HRT Choices

Welcome to the podcast, where we explore Hormone Replacement Therapy — often known as HRT — and the choices available to women during perimenopause and menopause.

For many women, navigating menopause can feel confusing and overwhelming. Alongside symptoms such as hot flushes, night sweats, anxiety, poor sleep, brain fog, low mood, and joint aches, many are faced with trying to understand whether HRT is the right option for them — and if so, which type.

With so much information available, and sometimes conflicting advice, it can be difficult to know where to start.

This podcast is here to help simplify those choices.

Together, we’ll explore the different types of HRT available, including oestrogen, progesterone, testosterone, body-identical hormones, patches, gels, sprays, tablets, and vaginal oestrogen. We’ll discuss the benefits, possible risks, common myths, who can safely use HRT, and how treatment can be tailored to your individual needs and symptoms.

Whether you’re just beginning to consider HRT, already using it and wondering if your treatment is right for you, or simply want clear, evidence-based information to help you make informed decisions, this podcast will provide practical guidance and compassionate support.

Menopause is not one-size-fits-all — and neither is HRT.

So wherever you’re listening from, join us as we break down the options, answer common questions, and empower women to make confident choices about their menopause care.

https://calmmenopause.co.uk/

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Transcript

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Now HRT is often spoken about in the context of menopause, but it's not always well understood. There are different types, different routes, different risks and different benefits, and today we are going to unpack all of that. We'll also be shining a light on one particular form, vaginal estrogen, which can make a huge difference but often doesn't get the attention it deserves. So grab a cup of tea, coffee and maybe a notebook because we're going to make sense of it all. Welcome to Menopause Nurse Memos. Empowering Midlife One Memo at a Time, the podcast where we tackle perimenopause and menopause topics head on with honesty, empathy and a whole lot of heart. I'm Vicky Ellison, a nurse for 33 years and an menopause specialist nurse practitioner, an independent prescriber and founder of CARM Menopause and Wellbeing Clinic based in Appleybridge. So what is HRT? Well let's start at the beginning. HRT stands for hormone replacement therapy, and as the name suggests, it's about topping up or replacing hormones that naturally decline, usually during the perimenopause and menopause. The two key hormones here are estrogen and progesterone, and sometimes testosterone is also part of the conversation. When estrogen levels fall, people can experience hot flushes, night sweats, mood changes, joint aches and pains, brain fog, reduced libido, vaginal dryness, urinary symptoms, and even changes to bone density and cardiovascular health. HRT is about relieving these symptoms and protecting long-term health from cardiovascular and bone health. But it's not a one-size-fits all treatment. There are different types and ways of taking it, and that's where the confusion often sets in. So let's break down the types of HRT into the main categories. This is usually prescribed for women who have had a hysterectomy, so they don't need progesterone to protect the lining of the womb. Estrogen can be prescribed as tablets, patches, gels or sprays. Tablets are taken daily, gels and sprays are applied daily and can be increased depending on symptoms, and patches are changed either weekly or twice weekly. Combined HRT is estrogen and progesterone. So if you still have your womb, you will need both. This is because estrogen on its own can thicken the lining of the womb, which potentially increases the risk of cancer. However, by taking progesterone, this keeps the lining of the womb stable. Progesterone can be synthetic, also called progestins, or micronized progesterone, which is closer to the body's natural version, also known as body identical. And patches, sprays, and gels are all body-identical estrogens. When it comes to hormone replacement therapy, one of the biggest decisions is which regime is right for you: sequential HRT or continuous combined HRT. Both involve taking estrogen and progesterone, but they are tailored to different stages of menopause and different needs. Sequential HRT, which generally is two weeks of estrogen only, followed by two weeks of estrogen and progesterone. This type of HRT is usually recommended for women who are perimenopausal or within the first few years of menopause for those still having periods even if they are irregular. Sequential HRT works by giving estrogen every day, then progestogen is added for part of the month, usually two weeks on and two weeks off. Because of this, it leads to a monthly withdrawal bleed, very similar to a light period, and can often make a woman's period more regular and manageable during perimenopause. It's a good choice for women who are still having some natural cycles, or for those who have stopped but are in the early stages of menopause where their body may still expect that cyclical pattern. Whereas continuous combined HRT is generally recommended for women who are postmenopausal. That means at least 12 months since their last natural period. In this approach, estrogen and progesterone are taken every day together so the hormone levels remain steady. The big advantage here is that it usually leads to being bleed-free, which is what many women prefer. It's also protective for the womb lining, just like sequential therapy but without the monthly withdrawal bleeds. So, in summary, if you are in the early stages of menopause or haven't gone a full year without periods, sequential HRT is often the better fit. However, if you are further along, more