FAQ

Sequential combined

Sequential combined hormone replacement therapy imitates the natural cycle of a woman. While oestrogen is taken on every day of the 28-day treatment, progestogen is only added during the second half, for 10-14 days.

After the final tablet containing progestogen, a menstruation-like bleed occurs.

Continuous combined

Oestrogen and progestogen are taken together daily throughout the 28-day cycle leading to complete cessation of menstrual bleeding while relieving menopausal symptoms.

The most common and most convenient is a fixed combination of oestrogen and progestogen in a single tablet.

Although occasional spotting (loss of small amounts of blood) may occur, bleeding stops completely in the majority of women after a few months of therapy and a completely bleed-free condition may be achieved.

Risk factors for osteoporosis

Age > 60 years
Ethnicity: White women have a higher risk than Afro-Caribbean women.
Early menopause: Higher risk of osteoporosis with early menopause.
Family history of osteoporosis increases a woman’s risk
Weight: Very thin women are at increased risk of osteoporosis.
Smoking: Smoking increases risk of osteoporosis
Exercise: Lack of exercise may increase risk of osteoporosis
Diet: Low calcium intake may be associated with poor bone quality
Medicines: Some medicines, such as corticosteroids increase risk of osteoporosis

Foot Notes

Cancer Research UK.
Medicines and Healthcare products Regulatory Agency (MHRA) Drug Safety Update. Vol 1 Issue 2 September 2007.
HRT Core SPC, 3rd rev, Expert Statement.
IMS Updated Recommendations on postmenopausal hormone therapy, Climacteric 2007;10:181-194.
British Menopause Society Council Consensus Statement on Hormone Replacement Therapy February 2008.
MHRA Drug Safety Update September 2007 Vol 1 Issue 2 HRT-Updated Advice.
Estrogen and progestogen use in peri and postmenopausal women: March 2007 Position Statement of the North American Menopause Society. Menopause 2007 Vol 14 No 2 2007.

Why do I not have regular bleeds with sequential HRT?

Sequential combined (where you take oestrogen every day but add in the progestogen for 10 to 14 days of each 28-day cycle) should produce regular predictable and acceptable bleeds starting towards the end of, or soon after you finish the monthly progestogen. These bleeds may not be as regular as those you experienced before the menopause and some women (about one in 20) do not have a bleed at all when on sequential HRT. If you are unhappy with the timing of your bleeds, or their heaviness, see your doctor because a small dosage adjustment may produce more acceptable bleeds.

Why am I still bleeding with continuous combined, ‘period free’ HRT?

It can take several weeks for this type of HRT to have its full effect on lining of the womb. During this time it is very common for women to experience some vaginal bleeding. This bleeding is likely to be irregular and unpredictable. It can vary from the odd spot to normal period-like bleeding on and off for the first three months of therapy, gradually becoming less and less. It is important to persist with HRT in the first few months, since it is only with persistence that the bleeding stops. However, if you have any worries or if your bleeding has failed to stop, contact your doctor.

Please click here, click to read more about continuous combined.

My hot flushes have improved but my vagina still feels sore.

Hot flushes will normally start to improve after about one month of HRT, and you should have the full benefit after about three months. However, vaginal symptoms can take much longer to resolve, sometimes up to six months. Talk to your doctor if you should wait or take some extra treatment. Oestrogens can be given locally to the vagina in the form of a vaginal tablet, cream, suppository or ring. The ring has to be inserted into the vagina by a doctor or nurse in contrast to the other application forms which you can insert yourself. They usually contain a low dose of oestrogen. These products act locally on vaginal tissues and have little or no effect on the rest of the body.

My breasts are particularly tender, what can I do about it?

Increased breast density and tenderness are very common in the first few weeks after starting HRT but should improve within three months of therapy. Dosage plays a major role in the occurrence of breast complaints. Thus, it is worth checking with your doctor that you start with the lowest dose of HRT that is effective for you.

If tenderness has not improved after three months you may want to try a different kind of HRT. Your doctor may suggest a brand with a lower dose of oestrogen or a different type of progestogen. It is worth checking with your doctor that you are on the lowest dose of HRT that is effective for you.

Why have I gained weight on HRT?

Contrary to popular belief, HRT does not cause weight gain. In the first few months, you may notice some fluid retention, which can cause you to feel bloated, but studies have shown no evidence that HRT causes significantly more weight gain overall than taking a placebo (dummy treatment, with no active medicine). However, it is true that most women, whether or not they take HRT, put on some weight after the menopause as this is just a normal part of ageing when you need fewer calories than when you were younger. Exercise and a healthy diet can help.

I have heard that HRT can help to prevent bone fractures as I get older. Is this true?

Numerous studies have confirmed that oestrogen, in the doses used in HRT maintains bone in nine out of 10 women during the menopause, so it is less likely to fracture.

