HRT Choices

During the perimenopause, the ovaries begin to fail, resulting in reduced production of oestrogen, progesterone, and testosterone. After menopause, this production ceases. For women experiencing symptoms, hormone replacement therapy (HRT) can restore their quality of life. But how do you determine what’s right for you?

NICE menopause guidelines recommend individualised care; it is only when women receive the correct balance of hormones that their symptoms improve. The decision on the most suitable HRT should be made collaboratively between the woman and her clinician, taking into account her lifestyle and treatment goals.

Oestrogen

Oestrogen in HRT can be administered through patches, gels, sprays, or tablets (typically, oestrogen therapy starts with a patch or gel)

Oestrogen delivered through the skin as a patch, gel, or spray is referred to as transdermal. Research indicates that taking oestrogen orally in tablet form is associated with a slightly increased risk of blood clots. This risk becomes more significant as we age, as our natural clot risk increases with age. Women who smoke, are obese, have underlying medical conditions that increase clot risk, or experience migraines should avoid taking HRT in tablet form and opt for transdermal oestrogen.

Oestrogen absorbed through the skin is directly absorbed and bypasses the liver, which means it doesn’t increase clot risk.

Some patches and tablets contain both oestrogen and a progestogen. These combination products can be convenient for some women who prefer a simpler HRT regimen. However, the patches come in a single strength, limiting the ability to tailor the oestrogen dose to manage symptoms.

The gel (either in a pump form applied 1-4 times daily or sachets, usually 1-2 times daily) dose can be easily adjusted if symptoms are not adequately controlled. It should be applied once daily to clean, dry skin on the upper outer arm or inner thigh.

Positives:

  • Easy to use
  • Dose flexibility
  • No visible sign of HRT treatment

Negatives

  • Needs to dry for 5 minutes before dressing.
  • Larger area needed for higher doses. Sandrena is more concentrated that Oestrogel and less volume to apply.
  • Sandrena sachets are easy for travel.
  • Avoid close skin-to-skin contact with others for 60 minutes after application.

Instructions

  1. Rub in like moisturiser.
  2. Apply to a large area (inner thighs or upper outer arms)
  3. Wash hands after application.
  4. Wait 5 minutes before dressing.
  5. Avoid skin-to-skin contact within 60 minutes. Pets should not touch or lick the application site.

Patches are available in strengths ranging from 25 to 100 micrograms, allowing for the selection of the appropriate initial dose for each woman. They should be applied to clean, dry, non-hair bearing skin below the waist and usually changed twice weekly (FemSeven is changed once weekly).

Positives

  • Easy to apply
  • Deliver a steady dose, useful for migraine
  • Twice weekly application with minimal disruption
  • No need to wait before dressing

Negatives

  • May leave a glue residue around the patch.
  • Some may react to the glue.
  • Visible patch

Instructions

  1. Remove from packet, peel back half of protective backing.
  2. Apply to clean, dry, non-hairy skin below the waist.
  3. Press firmly for 10 seconds.
  4. Change twice weekly, alternating sides.
  5. Use baby oil to remove glue residue.
  6. Ensure safe disposal of used patches.

Lenzetto is a spray that delivers oestrogen to the skin and is a more recent addition to HRT options. It can be used 1-3 sprays per day and should be applied to the inner aspect of the forearm or inner thigh.

Positives

  • Easy to apply.
  • Rapid absorption (2 minutes)
  • Smaller application area

Negatives

  • Avoid close skin-to-skin contact with others for 60 minutes after application.

Instructions

  1. Prime pump with 3 sprays with the cover on before first use
  2. Apply to healthy, clean, dry skin on the inner forearm.
  3. Hold the container upright.
  4. Ensure no gaps between the cone and skin.
  5. Wait 2 minutes to dry.
  6. Avoid close skin-to-skin contact within 60 minutes. Pets should not touch or lick the application site.

Progestogen

All women using oestrogen replacement therapy and having a womb (uterus) require the addition of a progestogen to protect the womb’s lining. Some tablets and patches are combined and contain both oestrogen and a synthetic progestogen. However, separate prescriptions for oestrogen and progestogen are often preferred as they allow for better adjustment of oestrogen dosage to manage symptoms. 

