Should everyone take HRT?

I’m a big fan of HRT, I’ve seen it transform people’s lives. I don’t however believe there is any drug or medical intervention that is always right for all of us. Saying that I strongly believe everyone should have access to accurate information to make their own informed choices. There has been a lot of misinformation about HRT over the years, and there are now types of HRT that are very similar to our natural hormones with a better safety profile, for example not increasing the risk of blood clots. I would strongly advise anyone with POI (menopause before the age of 40) to take HRT until the natural age of menopause, to protect their long-term health. I’m also a big advocate of local HRT, which is very low in dosage and can be used long-term by almost everyone to support the genito-urinary symptoms of menopause.

With all the different types of HRT available, how do I pick which to use?

Certain medical factors play a part in decision-making, so your clinician looks at your medical history, any medical conditions in your family, and any medications you already take. Personal preference is key too – some of us prefer the convenience of a daily tablet over applying a gel with a separate progestogen, some of us find an oestrogen patch easy to use alongside a hormonal coil, and some of us like the oestrogen spray. Local HRT can be added, or used alone, and some people find great benefit from adding in testosterone. We’re all different, so an individual approach is needed. Sometimes there’s some trial and error too, to get the right product that suits you, and at the right dosage to support your symptoms.

Why do some people take it every day and not others?

If we start HRT when we are still having periods, when we are perimenopausal, we initially use HRT in a cyclical pattern, to replicate the menstrual cycle. Oestrogen is used every day and progestogen usually for 2 weeks out of 4 to give a withdrawal bleed. Over time we can change to a continuous combined HRT where oestrogen and progestogen are used continually. If we go straight on to the bleed-free continuous HRT before our body is ready we tend to get lots of random bleeding. If our periods have stopped for a year or more when we begin HRT we can go straight onto the continuous combined bleed-free HRT.

I’m 64, is it too late for me to consider HRT?

If you are over 60 and have troublesome symptoms, HRT can still be beneficial. It is a good idea to start at a low dose and to go for a transdermal (through the skin) oestrogen, your clinician can advise you of the options that might suit you best. For the potential preventative benefits of HRT relating to the heart and blood vessels, research has shown there is a “window of opportunity” of starting HRT within 5-10 years of the onset of menopause, so if we start HRT after this it is to help our symptoms. 

What are your thoughts on starting HRT earlier rather than later?

There is much less research and evidence about starting HRT for early perimenopause, between the ages of 40 and 45. For POI (menopause before the age of 40) there is a lot of robust evidence to show the benefits far outweigh the risks, and when HRT is started before the age of 40 it would be strongly advised to continue until at least the typical age of menopause, 51.

Starting at age 40-45 we presume is likely to be very safe, our background rates of medical conditions are lower, and we are likely to have more to gain regarding longer-term preventative benefits if we go through menopause earlier, but there is a gap in the research data here to know for sure.

It has taken me a few years to sort out my HRT and manage my symptoms – when do I need to think about stopping it, or do I continue for life?

HRT can take a while to stabilise, there’s no one-size-fits-all approach and we can all respond differently to different formulations, and need different dosages. The dosage we need to support our symptoms can vary over time too. There are no arbitrary limits now on the duration of treatment, an annual check is advised but some people do now choose to stay on it longer-term. In POI (menopause before the age of 40) it’s advised until at least 51, the typical age of menopause. If you are benefitting from local HRT I would advise you to continue it lifelong. So it depends on factors like our individual medical history and the type of HRT.

How do you get the black sticky patch marks off without scrubbing til your skin is raw?

Patches can leave an annoying plaster mark on the skin when you take them off, this comes off with baby oil or alcohol gel. There’s a new spray out, nudi, that works well too.

Where is the best place to apply the gel?

It’s usually applied every day to the outer upper arm, or inner upper thigh. It’s important to avoid hormone-sensitive areas, so if you use it on the upper arm, remember that the breast tissue extends into the armpit area. If you use the inner thigh, avoid the genital area. It’s been shown that ideally each pump of gel should be applied to an area about the size of an A4 piece of paper and if you use the sachets of gel each sachet to an area about the size of your hand. You don’t rub it in, just apply it and leave it to dry.

