Menopause, Perimenopause and HRT

What is menopause?

Menopause is a natural biological stage in a woman's life when menstruation permanently stops. It is diagnosed after 12 consecutive months without a period, assuming no other medical cause (e.g., pregnancy, illness).

This transition occurs when the ovaries stop releasing eggs and stop producing oestrogen and progesterone. Menopause typically occurs between the ages of 45 and 55.

What is perimenopause?

Perimenopause is the transitional phase leading up to the menopause, during which hormone levels (particularly oestrogen and progesterone) begin to decline. This phase typically starts in a woman's 40s, but it may begin earlier or later. For those with significant/debilitating symptoms during perimenopause, HRT maybe considered after a discussion of risks, benefits and alternatives. If you are under 45years old the doctor might recommend doing two menopausal blood test 4 to 6 weeks prior to starting HRT.

Key features of perimenopause:

• Irregular periods (may be closer together or months apart)
• Heavier or lighter bleeding pattern when having period
• Hormonal symptoms such as hot flushes, mood changes, and sleep disturbances

What is premature ovarian insufficiency (POI)

Premature ovarian insufficiency (also known as premature menopause) occurs when menopause begins before the age 40. It may happen naturally or because of medical or surgical treatments such as having uterus removed.

What is HRT (hormone replacement therapy)?

HRT (Hormone Replacement Therapy) is a treatment that relieves the symptoms of menopause and perimenopause. It involves two types of hormones mainly oestrogen and progesterone.

Progesterone is the hormone that is used to protect the lining of the womb from the effects of oestrogen.

During menopause or perimenopause, your body produces less oestrogen and progesterone. HRT replaces these hormones to improve how you feel.

It can help relieve common symptoms like hot flushes, mood swings, and vaginal dryness.

HRT can also be used in gender-affirming care.

Identifying menopause

1. Vasomotor symptoms

Physical symptoms caused by changes in the blood vessels tone and dilation typically due to hormonal fluctuation):

• Hot flushes
• Night sweats
• Sleep disturbances
• Heart racing
• Irritability, anxiety
• Low mood or mild depression
• Difficulty concentrating, poor memory
• Fatigue

Triggers may include caffeine, spicy food, and alcohol because these also cause blood vessel changes which can exacerbate symptoms.

2. Urogenital atrophy

Thinning/Drying of Tissues :

• Vaginal dryness or itching
• Painful sexual intercourse
• Increased risk of UTIs- Increased urinary urgency, frequency, or burning

3. Other symptoms

• Joint and muscle pain
• Changes in libido

Diagnosis of menopause

• Diagnosis is usually clinical, based on symptoms.
• Blood tests are not always reliable as hormone levels fluctuate with the days in the month.
• Patients are advised to keep a symptom diary for at least 2 to 4 weeks before an HRT appointment to help guide the treatment.

Management of menopause

Not everyone going through menopause will be troubled by symptoms and therefore often no treatment is needed. For those who are troubled by symptoms there are number of things which may help:

1. Symptom diary

• Track symptoms for at least 2 to 4 weeks.

2. Lifestyle modifications

• Regular exercise
• Stress management
• Relaxation techniques
• Limiting alcohol and caffeine
• Quitting smoking
• Maintaining a healthy weight and blood pressure
• Wearing lighter clothing, sleeping in a cooler room

3. Cognitive behavioural therapy (CBT) for menopause

4. Hormone teplacement therapy (HRT)

5. Non-hormonal alternatives

1. Antidepressants (e.g., SSRIs or SNRIs)/ Clonidine- not commonly used

Indications for HRT (hormone replacement therapy)

• To relieve menopausal symptoms like hot flushes, night sweats, mood swings, irritability, sleep problems, vaginal dryness, itching, and pain during sex.
• To help protect your bones and reduce the risk of fractures caused by low bone density in the future.
• To replace hormones if you have early menopause/ surgery to remove your womb or your ovaries stop working before age 40 (premature ovarian failure).

Contraindications to HRT

• History of oestrogen-dependent cancer (e.g., breast, ovarian, endometrial).
• Unexplained vaginal bleeding.
• Untreated endometrial hyperplasia.
• History of blood clots would affect the type of HRT we are able to prescribe.
• Thrombophlebitis (swollen on inflamed vein because of blood clot).
• Uncontrolled high blood pressure.
• Active liver disease.
• Pregnancy.

Risks of HRT

• Blood clots: Higher risk with oral HRT tablets.
• Stroke: Slight increase with oral oestrogen related tablets.
• Coronary heart disease: Minimal or no increased risk with combined HRT.
• Ovarian cancer: Slight increased risk with long-term combined HRT.
• Endometrial cancer: Risk depends on duration of oestrogen-only therapy.
• Breast cancer: Oestrogen only HRT associated with little or no change, any increase in breast cancer is related to treatment duration.

Risk varies by HRT type, dose, duration, and personal health history.

Types of hormones in HRT

Oestrogen-only HRT

For women who have had their womb/uterus removed (hysterectomy). No progesterone is needed because there’s no risk to the womb.

Combined HRT

Contains both oestrogen and progesterone (or a similar hormone called progestogen). This is for women who still have their womb/uterus to protect it from risks linked to oestrogen alone.

Testosterone

Sometimes given as a gel or cream to help with low sex drive if regular HRT doesn’t help (only on specialist advice)

How is HRT given?

Pills

Taken by mouth every day. Pills may slightly increase the risk of blood clots compared to other types. Take it with water, with or without food.