than a year past your last period, then continuous combined HRT is usually recommended. And of course, as with any medical treatment, the best choice depends on your individual health history, your symptoms, and your personal preferences, so it's always a good idea to discuss the options with a healthcare professional. Finally, testosterone, the third hormone, often overlooked, but it can make a big difference for energy, mood, libido, and muscle strength. Usually given as a gel daily. However, currently there is only one testosterone gel that is licensed for women known as Androphem, and this is only available privately. It is hoped that it will be available on the NHS in early 2026. For many women starting testosterone, blood tests and monitoring will need to be arranged. This is to make sure that levels stay within the female therapeutic range. As mentioned, there are various delivery routes of HRT. Estrogen tablets are easy but have a slightly higher clot risk, so are avoided in anyone with risk of clots, high blood pressure and high body mass index or anyone over the age of 60. Patches stick on the skin, good for steady absorption. However, it should be noted that if the glue is not sticking, then the patch will not be working as its method of delivery is through the skin, and if the glue does not stick, the medicine cannot be absorbed. Patches are changed either weekly or twice weekly. Gels and sprays should be applied daily. They are flexible and popular. Women should be advised not to overrub the gel and allow both methods to absorb into the skin before dressing, so all the medication is absorbed and not transferred onto clothing. Sprays should be applied to the forearm and gel to the upper outer arms or inner thighs. The progesterone side of HRT is either given in a patch combined with a estrogen in a levinogesteral intrauterine device, also known as a coil, or as a tablet, such as mycronized progesterone. It is important to remember mycronized progesterone is a mild sedative, so should be taken at night, and if taken with food such as a biscuit or a glass of milk, it will have more of a sedative effect. So for many women who suffer with sleep disruption during perimenopause and menopause, this can be a good option. And as we have mentioned, HRT can come in body-identical form, and this includes patches, sprays, gels and micronized progesterone. Now vaginal estrogen, the unsung hero. Let's talk about a type of HRT that deserves its own spotlight. This is sometimes called local HRT and it is exactly what it sounds like, estrogen applied directly to the vaginal area, usually as a cream, pessary, tablet or ring. So why does this matter? Well cross-falling estrogen levels don't just cause hot flushes, also affects the uterus system. That includes the vagina, vulva, urethra and urinary tract. Symptoms can include vaginal dryness, burning or itching, painful sex or dryness during intercourse, recurrent urinary tract infections or that feeling of recurrent infections, the needing to wee more often, especially at night, or that key in the door when you've just got to go to the toilet immediately. Leaking urine when coughing or sneezing. These symptoms are part of something called genitourinary syndrome of menopause or GSM for short, and it's incredibly common. But here's the terrible thing: many women don't bring it up with their healthcare provider, either because they are too embarrassed or they think it's just something that they have to live with. Vaginal estrogen can transform this. It restores the tissue, improves blood flow, thickens the lining of the vagina and reduces infections. And the best part is that it works locally with minimal absorption into the bloodstream. Vaginal estrogen is considered safe for most people, even those who can't take systemic HRT. Some women who've had breast cancer are prescribed it under specialist guidance because the risks are so low compared to the benefits. If vaginal estrogen is used alone, progesterone is not required. It's often called the unsung hero of menopause treatment because it can make such a difference to quality of life and yet it is so underused. It is often confused that vaginal estrogen is the same as HRT, tablets, patches or gel. But it is so different. Local estrogen works locally to the area applied, not systemically. Some women think it's only for women who are sexually active. However, it's about bladder health, comfort and infection prevention too. So women don't need to be sexually active to use vaginal estrogen. Finally, it should be noted that if vaginal estrogen is stopped, then symptoms will return. Most people can and should stay on vaginal estrogen indefinitely if it is helping with their symptoms. So how do you know what treatment is right for you? The truth is it depends on your symptoms, medical history, preferences, and lifestyle. For example, someone with severe hot flushes and night sweats might prefer systemic HRT like patches or gel. Someone struggling mainly with urinary symptoms may just need vaginal estrogen, and many people will benefit from both. The key is to have the conversation with a healthcare professional and don't be afraid to ask questions or advocate for yourself. So there you have it, a whistle stop tour of the different types of HRT, including vaginal estrogen. HRT isn't about one size fits all, it's about tailoring treatment to your needs, and whether that's a patch, a gel, or a tiny pessary of estrogen, the goal is the same to help you live your healthiest, happiest life during and after menopause. Next time on the podcast, we will be discussing contraception during the perimenopause. Thank you for spending time with me today on Menopause Nurse Memos. If this episode resonates with you or you know someone who needs to hear it, then share and leave your comments in the chat. And don't forget to subscribe so you never miss an episode. Until the next time, take care of yourselves. You are worth it.