My friend uses 4 sprays each day, and I use 3, who is correct?

Just like with other common medications such as thyroxine, different people need different dosages for the same effect. The right dose is the dose that supports our symptoms. It is important to talk to your prescriber about your dose, and not to increase it without them knowing, as at some levels of oestrogen more progesterone is also recommended. So I can’t tell you what the right dose will be for you, it’s like finding the right pair of shoes, some fit better than others even if they’re both a size 6. So there can be some trial and error needed, both with the product and the dose. That can be hard if you’re experiencing lots of symptoms I know, you just want it to work straight away.

How can I know if the spray has run out?

It can be tricky to know when you’ve run out, the device doesn’t feel empty. There is a tick chart on the box to count down what’s left. There are 56 doses in each device, so if you’re using 2 sprays a day another option is to set a reminder on your phone that it will run out after 28 days.

My nurse told me I should change off tablet HRT now I’m 60. Why is that?

Oral HRT is very convenient but is less suitable for certain medical conditions that can affect us more with age like strokes and blood clots, so if we take oral HRT at age 60 it is often recommended to change to transdermal HRT like a patch, gel or spray to reduce these risks.

Does HRT cause weight gain?

Weight gain is typical in mid-life. Research has consistently shown no evidence of weight gain with oestrogen and progestogen HRT. There can be some weight gain for some people with testosterone HRT.

Why isn’t my HRT covered by the HRT pre-payment certificate?

Not everyone is aware that the HRT prepayment certificate is available, and lasting 12 months at 2 prescription charges it can lead to big cost savings over a year. It includes HRT products that are licensed for the treatment of menopause, so all of the oestrogen tablets, gels, patches, and sprays, aswell as the local oestrogen treatments. Most progestogens are covered too, but not the vaginal micronized progesterone capsules or some of the synthetic oral progestogens. Testosterone is not included either. You can get a prepayment certificate from your pharmacy, or online via the NHS Business Services Authority, but not your GP surgery.

Does testosterone help brain fog?

Thanks in part to Davina, testosterone is now well known for its effect on libido. The other effects though are still being debated. People using testosterone as part of their HRT often report improvements in mood, memory, concentration, and energy levels, aswell as strength and vulvovaginal health. These effects have not been proven in studies, but more research is needed. For some people adding testosterone certainly seems to significantly improve their quality of life.

What about breast cancer? Can I take HRT if there’s breast cancer in my family?

Breast cancer is the most common cancer in women, with a lifetime risk of 1 in 8, so many of us know someone close to us who has been affected. Breast cancer is age-linked, and genetics can affect our background risk, so an assessment of family history is important and your clinician will be able to guide you as to whether your family history is higher risk. Other factors are important too, such as being overweight, smoking, and drinking alcohol increasing our risk, and exercise decreasing our risk. In terms of HRT, the risk relates to the type of HRT we use, the dose, and the length of time we use it. The risk from HRT is less than the risk from a glass of wine every day. So again, it’s a personal decision to talk through with your clinician.

I’ve started to get migraines linked to my cycle again. I’m 47 and using HRT. Is this likely to be a perimenopause symptom? Is there anything I can do to help?

Hormonal migraines are common and usually relate to fluctuations in hormone levels. They typically start at puberty and are common with a lowering of oestrogen so pre-period or on the pill-free week of the pill, they often stabilise in pregnancy, flare at perimenopause then improve again in postmenopause.

A brain that is prone to migraine likes stability, so thinking holistically and more broadly than just about hormones is important. So steady caffeine, exercise, stress, alcohol, etc is great to support prevention. In terms of HRT, transdermal oestrogen regimes like the patch or gel with the hormonal coil or continuous progesterone are often preferred. Standard HRT doesn’t stop our natural background cycle but sometimes higher doses can help. Migraine-specific reliever treatments like triptans are important to look at too for when symptoms do occur. 

I’m not sure what to do

For personal advice about starting or optimising your HRT, you can book a consultation with BMS Accredited Menopause Specialist Dr Sam Morgan here. We’ll have the time we need to talk through your medical history and preferences and work out a regime to suit you. We can talk about your lifestyle and non-hormonal treatments too.