Different types of hormone replacement therapy (HRT) are available.

If you're considering HRT, talk to your GP about the options suitable for you, as well as possible alternatives to HRT.

HRT hormones

HRT replaces the hormones that a woman's body no longer produces because of the menopause.

The 2 main hormones used in HRT are:

• oestrogen – types used include estradiol, estrone and estriol
• progestogen – a synthetic version of the hormone progesterone, such as dydrogesterone, medroxyprogesterone, norethisterone and levonorgestrel

HRT involves either taking both of these hormones (combined HRT) or just taking oestrogen (oestrogen-only HRT).

Most women take combined HRT because taking oestrogen on its own can increase your risk of developing womb (endometrial) cancer. Taking progestogen alongside oestrogen minimises this risk.

Oestrogen-only HRT is usually only recommended for women who have had their womb removed during a hysterectomy.

Ways of taking HRT

HRT comes in several different forms. Talk to a GP about the pros and cons of each option.

Tablets 

Tablets are 1 of the most common forms of HRT. They are usually taken once a day.

Both oestrogen-only and combined HRT are available as tablets. For some women this may be the simplest way of having treatment.

However, it's important to be aware that some of the risks of HRT, such as blood clots, are higher with tablets than with other forms of HRT (although the overall risk is still small).

Skin patches

Skin patches are also a common way of taking HRT. You stick them to your skin and replace them every few days.

Oestrogen-only and combined HRT patches are available.

Skin patches may be a better option than tablets if you find it inconvenient to take a tablet every day.

Using patches can also help avoid some side effects of HRT, such as indigestion, and unlike tablets, they do not increase your risk of blood clots.

Oestrogen gel

Oestrogen gel is an increasingly popular form of HRT. It's rubbed onto your skin once a day.

Like skin patches, gel can be a convenient way of taking HRT and does not increase your risk of blood clots.

But if you still have your womb, you'll need to take some form of progestogen separately too, to reduce your risk of womb cancer.

Implants

HRT also comes as small pellet-like implants that are inserted under your skin (usually in the tummy area) after your skin has been numbed with local anaesthetic.

The implant releases oestrogen gradually and lasts for several months before needing to be replaced.

This may be a convenient option if you do not want to worry about taking your treatment every day or every few days. But if you still have your womb, you'll need to take progestogen separately too.

If you're taking a different form of oestrogen and need to take progestogen alongside it, another implant option is the intrauterine system (IUS). An IUS releases a progestogen hormone into the womb. It can stay in place for 3 to 5 years and also acts as a contraceptive.

Implants of HRT are not widely available and are not used very often.

Vaginal oestrogen

Oestrogen is also available as a cream, pessary or ring that is placed inside your vagina.

This can help relieve vaginal dryness, but will not help with other symptoms such as hot flushes.

It does not carry the usual risks of HRT and does not increase your risk of breast cancer, so you can use it without taking progestogen, even if you still have a womb.

Testosterone

Testosterone is available as a gel that you rub onto your skin. It is usually only recommended for women whose low sex drive (libido) does not improve after using HRT. It is used alongside another type of HRT.

Current testosterone products available in the UK (such as Tostran and Testogel) are currently unlicensed for the treatment of low sex drive. This means the manufacturers of these products have not specified that they can be used in this way. Despite this, there is evidence that testosterone can be effective.

Ask a GP for more information on testosterone products.

HRT treatment routines

Your treatment routine for HRT depends on whether you're in the early stages of the menopause or have had menopausal symptoms for some time.

The 2 types of routines are cyclical (or sequential) HRT and continuous combined HRT.

Cyclical HRT

Cyclical HRT, also known as sequential HRT, is often recommended for women taking combined HRT who have menopausal symptoms but still have their periods.

There are 2 types of cyclical HRT:

• monthly HRT – you take oestrogen every day, and take progestogen alongside it for the last 14 days of your menstrual cycle
• 3-monthly HRT – you take oestrogen every day, and take progestogen alongside it for around 14 days every 3 months

Monthly HRT is usually recommended for women having regular periods.

3-monthly HRT is usually recommended for women having irregular periods. You should have a period every 3 months.

It's useful to maintain regular periods so you know when your periods naturally stop and when you're likely to progress to the last stage of the menopause.

Continuous combined HRT

Continuous combined HRT is usually recommended for women who are postmenopausal. A woman is usually said to be postmenopausal if she has not had a period for 1 year.

Continuous combined HRT involves taking oestrogen and progestogen every day without a break.

Oestrogen-only HRT is also usually taken every day without a break.

Like any medicine, the hormones used in hormone replacement therapy (HRT) can cause side effects.

