FAQs: HRT/Menopause

Symptoms of the menopause in women are caused by fluctuating and dropping levels of the female hormone oestrogen and the body's response to this. The main effect is often hot flushes however the symptoms can affect various systems causing a wide range of physical and emotional symptoms. Most women have some effects from this but not all find them troublesome.

As a woman's ovaries begin to run out of eggs, the amount of oestrogen produced by them begins to fall, which causes the symptoms of the menopause. Periods continue at first, but as this fluctuates the bleeding pattern can become irregular, more heavy and then reduce and stop. This is called the perimenopause, and can last several years. Once periods have not occurred for 12 months, this is then defined as the menopause.

In the UK, the term hot flush is used, whereas in the USA it is described as a hot flash. Both are terms for the sudden feelings of heat mainly over the face, neck and chest, which many menopausal women get. The heat can be enough to cause redness and sweating but usually lasts only a few minutes.

Unfortunately Yes! Menopause can sometimes happen at a much younger age. Between 40 and 45 it is classed as early menopause. Before 40 it is termed premature menopause or premature ovarian insufficiency (POI). If you are under 45, having symptoms of menopause and very irregular or no periods and you know you are not pregnant, consult your GP who will usually arrange a hormone blood test to check for early or premature menopause.

In most cases there is no obvious cause for the ovaries to fail earlier in life, though premature and early menopause sometimes runs in families. Occasionally it can be caused by a medical treatment such as chemotherapy or by surgery such as removal of the ovaries. Women with premature or early menopause are generally recommended to take HRT until age 51 (average usual age of menopause).

A trans-woman, who is using external oestrogen to maintain their feminine characteristics, will not suffer menopause symptoms, unless she stops the oestrogen for some reason such as impending surgery, or chooses to reduce her dose as she gets older. A trans-man may still retain functioning ovaries unless they have been blocked by medication or surgically removed. These functioning ovaries may well cause some symptoms of menopause for trans-men when they begin to fail. Different doses and monitoring is required for treatment of menopausal symptoms in these situations so it is recommended to speak with your usual healthcare provider to ensure you have the correct treatment and dosage.

It is possible to indicate whether the ovaries are failing by having a FSH (Follicular Stimulating Hormone) blood test. This is generally high if the ovaries are failing. However, the ovaries tend to fail in fits and starts, so the timing of the test can easily miss a low oestrogen phase and then confusingly be normal. If a woman, between 45 and 55, has classic symptoms of the menopause, the blood test is not needed to diagnose the menopause. These tests can also be bought privately, but they are not recommended by NICE or the British Menopause Society as there are no rules or checks confirming their reliability.

However, if you are developing symptoms of the menopause and are under 45, and not using combined hormonal contraception, then FSH blood tests should be done to confirm premature or early menopause. Two tests would normally be taken 4-6 weeks apart. Sometimes other hormone tests would also be checked, to help exclude other causes of your symptoms. If you are concerned about early or premature menopause, it is important to discuss this with your GP.

AMH is a hormone produced by each ovarian follicle (a follicle is the egg producing part of an ovary). A woman is born with all the ovarian follicles she will ever have, and so AMH can be used to determine roughly how many there are left. AMH will drop to lower levels close to the menopause. However, the AMH level is not a very precise determinant of impending menopause, so should not be used to assist in diagnosis.

The hormones used in HRT are usually natural oestrogens derived from plants, such as yams and soy, however some are synthesised. They have the same molecular structure to the hormones produced by the body and are sometimes known as 'body-identical' hormones.

In the past oestrogen was sometimes extracted from pregnant horses urine which is now less commonly done, however Premarin tablets are an example.

Yes, but you need to be aware that taking hormones in HRT may flare up symptoms of endometriosis. If you have had a hysterectomy and have a history of endometriosis you should also use a progestogen alongside oestrogen as there may be deposits left which could be triggered by taking oestrogen only HRT and increase the risk of malignancy.

The Mirena IUS can be used for 5 years for HRT use. For the 5th year this is off label (outside the manufacturer's licence) and so the doctor prescribing the HRT takes responsibility for its use. Other hormonal IUS that contain the same amount of progestogen, 52mg levonorgestrel, for example Benilexa or Levosart, can also be used ‘off label’. The contraceptive effect of the these lasts 8 years if inserted under 45 years and up to 55 years of age if inserted after 45 years.

There is ongoing research into HRT and associated eye problems. The main symptoms that can occur include dry eyes, blurry or dim vision. Rarer problems include retinal vein occlusion, where a blood clot blocks the vein in the retina, and a change in eye pressure (uncommon with transdermal HRT). There may be an increased risk of cataracts but at present this is unclear and more research is needed.