However, although it is known that HRT protects against postmenopausal osteoporosis and fractures, it is not recommended as a first-line treatment for fracture-prevention. If you have been diagnosed with or are at increased risk of developing osteoporosis, but you do not have any menopausal symptoms which you would need to take HRT for, there are several effective osteoporosis treatments which your doctor may try first.

Will HRT increase my risk of being diagnosed with breast cancer?

The cause of most breast cancers is unknown. While the relationship, if any, between HRT and diagnosis of breast cancer is complex, it has been hypothesized that HRT either may cause breast cancer or may speed up the growth of any already existing tumor.

Do I need to have a smear because I have started HRT?

There is no need to have a smear because you have started HRT. However you need to continue to have cervical smears (to detect abnormalities or cancer of the womb entrance or cervix) according to local recommendations. Ask your doctor when you are next due for a smear.

I suffer from vaginal symptoms but I don't want to take HRT.

If you prefer not to take oral HRT but suffer from vaginal symptoms, then you may want to try vaginal oestrogen. Oestrogens can be given locally to the vagina in the form of a vaginal tablet, cream, suppository or a vaginal ring. These are all inserted directly into the vagina where they restore the cells lining the vagina to their normal thickness and improve lubrication, largely without any absorption of oestrogen into the bloodstream. This method relieves problems such as vaginal dryness, itching and soreness and can help making intercourse less painful. It may be a suitable alternative if these are your main symptoms, but you should be aware that this type of oestrogen does not improve other menopausal symptoms such as hot flushes.

Will HRT increase my risk of heart disease, stroke, or a blood clot in my veins?

The risk of heart disease may be increased in women starting combined oestrogen-progestogen therapy more than 10 years since their last period, i.e., in elderly women. This appears not to be the case in younger healthy women starting HRT early after menopause. Oestrogen only HRT is not associated with an increased risk of heart disease (coronary artery disease)³.

There is a small increased risk of stroke among HRT users – in the order of one additional stroke for 1000 women treated for one year. This risk is less for lower doses of oestrogen⁴.

All women have a small chance of developing venous thromboembolism, or VTE, (a blood clot that forms in the veins of the leg and moves to the lungs) whether or not they use HRT. For women aged over 50 who are not taking HRT, about 17 out of 10,000 will have a VTE. If they are taking HRT, this risk increases two-fold⁵. Evidence suggests that risk is higher with combined HRT than with oestrogen-only HRT and that risk is highest during the first year of HRT use and with higher dose oestrogen tablets^6,7.

I have had liver disease. Is HRT safe for me?

If your liver has recovered and liver function tests show it is working as normal, you should be able to use HRT. Women with active liver disease should not take HRT. Your doctor will advise you.

Are there any other medical conditions that make it inappropriate to use HRT?

Women who have current, past or suspected breast cancer should not take HRT. Neither should those with known or suspected endometrial cancer (cancer of the lining of the womb), heart disease, genital bleeding of unknown cause, or deep vein thrombosis. As with most medicines there is a long list of ‘contraindications’ (people who should not take that medicine) and these are spelled out in the patient information that comes with the product your doctor prescribes. Ask your doctor whether taking HRT is appropriate for you.

I started HRT while I was still having periods at irregular intervals. Do I need to use contraception?

HRT is not a contraceptive. Although your chances of becoming pregnant around the age of the menopause are slim, you should still use contraception until your doctor advises you it is no longer necessary.

I've heard women should try to take a low dose or ultra low dose HRT - is this true?

Current recommendations are to use the lowest effective dose for the shortest possible time. This makes good medical sense and should maximise the benefits of HRT, whilst reducing side effects. Your doctor will advise on the lowest dose that is suitable for your individual circumstances.

Please click here to read more about low dose and ultra low dose.

I've been on sequential HRT for five years and I'm getting tired of having periods well into my fifties. Now what?

Most women are post-menopausal by the time they are about 54 so if you are close to that age, you may want to consult with your doctor about moving to a continuous combined, bleed-free HRT.

Please click here, click to read more about sequential HRT.

What will happen if I stop taking my treatment after only a few weeks treatment?

If you stop taking HRT after only a few weeks, it is very likely that your symptoms, such as hot flushes, will come back. They may come back within a few days or weeks and may be worse than before, since there may have been a sudden change in hormone levels. Vaginal symptoms may also come back.

How long should I take HRT for?

The advice from the International Menopause Society is that there is no fixed time limit when HRT should stop. The lowest effective dose for the shortest time necessary to control symptoms is generally recommended. However, although it is known that risks of complications increase with age and number of years on HRT, so long as a woman continues to have symptoms she may decide to remain on HRT after consultation with her doctor and after due consideration of the risks and benefits.

Please click here to read more about this subject.