What are the different types of HRT?

HRT (hormone replacement therapy) comes in two main kinds: combined HRT, which has oestrogen and a progestogen, and oestrogen-only HRT, which is usually for women who have had their womb removed. Combined HRT is taken either in a monthly cycle (if you still have periods) or every day without a break (if your periods have stopped). And you can take it in several ways: tablets, skin patches, gel, spray, or with a hormone coil, plus vaginal oestrogen for local symptoms. Your GP will help you choose, and it’s normal to try more than one before you find what suits you.

The hormones in HRT

As you approach menopause, your levels of the hormones oestrogen and progesterone fall. The HSE explains that HRT replaces them, which can help with hot flushes, night sweats, sleep problems, anxiety and low mood, and vaginal dryness.

There are two main ingredients:

• Oestrogen is the main hormone that eases symptoms. The NHS says the type most commonly used in HRT is called estradiol.
• Progestogen is the name for progesterone and medicines that act like it. Its main job in HRT is to protect your womb.

A doctor may also sometimes prescribe testosterone, which we cover below.

Combined HRT or oestrogen-only?

This depends mostly on whether you still have your womb.

If you still have your womb, you need both oestrogen and a progestogen. The NHS explains that oestrogen on its own can thicken the womb lining, which slightly increases the risk of womb cancer, and the progestogen protects against that. The HSE says most women are prescribed combined HRT. You can get it as one product with both hormones, or as two separate products, for example an oestrogen patch or gel with progestogen tablets.

If you’ve had a hysterectomy (an operation to remove the womb), both the HSE and NHS say oestrogen-only HRT is recommended.

Cyclical or continuous: the two routines

Combined HRT comes in two routines, and which one you’re offered depends on where you are in the menopause.

Sequential (cyclical) combined HRT is usually recommended if you have menopause symptoms but still have periods. The NHS describes it as oestrogen every day with a progestogen added for the last 10 to 14 days of each cycle. You should get a bleed at the end of each progestogen phase. Both the HSE and NHS say to talk to your doctor if that bleed doesn’t come.

Continuous combined HRT means taking oestrogen and progestogen every day without a break. It’s usually recommended once you’re post-menopausal, which means you haven’t had a period for 1 year. If you start on sequential HRT, your GP may suggest switching to continuous combined later on.

If you’re on oestrogen-only HRT, you take it every day.

The different ways to take HRT

This is where most of the choice is. Here’s what the HSE and NHS say about each form.

Tablets. Usually taken once a day, and available as oestrogen-only or combined. They may be the easiest option. However, both the HSE and NHS say some risks of HRT, such as blood clots, are higher with tablets than with patches, gel or spray, although the overall risk is still small.

Patches. You stick a patch on your skin below the waist and change it every few days, depending on the brand. They come as oestrogen-only or combined. Unlike tablets, patches don’t increase your risk of blood clots. They can be handy if you find tablets hard to swallow or easy to forget. The downsides: they may not stick well, especially on moisturised skin, and can leave redness or irritation.

Oestrogen gel. You smooth it onto your skin once a day. It doesn’t increase your risk of blood clots, though it can take 5 minutes or more to dry. If you still have your womb, you’ll need a progestogen alongside it.

Oestrogen spray. One to 3 sprays on the inner arm or inner thigh, once a day. Like gel, it doesn’t increase your risk of blood clots, and you need a progestogen with it if you have a womb. You can get dressed 2 minutes after spraying but should wait an hour before a bath or shower.

The Mirena coil (an IUS). An intrauterine system is a small device placed in your womb that slowly releases a progestogen called levonorgestrel. It can provide the progestogen part of combined HRT if you’re using oestrogen tablets, patches, gel or spray. It can stay in for up to 5 years and also works as contraception. It can cause tummy pain and bleeding.

Vaginal oestrogen. This comes as a cream, gel, vaginal tablet or pessary (the NHS also lists a ring), used inside the vagina for dryness, burning or pain during sex. Both the HSE and NHS say it doesn’t carry the usual risks of HRT and doesn’t increase your risk of breast cancer, and you can use it without a progestogen even if you still have your womb. It won’t help with hot flushes, mood swings or sleep, though, so some women use it alongside other HRT.

If you’ve had blood clots in the past, the HSE notes you may need patches or gels rather than tablets. This is exactly the kind of thing to go through with your GP.

Testosterone and tibolone

Testosterone also falls around menopause, more gradually. Both services say it isn’t currently licensed to treat menopause symptoms, but a doctor can prescribe it (the HSE calls this “off label”, which it says does not mean the medicine is unsafe). It’s usually only considered if you’re post-menopausal, have a low sex drive and HRT alone hasn’t helped. It comes as a gel. The NHS says more evidence is needed on whether it helps other symptoms.

Tibolone (brand name Livial) is a daily tablet that works like combined HRT with a testosterone-like effect. It’s only suitable if your last period was more than a year ago, and the HSE and NHS note it may not be as effective as combined HRT.

Finding the type that suits you

The NHS says it’s normal to try different brands and methods before finding one that suits you. According to the HSE, you’ll usually start on a low dose, and any side effects are usually mild and pass within 3 months. The NHS adds that HRT can take up to 3 months to work fully, and that common side effects such as headaches, breast tenderness and vaginal bleeding usually improve in the first few months.

The HSE says a GP will usually review your treatment 3 months after you start, or after you change type, and then about once a year. If your symptoms don’t improve, the options include changing the dose or type, or a referral to a menopause specialist.

HRT isn’t suitable for everyone. The HSE lists situations where it may not be, including a history of breast, ovarian or womb cancer, a history of blood clots, untreated high blood pressure and liver disease. Your GP will weigh up the benefits and risks for you personally. Please don’t start, stop or switch HRT without talking to your GP or pharmacist first: the HSE notes that if you stop, your symptoms may come back.

Ireland and the UK

In Ireland, HRT is free on prescription at participating pharmacies if you have a medical card or a Drugs Payment Scheme card, as the HSE explains (see our guide Can I get HRT for free in Ireland?). In England, an HRT prescription prepayment certificate can cut the cost; that guide covers it too. The types of HRT described here are the same on both sides of the Irish Sea.

What to do next

• Note what matters most to you. Write down your main symptoms, whether you still have periods (and when your last one was), and anything about your health history such as blood clots, cancer, high blood pressure or liver disease.
• Ask your GP these questions, some of which the HSE suggests: which type would suit me and why? Would a patch or gel be better for me than tablets? How soon should I feel better? What are the benefits and risks for me? How long might I take it?
• Give it time, then go back. Keep a simple diary of symptoms and side effects for the first 3 months, and bring it to your review.
• Contact your GP about unexpected bleeding. The HSE says to see your GP about any bleeding from the vagina after menopause, even spotting. And if you’re on sequential HRT and the expected bleed doesn’t come, both services say to talk to your doctor.