The risk of dementia is increased if starting HRT over 65 years of age. Studies have shown that 9 more women in 1000 will develop dementia compared to women who never take HRT. It has not been shown to increase dementia risk for women under 65.

A strong family history is where 2 or more of your immediate family (parents, siblings or children) have experienced a blood clot, specifically a DVT (deep vein thrombosis) or PE (pulmonary embolism), before the age of 50.

There is a lot of research about cancer risks with HRT. The research results are complicated by the fact that HRT types and doses have changed a lot over the years, and often new results can appear to contradict other studies.

One fact which is clear is that using oestrogen alone, can overstimulate the womb lining (endometrium) and cause it to thicken and in some cases develop into a cancer of the endometrium. This is largely prevented by taking progestogen as well which limits the thickening. In sequential HRT, the progestogen is stopped regularly leading to shedding of the endometrium as a “period”. If you have had a hysterectomy, there is no womb and no risk of endometrial cancer when taking HRT.

There does appear to be a small increased risk of breast cancer in women over 50 who use HRT. However it is much less than the increased risk of breast cancer caused by drinking alcohol, or being overweight. This slight increased risk of breast cancer on HRT is most apparent in women using a combination HRT (containing both oestrogen and progestogen.) Taking Utrogestan (micronised natural progesterone) seems to have little effect. Studies have shown that oestrogen only HRT either does not increase breast cancer risk at all, or that the risk is lower than for combined HRT. Vaginal HRT does not increase the risk of breast cancer. The effect on breast cancer risk gradually reduces after stopping HRT.

There have been many studies looking at whether there are links between HRT and ovarian cancer. It is still not completely clear, but it may be that taking HRT contributes to up to one extra case per 1000 users which is less than 1% of all ovarian cancer diagnoses. Most cases of ovarian cancer are found in postmenopausal women. Other risk factors such as smoking and obesity are probably much more important than taking HRT. Ovarian cancer can be difficult to diagnose as the symptoms are often vague, so consult a GP if you are concerned.

Symptoms of ovarian cancer can be very vague. They can include:

• Bloating.
• Loss of appetite.
• Feeling full quickly.
• Abdominal pain, especially low down.
• Feeling the need to pee more frequently.
• Fatigue.
• Unexpected weight loss.
• New bowel symptoms after age 50.

Consult a GP if any of these symptoms become persistent.

The main risk factors for ovarian cancer are;

• Increasing age.
• Alcohol.
• Smoking.
• Being overweight.
• Faulty inherited genes, including the BRCA breast cancer genes.

It also seems that having fewer ovulation cycles will protect a woman against ovarian cancer. Starting periods young and having a late menopause increases the number of cycles a woman experiences. Ovarian cycles are reduced by; being pregnant, breast feeding, or taking a hormonal contraceptive.

This depends very much on what cancer you have had. Some cancers are hormone dependent and so you would be strongly recommended not to take HRT. It is best to check with your cancer specialist for each individual situation.

Usually if there has been breast cancer in a “first degree” relative (mother or sister), before age 50, then HRT would not be recommended. Some of these younger age breast cancers can be linked to faulty inherited genes, including the BRCA breast cancer genes, so genetic breast cancer screening and counselling may be offered. Discuss this with your GP.

HRT comes in many different formulations, which can be confusing! But, they all essentially provide oestrogen to the body. The different products allow a woman to choose the type which suits her best. In some products, progestogen is included, but sometimes it has to be taken separately as a tablet.

Patches, gels and sprays allow oestrogen to be absorbed through the skin (transdermal absorption). As oestrogen does not pass through the gut, less oestrogen is processed through the liver. This means there is a lower risk of blood clots (deep vein thrombosis and pulmonary embolism) with transdermal HRT than with some HRT tablets. It may also mean fewer side effects.

That depends on your age, when you last had a period, and how long you've been taking HRT. It is complicated!

If it is less than a year since your last natural period, then the HRT is likely to cause some thickening of the lining which will need to be shed regularly as a period. Taking sequential HRT leads to a regular bleed when progestogen levels drop.

If it is over a year since your last natural period, then the womb lining does not need to shed regularly and you can take continuous progestogen and you should be “bleed free”. However if you start a “bleed free” preparation before your body is ready, then you may get irregular bleeding. If this happens, you should swap to a sequential HRT to trigger regular monthly bleeds. This monthly bleed may eventually stop even when taking sequential HRT.

