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Women prescribed HRT often say: “I’ve got my life back”. As a doctor, this is a hugely rewarding phrase to hear. Achieving good midlife health is a holistic process. Underpinning this is HRT’s ability to even out rollercoastering hormones. This guide to HRT prescribing aims to provide knowledge of when, why and how HRT is prescribed, how to adjust it and when to stop, as well as touching on vaginal health and contraception. Hopefully, you’ll be empowered to work with your healthcare professional to manage your individual HRT needs.

This article was included in issue 79 (winter 2018/2019) of The Menopause Exchange newsletter.

When to prescribe HRT
The menopause means your last menstrual period. The average age for this is 51, but the menopause can occur much earlier. The menopause can also occur after surgery or chemotherapy.

Your symptoms may start before or after your periods stop. How long they last varies from woman to woman. The symptoms include hot flushes, night sweats, difficulty sleeping, lower sex drive, vaginal dryness, headaches, mood changes and/or joint aches and pains. In 2016, the National Institute for Health and Care Excellence (NICE) gave a green light to consider HRT for women over 45 who have menopausal symptoms without the need for diagnostic tests. Younger women shouldn’t ignore menopausal symptoms, as they may also benefit from HRT.

Why prescribe HRT
HRT is the most effective treatment for menopausal symptoms. This is why, for most women under 60, the benefits of symptom relief and protection from osteoporosis outweigh the risks. However, you have to consider your own balance of risks and benefits.

How to prescribe HRT
Pills are the best known forms of HRT, but there are also patches and gels. The patches are clear, usually applied on your buttocks and need to be changed twice weekly. Some women struggle with adherence or skin sensitivity, but most get on well with the patches. The gels come in a pump pack or individual sachets and are applied to your skin every day.

The basic principle is that women experiencing menopausal symptoms need oestrogen. On its own, oestrogen over a long time may cause uterine (womb) cancer. So if you haven’t had a hysterectomy, you’ll need protection in the form of a progestogen. This is known as ‘combined HRT’. Women without a uterus only need oestrogen.

For combined HRT, there are different bleed patterns, depending on when your last period occurred. Women under 50 whose last period was within two years, and women over 50 whose period was within the last year, will need a ‘bleed’ preparation. This is called ‘sequential HRT’. There are two prescription charges for this type of HRT. Women whose bleeding has stopped can use a ‘no bleed’ or ‘continuous combined preparation’.

Erratic bleeding is common in the first few months of starting HRT; especially if you use continuous combined HRT too soon. But continuous combined HRT gives better protection overall and only has one prescription charge. So if you’ve been on a ‘bleed’ HRT for some time, you may wish to discuss changing to a ‘no bleed’ preparation.

Formulation of HRT
Most HRT contains oestradiol, which is the same hormone as your body’s natural oestrogen. The progestogen in HRT varies. The choice is based on a careful balance between your own need, risk and preference. Patches and gels have a superior safety profile, so may be chosen if you’re at a higher risk of blood clots, strokes and heart disease. Oestradiol given through your skin also avoids any problems with absorption from your gut.

The key to adjusting HRT is to identify any side effects. If HRT isn’t working for you, your healthcare professional needs to know how, so they can adjust the strength or formulation. If a standard combined oral contraceptive pill has always worked for you, you’re likely to get on with a similar progestogen in HRT, so knowing the name of this pill is helpful. If you have side effects such as acne, irritability or depression, you may be able to avoid these by using a specific progestogen. If you desire a more natural approach, you can use micronised progesterone, which is most similar to your natural hormones. Taking this at night may help you sleep.

Contraception is recommended until age 55 if you’re on HRT. You can use the contraceptive implant or progesterone-only pill alongside HRT. Or you can use a progestogen-containing intrauterine device, for reliable contraception and excellent bleed control. If used with HRT you only need oestradiol, making this a neat and convenient option.

Vaginal health
Vaginal dryness, itching, prickling and painful intercourse are common and little-discussed menopausal difficulties. These can be eased with vaginal oestrogen, which comes as a cream, vaginal ring or pessary. These have a very good safety profile and are commonly used long term to good effect. Using non-hormonal additional measures, such as oil-based lubricants and vaginal moisturisers can be very beneficial. It’s common to prescribe both HRT and vaginal oestrogen.

When to stop
There’s no particular cut off length of time for using HRT. But it’s considered good practice for women to take the lowest effective dose for the shortest amount of time.

For many women, this will be for around five years. But if you still need symptom control, or have other important factors (such as bone health) to take into consideration, this can be extended for as long as necessary, as long as your situation is reviewed at least once a year. Low-dose HRT tablets are available, while patches and gels can be adjusted quite easily.

About the author
Dr Jane Davis is a GP and speciality doctor in Sexual and Reproductive Healthcare in Cornwall.

Created Winter 2018/2019

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