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The Menopause Exchange Blog

OESTROGEN-ONLY AND MONTHLY-BLEED HRT

HRT can be used in many ways. The decision to prescribe HRT in a particular form is made once you have had a comprehensive medical history with risk-benefit evaluation and you’re happy to consider HRT. There is a settling in phase of up to three to four months when starting HRT or when changing formulations. In this article, we look at oestrogen-only HRT and ‘monthly bleed’ sequentially combined HRT. ‘No bleed’ continuous combined HRT was discussed in the last issue.

This article was included in issue 75 (winter 2017/2018) of The Menopause Exchange newsletter.

Oestrogen-only HRT
You have two options when considering oestrogen-only HRT – systemic use to control your menopausal symptoms, or local use, with lower doses to help control bladder symptoms and vaginal dryness.

Systemic oestrogen only HRT
This type of HRT is suitable if you have had a hysterectomy (surgery to remove your uterus). If your ovaries were removed at the same time as your uterus, you will be recommended oestrogen-only HRT immediately. If your ovaries were left in place during your hysterectomy, you can wait until you have menopausal symptoms such as hot flushes and night sweats before starting HRT. These symptoms are a sign that your ovaries have failed and are now not providing oestrogen.

Two types of oestrogens are available for systemic use: oestradiol or conjugated equine oestrogens. Oestradiol can be prescribed in various forms including tablets, patches and gels, but conjugated equine oestrogens are available as tablets only. There are currently problems with obtaining supplies of oestrogen implants. The National Institute for Health and Care Excellence (NICE) published guidance for menopause management in November 2015. This guidance recommends patches or gels for any woman with a high body mass index (BMI greater than 30) or with a risk for deep vein thrombosis (blood clot). Otherwise, tablets suit most women.

It’s easier to remember to take a daily dose, especially if you are already on tablets for another condition, such as high blood pressure. Women with skin conditions or an allergy to adhesive plasters may need to avoid patches. Some patches are changed once a week and others twice a week. Gels are applied on a daily basis, with the dose amount applied lightly over a large surface area.

Local oestrogen-only HRT
Oestrogen-only HRT is prescribed for bladder symptoms and vaginal dryness. It is mainly for local symptom relief. The low potency and doses available won’t help to control hot flushes and night sweats. Local HRT can be prescribed as vaginal tablets, creams or vaginal ring.

Combined HRT
Women with an intact uterus will be prescribed HRT that combines oestrogen and progestogen. Oestrogen helps to control classic menopausal symptoms such as hot flushes and night sweats. As oestrogen stimulates the uterine lining, women with a uterus should be prescribed a progestogen as well to protect against uterine lining (endometrial) overgrowth or cancer.

Combined HRT is available in two forms. If you are peri-menopausal, this means you still have some internal cycling of your own hormones and haven’t become totally bleed free, and you should be prescribed a type of HRT that gives you monthly bleeds.

Once you have had a year free from natural periods or bleeds, you are post-menopausal. Post-menopausal women can be prescribed HRT formulated as ‘bleed free’. If a post-menopausal woman is prescribed a ‘no bleed’ type of HRT, and hasn’t settled on this treatment by six months and become bleed free, she will have investigations. If she has no specific risks associated with using HRT, she can revert back to using monthly bleed HRT. For more information on ‘No bleed’ HRT, see the article in the last issue.

Monthly bleed HRT products are available as tablets and patches. If a gel oestrogen is prescribed in a woman with an intact uterus, she will also need a progestogen to protect her uterine lining. Progestogen can be given separately as tablets or capsules or via the Mirena intra-uterine system (coil embedded with progestogen and inserted into the uterus).

Available products
Monthly bleed HRT provides a choice of different progestogens. Your doctor will help you decide which one to use after taking a medical history. For example, if you have had a heavy bleed pattern, norethisterone will be the progestogen of choice as it’s good for bleed control. But if you have diabetes where a decision is made to use tablets, then dydrogesterone is the progestogen chosen as this doesn’t have any impact on insulin resistance.

Utrogestan is a natural progesterone that’s used in women who have problems with progestogen sensitivity. The Mirena coil can be used with oestrogen as HRT as long as it’s considered to be suitable for the woman. It also helps to control heavy bleeds and provides contraception.

Women who use monthly bleed HRT tablets or patches are advised that they need additional contraception, generally until they reach 55. This can be in the form of barrier methods, such as condoms or vaginal diaphragms, or the progestogen-only pill, which can be taken with HRT.

Tridestra is a form of HRT that can be used in perimenopausal women, providing a three-monthly bleed pattern. It can be considered in women with erratic bleeds that are more than three months apart. Many women may, however, prefer light monthly bleeds, rather than the heavier three-monthly bleed with Tridestra.

Summary
If you’re going through the menopause and struggling with symptoms, speak to your GP. A number of options may be available to you so that your symptoms can be controlled effectively.

You will need to have a risk-benefit evaluation at the beginning of your treatment and then on an annual basis after starting HRT. With time, the type of HRT formulation can be changed and, depending on how long you have been on HRT, if a decision is made that you can continue with HRT, you may be able to take lower doses.

About the author
Dr Nuttan Tanna is a pharmacist consultant at The Northwick Park Menopause Clinical & Research Unit at London North West Healthcare NHS Trust, Harrow, Middlesex

Created Winter 2017/2018

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