If you are taking sequential HRT and bleeding has stopped for over 12 months you can swap to continuous period free HRT or when you reach age 54.

If at any time, you develop irregular bleeding, whilst taking HRT, having previously been in a settled regular bleeding pattern, or not bleeding at all, consult your GP as this may be an indication of endometrial overstimulation or early endometrial cancer.

Yes! In most cases. However, there may be some rare situations where the reasons for the hysterectomy would mean that HRT would not be recommended (e.g. endometrial hyperplasia or endometrial cancer). If in doubt, discuss with your gynaecologist or GP. If you have had a hysterectomy, you will be able to take oestrogen only HRT and will not need progestogen as well to protect the womb lining, unless you have a history of endometriosis.

Progestogen is needed to protect the womb lining (endometrium) from overstimulation which can lead to endometrial cancer. It is very important to take it as instructed. There are several different progestogens and if one doesn't agree with you, then you may want to try a different one. Dr Fox only supplies Utrogestan as a progestogen as it is the most similar to natural progesterone.

Yes, you can, as long as there are no medical reasons not to take HRT. If the IUS is the Mirena (or other 52mg levonorgestrel coil eg Benilexa or Levosart), and it is within 5 years of fitting, then it will provide the progestogen needed to protect the endometrium from overstimulation and potential cancer. You can use an oestrogen only HRT, alongside the Mirena coil. This is one of the best ways of getting the progestogen when needed with HRT.
However, if it is a different lower dose progestogen IUS e.g. Kyleena or Jaydess, then you will need to use an HRT with oral progestogen as well. The hormone level from these is not sufficient to protect the womb lining from overstimulation and potential endometrial cancer. An IUS containing the same amount of progestogen as a Mirena IUS, such as Levosert or Benilexa, could be used but they are currently not licensed so would be used 'off label'.

Yes. Smoking does not affect HRT or increase the risk from using it. However smoking is a separate risk factor for many cancers including breast cancer, ovarian cancer and womb cancer and increases your risk of heart disease and osteoporosis. These are all conditions which increase in later life and so it is a very good idea to stop smoking at the menopause.

Osteoporosis is a condition usually of later life, where the spaces in the internal honeycomb structure of bones become larger. The “density” of the bones is reduced which can be diagnosed on a bone density scan. This weakens the bones, making them more susceptible to fractures and breaks.

Osteopenia is usually diagnosed after a bone density scan. It means that the bone density is lower than the average adult, but not low enough to be diagnosed as osteoporosis.

• Genes - close relative with osteoporosis.
• Elderly, females, caucasians and asians are at greater risk.
• Anorexia nervosa, low body weight.
• Previous fractures.
• Smoking.
• Excessive alcohol use.
• Rheumatoid arthritis.
• Overactive thyroid.
• Long term steroid use.
• Long term antiepileptic drugs.
• Over exercising (but moderate exercise levels help to strengthen bones).
• Coeliac and Crohn's disease.
• Hyperparathyroidism.
• Long term depo-provera contraceptive use.
• Some breast and prostate cancer treatments.
• Other medications- PPIs (gastric acid inhibitors), Glitazones (diabetes), some antidepressants.

Other conditions that may be linked to osteoporosis include diabetes and HIV (AIDS). People who have had an organ transplant, have respiratory diseases such as chronic obstructive pulmonary disease (COPD), and who are undergoing treatment for gender reassignment, may also be at increased risk.

HRT can be a very effective aid to maintaining bone strength, if you have, or are at risk of, developing osteoporosis. HRT is thought to be as effective as other osteoporosis drugs including bisphosphonates. It increases bone density and has been shown to reduce fractures. However as there are many different factors to be considered, this is a discussion to have with your GP, who may suggest tests including a bone density (DEXA) scan before making a decision.

There are several lifestyle choices which can help to maintain bone strength after the menopause:

• Healthy diet with adequate calcium and vitamin D (or take a vitamin D supplement).
• Keep active and exercise regularly with weight bearing exercise to increase muscle strength and, balance and coordination.
• Don't smoke.
• Avoid excessive alcohol.
• Maintain a healthy body weight.

See also Better bone health for everybody

Most HRT tablets contain lactose so if this is a problem you are better using a patch, gel or spray HRT preparation.

Most combined HRT tablets do not contain soya or peanut derivatives. However Utrogestan tablets contain soybean lecithin and cannot be taken by anyone with soya or peanut allergy. Estriol 0.01% vaginal cream contains peanut oil but Estriol 1mg cream and Blissel gel do not.

Tridestra and Indivina HRT tablets and Utrogestan contain gelatin but most other HRT products do not.