Natural micronised progesterone is chemically identical to the progesterone produced by the ovaries and is derived from the yam root. In the UK, the licensed medication is a capsule called Utrogestan. Micronised progesterone has several advantages over synthetic progestogens:

  • More selective action, leading to fewer side effects.
  • Better tolerance
  • Sedative effect, aiding sleep when taken at night.
  • Calming, helpful for reducing anxiety.
  • Lower risk of breast cancer compared to synthetic progestogens.
  • No increased clot risk.
  • Micronised progesterone can be used in combination with oestrogen patch, gel, or spray in either a sequential (cyclical) or continuous combined HRT regimen.

 

Top Tips for Micronised Progesterone:

  • Take on an empty stomach (1 hour before or 2 hours after eating)
  • Take 30-60 minutes before bedtime for better sleep.
  • In sequential HRT, usually taken as 2 capsules at night for 12-14 days out of 28.
  • In continuous combined HRT, typically taken as 1 capsule at night, every night.

The Mirena intrauterine system (coil) can also provide the progestogen component of HRT. It is inserted into the womb and offers advantages such as reducing menstrual blood loss, contraception, and acting as a progestogen part of HRT for 5 years. This option can be particularly useful in the perimenopause when conception is still possible, and periods are often heavy.

Testosterone

There are currently no testosterone products licensed for use in women in the UK, and all testosterone products are prescribed off-label, supported by NICE guideline NG23. These products typically come in the form of a cream or gel, applied once daily to the outer thigh or lower abdomen. Rotation of the application site is advised to reduce the small risk of localised hair growth.

Localised Vaginal Oestrogen

Women experiencing symptoms of vaginal dryness, itchiness, soreness, pain during intercourse, frequent urination, nocturia (waking up at night to urinate), or recurrent urinary tract infections may be prescribed vaginal oestrogen for symptom relief. This treatment can be used alone or in combination with oestrogen patches, gels, sprays, or tablets. When used alone, there is no need for progestogen since the absorbed oestrogen dose is minimal and does not stimulate the womb’s lining. It comes in various forms:

Vagifem, Vagirux are available on prescription and Gina is available over the counter. A private prescription for Vagifem and Vagirux is normally more cost effective than buying Gina over the counter.

They are inserted high into the vagina using an applicator for 2 weeks, then continued twice weekly, usually inserted at night. 

Positives

  • No mess
  • Easy to use
  • Vagirux has a reusable applicator so more environmentally friendly.
  • Gina has been made available to buy without prescription (but there are restrictions which may make it unavailable to somebody who would benefit from it)

Negatives

  • Vagifem comes with a plastic applicator for daily use, which results in significant plastic waste.
  • Vagirux necessitates reloading the small tablet into the applicator, requiring good eyesight and coordination.

It is inserted into the vagina using the fingers, and normally used once daily for 3 weeks and then continued twice weekly.

Positives

  • There is no applicator, thus generating no waste.
  • The pessary has a waxy texture that can contribute to its lubricating qualities.

 

Negatives

  • May potentially harm latex condoms.
  • May result in a minor waxy discharge.

One applicatorful is inserted into the vagina once daily for 2 weeks and then continued twice weekly.

Positives

  • Can offer relief if the vaginal area is extremely dry.
  • Can also be applied to alleviate dryness and discomfort on the vulva if needed.

 

Negatives

  • May result in some messiness.
  • Individuals with peanut allergies (including partners) should steer clear of Estriol cream, as it contains peanut oil.
  • Can potentially harm latex condoms.

 

We may well prescribe Vagifem/ Vagirux for internal use and recommend using Ovestin cream with fingertip application to external vulval vaginal area (without the applicator)

One applicatorful is inserted into the vagina once daily for 3 weeks and then continued twice weekly.

Positives

  • Absorbed quickly in gel form.

 

Negatives

  • It is possible to experience itching or irritation upon initial usage.

It is inserted into the vagina either by the woman herself or with the assistance of a healthcare professional.

Positives

  • Remains in position for a duration of 90 days, eliminating the need for daily or weekly treatments.

 

Negatives

  • Typically, does not disrupt sexual activity, but if it does, it can be taken out before and reinserted afterward.

Intrarosa is a vaginal insert devoid of oestrogen but containing prasterone, which converts to oestrogen and testosterone in vaginal cells. It can be applied once daily to alleviate menopause-related vaginal or bladder symptoms. It offers ease of use, although it may affect latex condoms.