Debby Holloway MBE, RCN Fellow, retired nurse consultant in gynaecology and menopause specialist, and member of the RCN Women’s Health Forum, answers the questions nursing staff are most likely to hear from patients and colleagues.
What does HRT do?
HRT replaces hormones that naturally decline during perimenopause and after menopause.
It helps control the symptoms some women experience. These include night sweats, hot flushes, sleep problems, anxiety and low mood.
Vaginal oestrogen is helpful for women who have a dry vagina and can find sex and/or walking painful and experience frequent urinary tract infections (UTIs).
Younger women who experience premature menopause when under 40 can take HRT to replace oestrogen and help protect their neurological, heart and bone health.
HRT can help to prevent osteoporosis and cardiovascular issues. Women who take HRT have a reduced likelihood of developing type 2 diabetes and colorectal cancers. There’s ongoing research into whether taking HRT can also help prevent dementia.
What are the alternatives?
For some people, diet and lifestyle changes can also be an effective way to ease symptoms and optimise health.
Cognitive behavioural therapy (CBT) can be useful to address some symptoms such as night flushes, sleep and mood.
Some people find it helpful to take herbs, such as red clover or black cohosh. However, there’s little evidence about the impact they have, as well as safety and drug interactions.
Where HRT is unsuitable or not preferred, alternative treatments may be considered, including certain antidepressants and painkillers.
Always ask
Don’t be afraid to ask about using vaginal oestrogen in combination with systemic HRT, says Debby.
“Vaginal dryness can cause a lot of pain, and this shouldn’t be ignored or accepted. As a workforce, nursing staff do a lot of walking, and with vaginal dryness, this can be distressing.
“You can use vaginal oestrogen at the same time as you’re taking HRT – it's not just used for making sex more comfortable. This should be addressed too, of course, but vaginal oestrogen is also used to minimise the chances of UTIs. It’s about people feeling comfortable in their daily lives.”
Is HRT safe?
For most women, HRT is considered a safe and effective treatment – it’s no more unsafe than any other prescription medicine. However, an individual’s suitability depends on their medical history, family history and personal risk factors, so treatment should always be tailored to the person.
Some people seek out transdermal progesterone gel on the internet, but this isn’t recommended as there is an endometrial risk. Patients should always speak to their prescriber before taking anything else.
What are the risks?
Different types of HRT carry different risks. The British Menopause Society has useful information on this.
There’s a higher risk of breast cancer if someone takes combined HRT for more than five years or more. But this risk drops after a person stops taking it. Read the NICE guidance on this.
- There’s a greater risk of a person developing breast cancer if they have a BMI of more than 30 and they smoke or drink. Exercise can help decrease the risk.
- There’s a lower risk of breast cancer if a person has oestrogen-only HRT.
- There’s a higher risk of blood clots if a person takes oestrogen orally.
- There’s also a greater risk of a stroke if HRT is taken orally. This is lower if transdermal HRT is used.
What are the side effects?
When someone starts taking HRT, they may have some irregular vaginal bleeding, but this should soon settle down.
Some people experience nausea, headaches, breast soreness, mood changes or acne. These are usually transient symptoms and can be addressed by changing the dose or method by which the treatment is taken. There’s often a swift improvement for people experiencing night sweats, but anxiousness and mood changes can take longer to adjust.
Patients should allow time for side effects to settle but seek advice sooner for catastrophic bleeding or if experiencing skin irritation when using patches.
Not all prescriptions work with an individual’s symptoms and patients should always return to their prescriber if they find their symptoms continue.
Some women who have experienced irregular cycles return to sequential bleeding and don’t want that back.
Patients need to be realistic though. While HRT can significantly improve symptoms, patients won’t feel the same as they did 10 years ago, and improvements may take time.
What’s the difference between oestrogen-only and combined HRT?
Oestrogen-only HRT is suitable for people who have had a hysterectomy, unless they had severe endometrosis or still have a cervix, as they would then need combined HRT. Women with a uterus also need combined HRT.