HRT can help with low libido by reducing physical symptoms of the menopause, such as vaginal dryness, and also by improving a woman's general wellbeing by reducing flushes, night sweats, and insomnia and improving her mood.

If low libido is not helped sufficiently by taking HRT, then low dose testosterone may be added.

A woman's natural testosterone levels decline significantly alongside declining oestrogen levels and testosterone is known to be linked with libido. Some women also find improved energy levels, memory and concentration when taking testosterone and it has a role in keeping bone and muscles strong.

However testosterone supplementation for women has not yet been licensed in the UK and so it is prescribed "off label" and is usually initiated by menopause specialists. Dr Fox does not supply testosterone for menopausal women.

Dr Fox supplies medications licensed and regulated by the MHRA (UK Medicines and Healthcare products Regulatory Agency). We only supply standard UK HRT products, most actually contain oestrogen in the form of bioidentical 17-β oestradiol, which is exactly the same chemical as a woman's natural oestrogen.

Compounded bioidentical HRT is often marketed as being safer and more natural having been produced from natural sources. The dose is often tailored to an individual, and usually contains combinations of several hormones - estradiol, estriol, and estrone. They sometimes also contain a progestogen and/or testosterone. However these products have not been tested and trialled extensively in the same way as standard HRT products. They do not have a licence from the MHRA, and therefore quality and consistency is not monitored. This can potentially lead to inadequate and varied dosing, in particular risking an insufficient progestogen dose to protect against endometrial cancer. NICE (National Institute for health and Care Excellence) states that "the efficacy and safety of unregulated compounded bioidentical hormones are unknown".

Further information:

• Bioidentical HRT
• Alternatives to hormone replacement therapy (HRT)

General healthy lifestyle measures can help with symptoms of the menopause. Eat a balanced diet, low in saturated fats and salt, with high calcium and vitamin D content. If you cannot obtain the recommended amount of calcium and vitamin D from your diet, you might wish to consider taking supplements.

Regular exercise helps to maintain bone and muscle mass. Alcohol is a known trigger for flushes and sweats, so a reduction can help, as will caffeine reduction. Losing excess weight can also reduce symptoms.

Smoking contributes to osteoporosis and heart disease risk. Smoking also increases the risk of breast cancer and many other cancers, so stopping smoking at the menopause will improve long term health.

Anxiety and mood symptoms, and also hot flushes and night sweats, may respond to Cognitive Behavioural therapy (CBT) either in person or online. St John's Wort, a herbal remedy for low mood, helps some women, but this cannot be used if also taking some other medications (including tamoxifen) and it should not be taken alongside HRT.

Herbal remedies which have been shown to help with menopausal symptoms are red clover, other soya based isoflavones and also black cohosh. Black cohosh can be effective but some black cohosh products have been linked to liver damage, which may recover on stopping. However, there are some reports of more serious, irreversible liver failure.

Vaginal dryness may be helped by non hormonal vaginal moisturisers such as Sylk, Replens MD , or YES. These can be used alone or in addition to a vaginal oestrogen.

It depends!
Yes, if you are over age 50 and have had a period in the last year, or under age 50 and have had a period in the last 2 years. HRT is NOT a contraceptive and contraception should be continued as well, until age 55. This would usually be either a barrier method such as condoms, a coil (IUD) or a progesterone only method of contraception; either POP, a hormone releasing intrauterine system (IUS), an implant or, if under 50 years, a depot injection.

No, if you are over 50, are not taking any hormones (HRT or contraceptive) and have had no period for over a year, OR are under 50, are not taking any hormones (HRT or contraceptive) and have had no period for two years. Or if you have had a hysterectomy!

If over 50 and not taking any hormones, either as a contraceptive or as HRT, contraception can be stopped 1 year after the final period/ menstrual bleed. If under 50 and not taking any hormones, either as a contraceptive or as HRT, contraception can be stopped 2 years after the final period/menstrual bleed. At age 55, all women can stop using contraception.

There is no clear consensus about the impact of oestrogen both natural and in the form of HRT on hearing loss, in particular otosclerosis and also on tinnitus. Otosclerosis is more common in women and there have been reports of it getting worse during pregnancy which is a natural high oestrogen state. Some studies have also shown that, in some women, tinnitus worsens at different stages of the menstrual cycle. For some women pregnancy can be associated with developing or worsening tinnitus. HRT itself has been linked to otosclerosis and tinnitus. However tinnitus often develops at a similar stage in life as the menopause so HRT may not be the cause. The answer is still unclear so if you have any concerns about your hearing discuss these with your GP.