using a double patch (containing oestrogen and progestogen) tablets or a Mirena coil.

The main advantage of the patch is that it contains a lower dose of oestrogen which is absorbed into the blood stream from the skin and so is less likely to cause nausea or affect the liver. Side effects can include skin irritation, swelling and blisters. However the matrix patches cause fewer skin reactions than the older reservoir type. An additional problem is that variations in the dosage absorbed from the patch can occur because of individual differences in the skin. The effects of long-term use of patches on the skin are not known.

Implants

These are small pellets containing oestrogen which are inserted under the skin. They usually contain a six-month supply of hormones and are inserted into the fatty layers of the abdomen, buttocks or thighs under a local anaesthetic. This means that the dosage is fixed for the specific time. If intolerable side effects occur, the implant has to be removed, but locating it may be difficult and removal may be painful. Implants can result in higher oestrogen levels than tablets or patches. With implants, the body may get accustomed to high oestrogen levels and as a result, some women may experience more side effects as the oestrogen in the implant runs out. However, some women find this a very convenient method as once the implant is in place they can forget about it. Women with a womb will need progestogen in some form as well.

Nasal spray

‘Aerodiol’ delivers oestrogen through the nasal passages creating a pulse of oestrogen. Unlike other HRT products it does not provide a constant dose of oestrogen throughout the day, but it is effective and easy to use. Women with a womb will also need progestogen.

Vaginal ring

Designed for women whose womb has been removed, ‘Menoring’ releases oestrogen into the bloodstream and treats symptoms like hot flushes and vaginal dryness. It is easy to insert and should be changed after three months. A user survey revealed that the vaginal ring is comfortable to wear and does not interfere with sex.

Creams

Oestrogen cream is put directly into the vagina in a measured dose with an applicator. The applied oestrogen has a local effect on the vaginal lining and is absorbed into the bloodstream. Because the oestrogen passes into the bloodstream, creams should only be used for short periods. If they are used for longer than 3-6 months, women who have not had a hysterectomy would need to take a progestogen.

Oestrogen cream will not work immediately — it should be applied for several days before attempting penetrative sex (oestrogen creams are prescribed to reduce vaginal irritation and soreness and should not be used as a lubricant). Unfortunately despite the use of oestrogen cream and/or HRT some women still find vaginal dryness a problem.

Gels

Oestrogen in gel form can be spread over the skin daily and acts in the same way as the patch. The advantage of a gel over a patch is that skin irritation is avoided. A disadvantage is that the gel must be used daily, whereas the patch only needs to be changed once or twice a week. Some women find the gel messy to use and women with a womb will need to take progestogen as well.

Bleed-free HRT continuous combined therapy

When progestogen is taken with the oestrogen on a cyclical basis (for 10-14 days of each oestrogen treatment cycle) most women will have a monthly bleed like a period. There are now some preparations that do not cause a bleed because the progestogen and oestrogen are combined in a continuous dose. Current bleed-free HRT formulations include Livial, Premique, Kliofem, Kliovance (this also contains a lower dose of oestrogen), Evorel Conti, Elleste-duet Conti, Climesse, Femoston-conti and Nuvelle continuous tablets.

Livial (tibolone) differs from the other preparations in that it is not a combination of oestrogen and progesterone but a single drug which combines the properties of both, as well as some of the properties of male sex hormones. Bleed-free preparations are not recommended in the first year after the last period. Women who are still having periods but are experiencing menopausal symptoms are prescribed cyclical HRT which causes a regular bleed. They may choose to change to continuous bleed-free HRT in their early fifties when it is thought that bleeding would have ceased naturally if they had not been taking HRT. Bleed-free HRT would also be appropriate for a younger woman who had no periods for a year and was experiencing menopausal symptoms. Another option is to take oestrogen continuously for three months and then take progestogen for 14 days (Tridestra). This creates a withdrawal bleed every three months.

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Written by Judy Fairlie and updated by Mary-Claire Mason for Women’s Health
and published in printed format by Women's Health

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