Living with HRT

If you've been on HRT for any period of time, you're hopefully having a review at least once a year. But, we all know that some routine things slipped during the pandemic, so if you haven't seen a medical professional in the last 12 months then get in touch with your practice. It may be a GP, nurse, or pharmacist who does the review - usually they will ask you how you're getting on, whether you're having any side-effects, and check your blood pressure and weight.

We know that women vary in how much oestrogen they need. Those who have premature ovarian insufficiency - the menopause before the age of 40 - often need much higher doses of HRT until they reach the average age of the menopause (51). Whereas those who continue into their 60s or longer can often use a lower dose. So if your symptoms are well controlled, and have been for months or years, the healthcare professional might suggest that you reduce the dose - maybe from two squirts of gel to one, from a higher to a lower dose sachet, or occasionally by cutting a patch in half. Don't cut patches without professional advice though - it only works for some of them.

If you use a Mirena coil for the progestogen part of your HRT they will want to check that it is in date. A Mirena used only for contraception and put in after the age of 45 can stay for 10 years, but it can only be used for five if it is part of HRT. When it runs out you'll need to have it changed, or use a different type of progestogen - using a tablet or combined patch - if you don't want another one. This doesn’t apply to women who have had a hysterectomy - they don’t need a progestogen at all.

Broadly speaking, HRT comes in three categories; tablets, transdermal HRT - sprays, patches and gels - and vaginal HRT which is used just for symptoms of genital dryness. We know that using tablets roughly doubles your background risk of a venous thromboembolism (VTE), a blood clot in your veins. Other risk factors for a VTE include obesity, being aged over 60, smoking, immobility - for example, after an operation - and cancer. So as you get older, your background risk of VTE goes up simply due to age, and more if you’ve gained a bit of weight or acquired a relevant medical condition - it might therefore be appropriate for your healthcare professional to suggest that you change to a transdermal preparation, which carries no increased risk of VTE.

Changing to a transdermal preparation is also sometimes suggested for people who find that their sex-drive is still a problem after starting HRT. Tablet HRT increases the levels of sex hormone binding globulin, a protein which binds to testosterone. Changing to a transdermal preparation might therefore increase the free testosterone in your blood, which might give your libido a boost.

Finally, the big question - do you need to stop? If so, why, when, and how? There are no cut and dried rules for this. Your healthcare professional needs to help you to balance the benefits of HRT on your menopausal symptoms, against the risks which increase with age, particularly of cardiovascular disease. When you decide that it's time to stop, it's usually sensible to cut the dose down gradually.

In a natural menopause the levels of oestrogen are all over the place - up one day, down the next - which can give rise to severe symptoms. A steady reduction in the dose of your HRT is much more predictable and most women don’t have any problems coming off HRT. Doctors usually discuss this for the first time around five years after starting.

Managing HRT is a good demonstration of why communication is important and medicine is an art not a science. If you’re worried about anything, talk to your healthcare professional. They will probably be able to help you make a shared decision about the best course of action for you.