HRT (hormone replacement therapy) is medication that replaces the hormones that fall during menopause: Oestrogen, Progesterone and Testosterone.
Oestrogen – fluctuating and falling levels can give rise to many symptoms for women. Oestrogen is the main component of HRT. The Oestrogens used in HRT are referred to as "natural" because they resemble substances produced in the body and include oestradiol, oestrone and oestriol which are usually made from soya beans or yam extracts. Conjugated equine Oestrogens made from horse urine are also sources of the naturally occurring Oestrogen, oestrone sulphate.
Oestrogen can be taken by a daily tablet, twice weekly or weekly patch, daily gel or implant. People respond differently to different types, routes and doses of oestrogen and sometimes several adjustments of therapy are required. If possible, any type should be tried for 3 months before deciding whether or not a change is required.
Benefits of oestrogen
- Relief from hot flushes and night sweats
- Probable protection from heart attacks and heart failure
- Possible reduced risk of Alzheimer's disease
- Reduced risk of osteoporosis and fractures
- Beneficial cosmetic effect on skin, improved hair and nails resilience
- Relief from vaginal dryness and discomfort
- Improved sleep
- Improved and stable mood
- Possible lower risk of type 2 diabetes
- Lower risk of urinary tract infections
Progesterone – this is a silent but essential component added to oestrogen for women who still have their uterus – or sometimes after hysterectomy too -
For women in whom the uterus remains a progestogen is added to the oestrogen to reduce the risk of oestrogen causing thickening, and possibly cancer of the endometrium (lining of the womb). Progestogens are mostly made from plant sources and resemble the naturally occurring progesterone, usually produced from the ovary in the second half of the menstrual cycle. The two main types of progestogen currently used in HRT are: those most closely resembling progesterone (dydrogesterone, drospirenone medroxyprogesterone acetate and micronised progesterone **see section below about utrogestan**) and those derived from testosterone (norethisterone, norgestrel and levonorgestrel) See section on mirena coil.
If side effects are experienced on one type, changing the type or route of progestogen may help. See section on mirena coil.
The duration and frequency of the progestogen determines the presence and pattern of bleeding and the type used is influenced by presence or absence of periods and age.
HRT in the Perimenopause: If HRT is commenced in the early stages of ovarian decline when periods are still present (the perimenopause), oestrogen is taken every day and progestogen for 10 to 14 days per month (sequential HRT). This cyclical progestogen induces a monthly withdrawal bleed in about 85% of women. If the periods are becoming infrequent, the progestogen can be taken for 2 weeks every 3 months, inducing a 3 monthly bleed (long cycle HRT).
HRT in the Postmenopause: If the periods have been stopped for more than 1 year (postmenopause) before starting HRT, or the women is aged 54 or more, progestogen can be taken every day along with the oestrogen (continuous combined HRT). Continuous combined, or period-free HRT, may cause some bleeding in the first 6 months, but should not induce bleeding thereafter.
This is a small device which fits inside the womb like an intrauterine conceptive device. It can usually be fitted in an out-patient clinic with minimal discomfort. Not only is it a contraceptive, but also it releases a small amount of progestogen hormone to the womb lining, making it thinner and hence making heavy periods lighter. At first it can sometimes be associated with irregular spot bleeding, which can be irritating, but this nearly always settles. Mirena can be used to provide the progestogen part of HRT in both the perimenopause and the postmenopause. With a Mirena in place, any form of oestrogen can be used to control menopausal symptoms. Mirena is particularly helpful when there are heavy bleeds with sequential HRT, when contraception is still required along with HRT, and when there are side effects from the progestogen part of HRT.
What is Utrogestan?
Utrogestan is a type of progestogen called micronised progesterone. It is derived from plants including yams, the root vegetable, and it is identical in structure to the hormone progesterone produced in our bodies. This is often referred to as being body identical. This is different to unregulated, compounded bioidentical hormones.
Women who take HRT and still have their womb (uterus) are required to take a type of progestogen in addition to oestrogen. This is because taking oestrogen can lead to a build-up of the lining of your womb over time. Taking a progestogen such as Utrogestan prevents this occurring.
How is Utrogestan taken?
Utrogestan is given as a 100 mg capsule. There are two ways of taking Utrogestan:
For women who have still been having periods in the last 6 to 12 months, the usual recommended dose is two 100mg capsules taken together each evening for two out of four weeks on a repeating basis.
For women who have not had a period for over a year, the usual recommended dose is taking one 100 mg capsule every evening without a break.
The information with the medication states slightly differently but it is far more straightforward to take it in this way and easier to remember. It is completely safe to take it in these ways.
Utrogestan is a natural sedative so can cause drowsiness in some women. It is therefore recommended to be taken at bedtime.
It is best to take Utrogestan on an empty stomach because eating food actually can increase its absorption.
What are side-effects with Utrogestan?
Some women experience side-effects initially which can include vaginal bleeding, abdominal bloating, lower abdominal pains or discomfort and breast tenderness. Bleeding can be intermittent or continual and can last for the first 3 to 6 months after starting HRT. If your bleeding worsens or does not improve with time then you should seek guidance from your menopause specialist or your GP.
Some women find that they feel lower in their mood when they take Utrogestan. This side-effect is less common compared with some of the older progestogens but can still occur in around one out of ten women. If you experience this side-effect which does not improve then there are alternative ways of taking Utrogestan which can be discussed with you by your menopause specialist.
What are the advantages of Utrogestan compared to other types of progestogens?
As Utrogestan is body identical, women usually experience less side effects compared to the older types of progestogens.
The older types of progestogens which can be given as tablets or as a combination patch, can be associated with a slightly higher risk of clot and heart disease. Studies have shown that women who take Utrogestan do not have a higher risk of clot or heart disease.
The small increased risk of breast cancer in women who take HRT is related to the type of progestogen in the HRT. Taking Utrogestan does not appear to be associated with an increased risk of breast cancer the first five years of taking it. After this time, the risk of breast cancer is very low and studies have shown that this risk is lower than the risk for a woman taking the older types of progestogens.
Even for women taking the older types of progestogen the risk of breast cancer is very low. The magnitude of increased risk with the older types of progestogen is similar to the increased risk of breast cancer that women have if they are overweight or drink around two glasses of wine each day.
Many people think of it as the “male” hormone which is true, but women produce testosterone too. In fact, women produce three times as much testosterone than oestrogen before the menopause.
Testosterone is made in the ovaries and adrenal glands, which are small glands near the kidneys.
Testosterone plays an important role in sexual arousal, sexual response, libido, bone strength, cardiovascular health, cognitive performance, energy levels and wellbeing in women. Many women find that taking testosterone improves their stamina and energy levels; both physically and mentally.
Testosterone is currently not licensed to women in the UK. However, it is prescribed by many menopause experts as it has proven benefits in numerous clinical trials. It is also very safe when it is used as prescribed.
There are usually no side effects with testosterone treatment as it is given to replace the testosterone that you are otherwise lacking. Very occasionally women notice some increased hair growth in the area in which they have applied the cream. This can be avoided by changing the area of skin on which you rub the cream.