Patches

Stick-on patches changed once or twice a week that release hormones steadily through the skin. Lower risk of blood clots than pills.

• Apply to clean, dry skin (lower abdomen, upper arm, or buttocks).
• Rotate sites to prevent irritation as you change it.
• Useful for those with:
  • Migraine
  • Stomach upset or poor oral absorption
  • History of blood clots
  • BMI >30 kg/m²

Gels and sprays

Applied to the skin and absorbed into the body. Flexible dosing and lower blood clot risk. Apply to skin (arms, thighs, or shoulders) and let it dry before dressing.

Intrauterine system (IUS or coil)

Placed inside the womb to release progesterone locally, protecting the womb lining and sometimes working as contraception. Given by a healthcare professional on a fixed schedule. At Salisbury Medical Practice there is a waiting list for implants/coil.

Vaginal oestrogen

Creams, rings, or tablets placed inside the vagina to treat dryness or irritation. These have minimal blood absorption and can be used alone, even if you still have your womb specially used for vaginal atrophy symptoms.

Types of HRT

Cyclical (sequential) HRT

For women still having periods. Oestrogen is taken daily, progesterone for 10 to 14 days each month, causing a monthly bleed.

Continuous combined HRT

For women who have stopped having periods (post menopause) for 12 months. Both hormones are taken daily with no break, so periods stop after a short time.

Duration of HRT treatment

• You can continue HRT as long as it helps you and as long as the benefits outweigh any risks.
• When stopping, it’s best to reduce the dose gradually to avoid symptoms coming back quickly.
• Gradual reduction or stopping suddenly makes no difference to symptoms in the long run.

What to expect with HRT?

• HRT can help relieve symptoms like hot flushes, mood swings, and fatigue.
• It’s common to have unscheduled bleeding, spotting, or light bleeding during the first 3 months, especially if you have a uterus. Your periods may become lighter, more regular, or stop if you’re on continuous HRT.
• Please report any bleeding at your 3-month review, or sooner if it continues beyond 3 months especially if the bleeding is heavier than a normal period, lasts longer, or you pass large clots or need to change pads frequently.
• Sticking to your treatment plan is important for the best results.
• Remember to keep up with your national health screenings, such as cervical smears and breast screening.
• It may take 3 to 6 months before you feel the full benefits of HRT.
• Regular follow-up appointments are important to monitor how well the treatment is working and to ensure your safety.

Side effects of HRT

• You might experience some breast tenderness or swelling, which can improve if you adjust your diet/low fat diet, after lowering the dose of medication, or switch to a skin patch.
• If you feel bloated or nauseous, try taking your HRT with food or we can change how you take it.
• If you get headaches, switching to a patch might help.
• Leg cramps can improve with regular exercise and stretching calf muscles.
• If you are taking both oestrogen and progestogen and notice symptoms like greasy skin, acne, depression, or mood swings we might review your progesterone prescription, or consider having it via different route example IUS (coil).

Considerations

• HRT is not contraceptive, so precautions are still needed for women specially in perimenopause or premature ovarian failure.
• If you’re still having symptoms, we might need to adjust your dose or switch your medication from tablets to a patch that goes on your skin.
• Sometimes patches don’t stick well and if that happens, we can try a different brand that might work better for you.
• If your symptoms don’t improve, we’ll also check to make sure the cause is correct, like looking into other conditions such as thyroid problems.
• If your body isn’t absorbing the medication well from tablets, switching to a patch can help it work better.

Contraception

• If you’re under 50, you may still be fertile for up to 2 years after your last period.
• If you’re over 50, you may still be fertile for up to 1 year after your last period.
• Therefore, it’s important to consider contraception even if you plan to start HRT.

When would we consider a specialist referral?

• Trouble confirming if you’re in menopause.
• You cannot take HRT because of health reasons.
• HRT isn’t helping your symptoms even after adjustments.
• Side effects continue despite changes in treatment.
• Warning signs like unexplained bleeding.
• Having a complex medical history.
• History of hormone-related cancer.
• If libido remains problematic after optimising oestrogen dose.
• Problems with bleeding:
  • On sequential HRT: heavier, longer, or irregular bleeding.
  • On continuous HRT: bleeding after 6 months or after no bleeding.

HRT review and follow-up

• Please have a blood pressure check and weight check prior to each review
• When you start HRT or change your treatment, you will have a review after 3 months.
• Once you are established on HRT, you should have a review at least once a year.
• During each review, we will check how well the treatment is working, discuss any side effects or bleeding changes, and make sure the type and dose of HRT are right for you.
• We will also talk about the benefits and any risks to help decide if continuing treatment is best for you.
• Do not change or stop HRT without medical advice.
• Report side effects such as unusual bleeding, chest pain, or severe headaches.
• Maintain a healthy lifestyle alongside treatment.

Stopping HRT

• You can continue taking HRT as long as it helps your symptoms and improves your quality of life more than it causes risks.
• When it’s time to stop, we will reduce the dose gradually to help prevent your symptoms from coming back quickly.

Testosterone

• Testosterone is sometimes used to help with low sexual desire if standard HRT doesn’t work, but only after specialist consultation.
• Herbal products, isoflavones, and bioidentical hormones are not regulated or tested for quality and safety like prescribed medicines.
• We don’t know for sure if these unregulated products work or are safe.
• If you want to try these therapies, be aware that the ingredients and quality can vary and may not be reliable.

There are some helpful information and support about menopause:

• British Menopause Society.
• NHS Menopause Support.
• Healthtalk.
• Let’s All Talk Menopause.