Any side effects usually improve over time, so it's a good idea to persevere with treatment for at least 3 months if possible.

Speak to a GP if you have severe side effects or they continue for longer than 3 months.

Side effects of oestrogen

The main side effects of taking oestrogen include:

• bloating
• breast tenderness or swelling
• swelling in other parts of the body
• feeling sick
• leg cramps
• headaches
• indigestion
• vaginal bleeding

These side effects will often pass after a few weeks. To ease side effects, try:

• taking your oestrogen dose with food, which may help feelings of sickness and indigestion
• eating a low-fat, high-carbohydrate diet, which may reduce breast tenderness
• doing regular exercise and stretching, to help leg cramps

If side effects persist, your GP may recommend switching to a different way of taking oestrogen (for example, changing from a tablet to a patch), changing the medicine you're taking, or lowering your dose.

Side effects of progestogen

The main side effects of taking progestogen include:

• breast tenderness
• swelling in other parts of the body
• headaches or migraines
• mood swings
• depression
• acne
• tummy (abdominal) pain
• back pain
• vaginal bleeding

As with side effects of oestrogen, these will usually pass after a few weeks.

If they persist, a GP may recommend switching to a different way of taking progestogen, changing the medicine you're taking, or lowering your dose.

Weight gain and HRT

Many women believe that taking HRT will make them put on weight, but there's no evidence to support this claim.

You may gain some weight during the menopause, but this often happens regardless of whether you take HRT.

Exercising regularly and eating a healthy diet should help you to lose any unwanted weight.

More serious risks

HRT has also been associated with an increased risk of blood clots and certain types of cancer.

Find out more about the risks of HRT

Reporting side effects

The Yellow Card Scheme allows you to report suspected side effects from any type of medicine you are taking.

It's run by a medicines safety watchdog called the Medicines and Healthcare products Regulatory Agency (MHRA).

When deciding whether to have hormone replacement therapy (HRT), it's important to understand the risks.

It's also important to consider HRT as only 1 of a range of options to improve menopausal and postmenopausal health and wellbeing.

Many studies on HRT that have been published over the past 15 years highlight the potential risks. As a result, some women and doctors have been reluctant to use HRT.

But more recent evidence says that the risks of HRT are small and are usually outweighed by the benefits.

Breast cancer

Women who take HRT for more than 1 year have a higher risk of breast cancer than women who never use HRT. The risk is linked to all types of HRT except vaginal oestrogen.

For women in their 40s and 50s who take HRT for 5 years there would be:

• 1 extra case for every 200 women taking oestrogen-only HRT
• 1 extra case for every 70 women taking cyclical HRT
• 1 extra case for every 50 women taking continuous HRT

The number of extra cases is thought to double among women who take these types of HRT for 10 years.

Research shows that the increased risk of breast cancer falls after you stop taking HRT, but some increased risk remains for more than 10 years compared to women who have never used HRT.

If you take it for less than 1 year, there is no increased risk of breast cancer.

Because of the risk of breast cancer, it's especially important to attend all your breast cancer screening appointments if you're taking HRT.

Ovarian cancer

Studies looking at whether HRT increases your risk of ovarian cancer have so far had conflicting results.

It's thought that if there is any increase in cases of ovarian cancer among women taking HRT, the increase is very small.

A recent study found that for every 1,000 women taking HRT for 5 years, there will be 1 extra case of ovarian cancer.

Any increased risk of ovarian cancer is thought to decrease once you stop taking HRT.

Womb cancer

Oestrogen-only HRT can increase the risk of womb cancer (also called uterine or endometrial cancer), which is why it's only used in women who do not have a womb (for example, because they've had a hysterectomy).

Taking combined HRT, particularly a course of continuous combined HRT (where you take both medicines without a regular break), largely eliminates this risk.

If you have a womb and you're taking HRT, it's important to take both medicines as advised by your doctor to avoid increasing your risk of womb cancer.

Blood clots

Blood clots can be serious if they become lodged in a blood vessel and block the flow of blood.

The evidence shows that:

• taking HRT tablets can increase your risk of blood clots
• there's no increased risk of blood clots from HRT patches or gels

It's thought the risk of developing a blood clot is 2 to 4 times higher than normal for women taking HRT tablets. But as the risk of menopausal women developing blood clots is usually very low, the overall risk from taking HRT tablets is still small.

It's estimated that for every 1,000 women taking HRT tablets for 7.5 years, fewer than 2 will develop a blood clot.

