Does Hormone Replacement Therapy (HRT) Need Adjusting Over Time?
Hormone replacement therapy (HRT) is the recommended first-line treatment to improve perimenopausal and menopausal symptoms. It works by replacing the estrogen, and for most women, progesterone, naturally produced by the ovaries. During the perimenopause (the stage of the menopause transition before periods stop), levels of estrogen start to fluctuate, resulting in the symptoms that most (75%) women experience during this time (1,2).
In addition to causing symptoms, declining levels of estrogen may also be associated with a range of medical conditions, including heart disease and strokes (6), osteoporosis (bone thinning), muscle and joint degeneration, and Alzheimer’s disease. Estrogen loss is also associated with fat re-distribution and aging effects on skin and hair.
Most women who start HRT will be given a combined preparation containing both estrogen and progesterone, as progesterone stops the lining of the uterus (womb) from building up under the influence of estrogen, which on its own carries an increased risk of cancer. However, women who’ve had their uterus removed (a hysterectomy) can have estrogen-only HRT, without progesterone. Some women may also be given testosterone in addition to their HRT (3,4).
HRT comes in the form of tablets, patches, gels, and sprays, and may consist of a combination of estrogen and progesterone in one preparation, or as separate individual preparations. For example, there are combined estrogen and progesterone tablets and patches, as well as separate ones. What’s best for an individual woman depends on their particular circumstances, medical history, and preferences (5).
What’s the difference between Sequential and Continuous Combined HRT?
Sequential Combined HRT
Women who are still having periods or whose last period was less than 12 months ago will usually be started on sequential (also called cyclical) HRT and will continue to have a monthly bleed. With sequential HRT, estrogen is taken throughout the whole month, and progesterone is taken for only part of the month (usually 12-14 days). This primes the uterus to shed its lining at the end of the progesterone phase. The bleeds that occur on sequential HRT aren’t real periods but are “withdrawal bleeds” caused by stopping the progesterone each month. After 4-5 years on sequential HRT, or around the age of 55, most women will be switched to continuous combined HRT.
Continuous combined HRT
With continuous HRT, estrogen and progesterone are taken all the time without a break. Continuous HRT is used in post-menopausal women who haven’t had a period for more than one year, or in women who’ve been on sequential HRT for more than 4-5 years. Continuous HRT isn’t generally used when the last period was less than 12 months ago, as this may result in irregular, troublesome bleeding.
How do I know my HRT is working?
Most women start HRT to relieve their menopausal symptoms, so the first sign that their HRT is working is that their symptoms improve and they start to feel better in themselves. However, some women find that some symptoms remain, or that they have side-effects, requiring an adjustment to their HRT, either by changing the dose or type of HRT. It may take several months and sometimes some trial and error to find the right dose or preparation, but it’s important to persevere.
It’s important to understand that HRT doesn’t always relieve all symptoms completely, and in this case the aim would be to reduce them to a tolerable level that doesn’t negatively affect quality of life. Remember that the effects on bone and heart health continue even if symptoms aren’t completely controlled.
Will my HRT stop working?
Some women find that even though they’ve been fine for many years on a particular HRT regimen, their symptoms start to come back. No one fully understands why this is, but for some women on transdermal HRT (patches, gels and sprays), absorption of the hormones through the skin may change. This could be because as women get older, the receptors and pathways responsible for estrogen’s effects are altered, but we don’t really know, and this is an important area for research. Reassuringly, adjusting the dose or changing to a different HRT preparation will usually improve things.
Should my HRT be reviewed and how often?
Guidelines recommend that once you’re stable on an HRT regimen, you have a yearly review to check that your symptoms are still controlled, that you don’t have side-effects and that you haven’t developed any problems that might have an impact on your HRT or your health in general. This is also an opportunity to discuss any new research data or menopause treatments, and to make adjustments to your dose and type of HRT if necessary.
Why New Woman Health?
At NewWoman Health we have a commitment to educating, advising, treating, and supporting women approaching, during, and following menopause. Our wide range of medical and lifestyle interventions helps women to manage or minimise their menopause symptoms and improve their quality (and potential longevity) of life in an aspirational and uplifting way.
If you’re concerned about your menopause transition and/ or other menopause-related problems, including treatment options, we can support you with our personalised medical consultations with menopause specialists. Take the next step in ensuring your long-term health and quality of life by booking a consultation with us today.
References
- NICE (2015) ‘Menopause: diagnosis and management’, www.nice.org.uk/guidance/ng23
- British Menopause Society (2020), ‘BMS & WHC’s 2020 recommendations on hormone replacement therapy in menopausal women’
- Furness S, Roberts H et al (2012). Hormone therapy in postmenopausal women and risk of endometrial hyperplasia. Cochrane Database Syst Rev. Aug 15;2012(8):CD000402. doi: 10.1002/14651858.CD000402.pub4.
- https://www.ncbi.nlm.nih.gov/books/NBK493191/
- https://www.webmd.com/menopause/menopause-hormone-therapy
- https://www.bhf.org.uk/informationsupport/conditions/heart-attack/women-and-heart-attacks