- Continuous combined HRT is both hormones, oestrogen and progesterone, and is used by post-menopausal women.
- Sequential combined HRT is both hormones but used by women experiencing perimenopause.
- Oestrogen-only HRT is used when a woman has had a hysterectomy.
- If a person's had endometrial ablation or womb ablation, they will be prescribed combined HRT as this protects the lining of the womb.
- If a person's in perimenopause, they may be prescribed oestrogen every day and progesterone every 10 to 14 days.
- A prescriber will also consider a person’s age and their periods. If they’re not having regular periods, they may be able to try moving to continuous. From around age 54, it’s probably OK to swap over to continuous anyway.
How is HRT taken?
HRT can be taken in a range of ways, including using a patch, gel or orally.
- Oestrogen can be taken orally, applied to the skin as a spray, gel or patch, or used vaginally. Oestrogen spray is a clear liquid that is applied to the skin of the arm and absorbed into the bloodstream. It must be applied to the same place for it to work.
- Progesterone is taken orally or intrauterine. It’s combined in some patches.
Is HRT contraception?
No. But a woman can take HRT alongside contraception, or tailor contraception to suit their individual needs and symptoms. For example, by using the Mirena coil.
If someone has problematic bleeding, a hormone intrauterine device (IUD) may be prescribed to provide additional oestrogen. This could be used as contraception, too.
Why do some women take testosterone?
If someone has had their ovaries removed, it can help as ovaries are the main source of testosterone. Some studies suggest taking testosterone may help with joint pain, brain fog and mood, but these aren’t currently prescribing reasons. There’s not been a lot of research on this, so long-term effects aren’t yet clear.
Testosterone can be used by women with a lower libido. It works for about half of women who take it.
Most testosterone products remain off-licence for female use in the UK. Find out more on the Women’s Health Concern website.
When should an individual stop taking HRT?
There's no fixed age at which someone must stop taking HRT. As women get older, clinicians may recommend lower doses or transdermal forms of HRT, such as patches or gels, which are associated with a lower risk of blood clots than oral preparations.
Some women can continue taking HRT into their eighties if they don't have side effects. However, starting HRT for the first time in the late sixties or seventies may be associated with a higher risk of cardiovascular complications, so treatment decisions should be made on an individual basis following specialist assessment where appropriate.
Myth or fact: does taking HRT lead to weight gain?
It’s a myth.
However, some women experience fluid retention. If they’re feeling low or have joint stiffness, they may eat more and exercise less too. Many women find that taking HRT can help their energy levels and motivation.
Menopause can also result in women putting weight on in their abdomen.
Who can’t take HRT?
Most women can take HRT safely, although some may need specialist advice before starting treatment. Women with a history of hormone-dependent cancers, such as breast or ovarian, can’t take HRT. If someone's had cancer in their twenties or thirties and it isn’t a hormone-dependent cancer, they can have HRT.
However, in some circumstances, women who have breast cancer may choose to use HRT to improve their quality of life. These decisions should be made with specialist guidance after considering the benefits and risks.
People need to be more careful if they have a history of blood clots or cardiovascular issues, such as myocardial infarction. Before taking HRT, these individuals should be referred to a menopause specialist.
For women who are overweight or have a higher risk of blood clots, transdermal HRT, such as patches, gels or sprays, may be recommended instead of oral preparations.
Why should all nursing staff understand HRT?
Menopause affects around half the population, and the nursing profession is female-dominated, so we’ll all regularly see and interact with people who could be benefitting from HRT. Understanding the basics of HRT can help nursing staff working in a range of roles support informed conversations, challenge misconceptions and signpost patients to appropriate care.
Further information
- Find out more about the RCN Women’s Health Forum.
- Visit the British Menopause Society website.
- Read NICE guidance: Menopause: identification and management.
- Read about Hormone Replacement Therapy (HRT) on the NHS website.
