The Menopause Exchange Blog

OESTROGEN AND HRT

Oestradiol is your body’s key form of oestrogen. At the menopause, your oestradiol levels drop dramatically, driving menopause symptoms such as hot flushes, insomnia and brain fog. HRT eases these symptoms by balancing your missing hormones.

This article was included in issue 91 (winter 2021-22) of The Menopause Exchange newsletter.

Most HRT products available in the UK contain body-identical oestradiol and are taken by mouth or through your skin. For symptoms affecting your bladder, vulva, vagina and other urogenital areas, vaginal oestrogen can work well when used on its own or with systemic HRT (such as tablets and patches).

Types of HRT products
You need to take oestrogen with a progestogen unless you’ve had a hysterectomy. You’re advised to use contraception until you reach the age of 55, as HRT isn’t a contraceptive.

Monthly bleed HRT
You use oestrogen every day, and progestogen for the last 12 to 14 days of each cycle, giving you a monthly bleed. This is suitable if you’ve had a period within the last 12 months. If you’ve struggled with unpredictable bleeding in the perimenopause, this regime provides a predictable bleed. But if your periods have almost stopped before you start HRT, this can be an unwelcome effect. Using a monthly bleed regime for more than five years isn’t recommended.

Three-monthly bleed HRT
Some HRT triggers a bleed every three months. In the UK, Tridestra is the only HRT tablet providing a quarterly bleed. Tailor-made regimes are sometimes prescribed to women struggling with side effects from progestogen. It’s important to take enough progestogen to reduce over-thickening of the uterine lining and endometrial cancer. Using progestogen for fewer than 12 to 14 days each month should be treated with caution.

No bleed HRT
This uses oestrogen and progestogen every day. It’s suitable if you’ve had no periods for the past 12 months. You can get bleeding in the first few months but this should be assessed if it carries on after four to six months.

Oestrogens used in HRT
Most HRT products currently available in the UK contain oestradiol. The oestradiol in HRT is made to look identical to your body’s oestradiol so it works in the same way. This is why it’s called “natural” or “body identical” oestrogen. There’s a small increased risk of blood clots if you’re taking oestrogens by mouth (in tablets). There’s less chance of blood clots if you use the “transdermal” route (through your skin). 

Oestradiol through your skin
Oestradiol can be taken through your skin as a gel, patch or spray.
Oestrogen gels are clear, and dry rapidly with no visible residue. You put them on the skin of your arms or thighs once a day. Your oestradiol levels peak within a few hours and tail off within 24 hours. The doses can be adjusted to suit your own needs. Oestradiol gels come in an 80g pump pack (Oestrogel 0.06%) or a single dose sachet (Sandrena). If you still have your uterus, you’ll need a separate progestogen product.
Oestradiol patches are square-shaped and transparent. You stick them on non-hairy skin below your waist, usually on your bottom so they’re covered by underwear/swimwear. Most patches are changed twice a week, but some are changed once a week. The oestradiol is absorbed steadily. Patches are suitable for women with conditions triggered by fluctuating hormones, such as migraines and mood swings. The doses can be easily adjusted with different-strength patches. Oestrogen-only patches are available for women who’ve had a hysterectomy or are using an up-to-date Mirena IUS. Popular examples include Evorel and Estradot. Women who haven’t had a hysterectomy need additional progestogen to protect their uterus; this is available in fixed-dose patches (e.g. Evorel Sequi/Evorel Conti). You can also use an oestrogen patch with a separate progestogen tablet.
Oestradiol spray (Lenzetto) is oestrogen only HRT. You put it on the lower part of your arm.

Oestradiol tablets
Oral oestradiol is convenient to use and suitable for fit, healthy, low risk women. It’s broken down by your liver. It has a higher risk of blood clots and is less good for your cholesterol profile than oestradiol patches. But oestradiol has much less impact on your body than the synthetic oestrogen used in the combined oral contraceptive pill. Oral oestradiol is available on its own (e.g. Elleste Solo, Bedol, Zumenon). Its negative effects may be reduced by the choice of progestogen. HRTs containing natural progestogens are favoured (such as Femoston/Femoston Conti or Bijuve). 

Conjugated oestrogen
Conjugated equine oestrogen was popular in the past. It contains forms of oestrogen found in horses. It’s available as oestrogen on its own (Premarin) or with a progestogen (Premique low-dose). These products are still helpful for some women today. This type of oestrogen can only be taken by mouth.

Vaginal oestrogen
Vaginal dryness, painful sex and an irritable bladder are caused by urogenital atrophy. This is when your bladder and genital tissues ‘cry out’ for oestrogen. Systemic HRT helps some women, but many women gain additional benefits from vaginal oestrogens. Oestradiol can be delivered by pessaries (Vagifem) or a vaginal ring (Estring). Oestriol is an oestrogen specific to vaginal products in the UK. It has a strong effect on vaginal tissues but a weak effect elsewhere. It’s available as oestriol cream and, more recently, Imvaggis (a soft pessary) and Blissel (a vaginal muco-adhesive gel).

About the author
Dr Jane Davis is a GP from Cornwall with a special interest in women’s health. She’s a FSRH registered trainer, BMS menopause specialist and PPMC tutor. She loves teaching and is a board member of the Primary Care Women’s Health Forum.

Created Winter 2021-2022
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