Heart disease and strokes

The evidence shows that:

• HRT does not significantly increase the risk of cardiovascular disease (including heart disease and strokes) when started before 60 years of age
• oestrogen-only HRT is associated with no, or reduced, risk of heart disease
• combined HRT is associated with little or no increase in the risk of heart disease
• taking oestrogen tablets is associated with a small increase in the risk of stroke, but the risk of stroke for women under age 60 is generally very low, so the overall risk is still small

Speak to a GP if you're taking HRT or are considering taking it and are worried about the risk of stroke or heart disease.

If you're unable to take hormone replacement therapy (HRT) or decide not to, you may want to consider alternative ways of controlling your menopausal symptoms.

Lifestyle measures

The following lifestyle measures can help reduce some menopausal symptoms:

• Do regular exercise – regular physical activity can reduce hot flushes and improve sleep. It's also a good way of boosting your mood if you feel anxious, irritable or depressed. Weight-bearing exercises can help keep your bones strong
• have a healthy diet – a balanced diet can help ensure you do not put on weight and can keep your bones healthy
• stay cool at night – wear loose clothes and sleep in a cool, well-ventilated room if you experience hot flushes and night sweats
• cut down on caffeine, alcohol and spicy food, as they have all been known to trigger hot flushes
• try to reduce your stress levels to improve mood swings, make sure you get plenty of rest, as well as getting regular exercise. Activities such as yoga and tai chi may help you relax
• give up smoking if you smoke – giving up will help reduce hot flushes and your risk of developing serious health conditions, such as heart disease, stroke and cancer
• try vaginal lubricant or moisturiser if you experience vaginal dryness – several different types are available to buy from shops and pharmacies

Tibolone

Tibolone (brand name Livial) is a prescription medicine that is similar to taking combined HRT (oestrogen and progestogen). It's taken as a tablet once a day.

It can help relieve symptoms such as hot flushes, low mood and reduced sex drive, although some studies have suggested it may not be as effective as combined HRT.

It's only suitable for women who had their last period more than a year ago (known as the post-menopause).

Side effects of tibolone can include tummy (abdominal) pain, pelvic pain, breast tenderness, itching and vaginal discharge.

Risks of tibolone are similar to the risks of HRT, and include an increased risk of breast cancer and strokes. Talk to your GP about the risks and benefits of tibolone if you're considering taking it.

Antidepressants

There are 2 types of antidepressants – selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) – which may help with hot flushes caused by the menopause.

These medicines are not licensed for this use. This means they have not undergone clinical trials to test if they help this symptom, but many experts believe they're likely to help and your doctor will discuss the possible benefits and risks with you.

Side effects of SSRIs and SNRIs can include feeling agitated, shaky or anxious, feeling sick, dizziness and a reduced sex drive.

Any side effects will usually improve over time, but you should see a GP if they do not.

Clonidine

Clonidine is a prescription medicine that can help reduce hot flushes and night sweats in some menopausal women. It's taken as tablets 2 or 3 times a day.

It does not affect hormone levels, so unlike HRT it does not carry an increased risk of problems such as breast cancer. But research suggests it only has a very small effect on menopausal symptoms.

Clonidine can also cause some unpleasant side effects, including dry mouth, drowsiness, depression and constipation.

It may take 2 to 4 weeks to notice the effects of clonidine. Speak to a GP if your symptoms do not improve or you experience troublesome side effects.

Bioidentical or "natural" hormones

Bioidentical hormones are hormone preparations made from plant sources that are promoted as being similar or identical to human hormones.

Practitioners claim these hormones are a "natural" and safer alternative to standard HRT medicines.

However, bioidentical preparations are not recommended because:

• they are not regulated and it's not clear how safe they are – there's no good evidence to suggest they're safer than standard HRT
• it's not known how effective they are in reducing menopausal symptoms
• the balance of hormones used in bioidentical preparations is usually based on the hormone levels in your saliva, but there's no evidence that these levels are related to your symptoms

Many standard HRT hormones are made from natural sources, but unlike bioidentical hormones, they're closely regulated and have been well researched to ensure they're as effective and safe as possible.

Complementary therapies

Several products are sold in health shops for treating menopausal symptoms, including herbal remedies such as evening primrose oil, black cohosh, angelica, ginseng and St John's wort.

There's evidence to suggest that some of these remedies, including black cohosh and St John's wort, may help reduce hot flushes, but many complementary therapies are not supported by scientific evidence.

Even when there is some supporting evidence, there's uncertainty about the right doses to use and whether the health benefits last. Some of these remedies (especially St John's wort) may also cause serious side effects if they're taken with other medicines.

These products are often marketed as "natural", but this does not necessarily mean they're safe. The quality, purity and ingredients cannot always be guaranteed, and they may cause unpleasant side effects.

It's a good idea to ask a GP or pharmacist for advice if you're thinking about using a complementary therapy.