What is the best hormone replacement therapy for menopause?

To make an informed decision if HRT is right for you, it is necessary to understand exactly how the treatment works.

When you go through menopause, your body will slowly produce less and less estrogen. Oestrogen actually refers to three types of reproductive hormone; oestradiol, oestrone and oestriol. Produced mostly in the ovaries, but also in the adrenal glands and fat tissue, estrogen is responsible for controlling a woman’s menstrual cycle and physical development during puberty.

As you age and stop ovulating, levels of estrogen drop - this is a very gradual process, and it will not happen overnight. Unfortunately, as these levels drop, a woman will start to suffer from the symptoms of menopause, namely:

• hot flashes (also known as hot flushes)
• mood swings
• loss of libido (lowered sex drive)
• insomnia
• vaginal dryness
• concentration problems

HRT artificially increases estrogen levels in your body so you never experience the symptoms of that deficit. Essentially, HRT is a hormone supplement that your body needs to stay healthy. Once a few years have gone by and symptoms ease, you can stop taking HRT.

Breast cancer

In 2002, a study was published that linked HRT to breast cancer. The Women’s Health Initiative invited 27,347 participants to take different forms of HRT under clinical supervision. 16,608 of them, all women with uteri, were given 0.625 mg of conjugated equine estrogens (CEE) and 2.5 mg of medroxyprogesterone acetate. The remaining 10,739, women without uteri, received 0.625 mg of conjugated equine estrogen or a placebo.

Five years later, the first results were published. The former group, women with uteri, recorded a higher frequency of coronary heart disease and breast cancer, although a reduced incidence of bone fractures and colorectal cancer. The trial continued for the latter group, women who had undergone hysterectomies, for almost seven years in total. It was found that this group experienced a slight increase in the risk of ischemic stroke.

Overwhelmingly, the result was a loss of confidence in the treatment - a sentiment that has lasted until today. However, since then, there have been several changes to the formula of treatment, including reducing the concentration of estrogen and introducing progesterone.

It was also realised that one of the largest limitations of the WHI’s study was that the majority of their participants had last menstruation over a decade ago. Subsequent studies and analysis has shown that HRT is considerably more effective and safer for women who are pre-empting menopause or have recently stopped ovulating.

There is also evidence to suggest that estrogen-only medications increase the risk of endometrial cancer in women who have not had a hysterectomy. However, that risk is mitigated when estrogen is combined with progesterone - this applies to the use of contraceptives as well as hormone therapy. In fact, many clinical trials have found the use of combined hormonal medication significantly reduces the chance of a woman developing endometrial disorders, including cancer.

HRT has evolved enormously since it was first made available in the 1960s. If you are considering taking it for the first time, it is very important to communicate your personal circumstances to your doctor.

Hormone replacement therapy can be divided into two types; estrogen-only treatments and combined treatments.

The estrogen-only option is prescribed if you have had a hysterectomy, whereas the combined option is prescribed if you still have a uterus. As mentioned previously, taking the relevant treatment will prevent serious complications and guard against future health conditions. If you are ever unsure about the suitability of a treatment, speak to your doctor.

The method of applying or ingesting treatment will depend as much on personal preference as medical recommendation. Everyone is different and your decision as to which of the following to use should be based on a consultation with your doctor.

Tablets

Probably the most popular form of HRT, oral medication is easy to take. Just as you would with an oral hormonal contraceptive, you should remember to take one tablet at around the same time every day.

Both estrogen-only and combined HRT is available in tablet form.

One downside of orally administered HRT is that it slightly increases the risk of blood clots compared to other methods - however, the benefits of treatment still far outweigh the risk.

Patches

Again, both estrogen-only and combined skin patches are available.

You should apply patches to an area of skin unlikely to rub. Unlike tablets, you do not have to remember to use this treatment daily, instead apply every few days.

Another advantage of this transdermal application method is that your risk of experiencing blood clots is not increased.

Implants

A doctor will perform a short, painless procedure when inserting implants. Your belly will be numbed with a local anaesthetic, and the implants will be inserted just beneath the skin. Implants will generally last a couple of months before losing their effects.

As the implants are estrogen-only, you will have to take supplemental progesterone if you still have your uterus.

As a method of HRT, implants are less common.

Vaginal estrogen

Vaginal estrogen comes in various forms - creams, pessaries and vaginal rings. All of these are inserted into the vagina and alleviate local symptoms, such a vaginal dryness.

Unfortunately, this method will not ease other menopausal symptoms, like hot flashes and mood swings. However, there is no increased risk of breast cancer with this method and no need to take progestogen (progestin), even if you have not had a hysterectomy.

On the other hand, vaginal estrogen is well-tolerated and you are unlikely to experience side effects.

Estrogen gel

Similar to the patch, estrogen gel is applied to your skin and does not increase the risk of blood clots. However, you should apply it every day with no breaks.

As it is an estrogen-only treatment, you will need to take progesterone alongside the gel if you still have your uterus.

Testosterone

Despite its reputation, testosterone is not exclusively a male-hormone. Women also produce testosterone, though in lower levels. When you go through menopause, these hormone levels decrease even further leading to symptoms like a loss of libido, lowered energy levels and mood changes.

Currently, testosterone is not an official HRT treatment for menopause. However, a doctor may still prescribe it if they think it might help. Speak to your GP if you think this treatment will benefit you.

You probably guessed this was coming, but the decision as to which hormone replacement therapy option is best really lies with you and your doctor. There are a number of risk factors that will make certain treatments unsafe, such as if you have had a hysterectomy, smoke, are overweight or have underlying health conditions. Other than that, you may find an option that suits many women well does not work for you - you should always communicate your feelings about all treatments to your GP or gynaecologist.

If you have previously been prescribed a treatment and are looking for the best place to reorder it without the need to return to the doctor or pharmacist, euroClinix offers various medications to order online. Due to the nature of this medication, you will need to complete an online consultation (where you should detail your medical history) - however, this is quick and easy to do.

Treatment available from euroClinix includes:

• Premarin
• Elleste
• Prempak C
• Kliovance
• Premique
• Livial
• Evorel
• Elleste Solo MX
• Evorel Sequi
• Evorel Conti

Click any of the above links to go to a treatment’s dedicated page.

The above medications are approved by the relevant healthcare bodies in either the US and UK, with the Food and Drug Administration (FDA) and National Health Service (NHS) as well as national institutes, such as the North American Menopause Society.