Menopause and Hormone Replacement Therapy (HRT)

Menopause causes the levels of the hormones oestrogen and progesterone to change. Some women go through the menopause without any troublesome symptoms, but some experience a range of distressing changes. The drop in oestrogen is the main cause of these symptoms.

Common symptoms include:

• sweating more than normal in the day
• night sweats
• hot flushes – warmth or intense heat on the face, neck, and chest, which can spread to the rest of the body
• trouble sleeping
• mood changes – being irritable, feeling depressed or anxious
• poor memory or concentration
• being tired
• heart palpitations or a fast heart rate – these can also occur with hot flushes

Symptoms related to your reproductive and urinary organs include:

• shortening and tightening of the vaginal canal
• vaginal dryness, itching, or burning
• discomfort or pain during or after sex
• lower sex drive or no desire to have sex at all
• pain or burning when peeing
• the need to pee urgently or more frequently
• recurrent urinary tract infections (UTIs)
• wetting yourself (incontinence)

Symptoms may also occur over a longer period of time and may not always be noticed straightaway. They include:

• general aches and pains in the joints or muscles – these can occur anywhere in the body such as hands, neck, back, knees, or ankles
• irregular periods – the length of time between each period may become shorter or longer (maybe even months apart)
• heavier periods
• hair loss
• dry, thin, or itchy skin – menopause causes some loss of your skin protein (collagen)
• osteoporosis (fragile bones) – this typically is not noticed unless there’s a bone fracture (hip, backbone, or wrist fracture are the most typical)

Menopause occurs in three stages:

• peri-menopause This is the period leading up to the menopause as your body starts to change. It usually lasts three to five years and typically starts in your late 40s. You may begin to experience symptoms like hot flushes, mood changes, vaginal dryness, and irregular periods
• menopause You are considered to be experiencing the menopause if you’ve not had a period for 12 months straight, without other possible causes like illness, medication, pregnancy or breastfeeding. The average age when a woman starts menopause in the UK is 51
• post-menopause This is the time after you’ve had no periods for 12 straight months. It’s not unusual to still experience some of the symptoms you had during the peri-menopause stage

The menopause test is a simple blood test. Your blood sample will be used to test your follicle-stimulating hormone (FSH) levels. This will show whether you have gone through the menopause.

The kit contains three lancets, which are used to prick the skin so you can collect a blood sample. There are also full instructions included in the kit.

• Wash your hands with warm, soapy water. The test is easier to do if your fingers are warm
• Dry your hands
• Use one of the swabs to wipe one of your fingertips. It’s a good idea to use the middle or ring finger of the hand you do not write with
• Wait until the fingertip is dry
• Twist and remove the purple stick from a lancet. Place it in the middle of your fingertip, and press down the purple button at the end
• A small drop of blood should start to form on your fingertip. If this does not work on the first go, you can try again with the other two other lancets
• Use the tissue to wipe the first drop of blood away, then pick up the collection tube
• Point your finger downwards and squeeze the sides of your fingertip to get another drop of blood into the collection tube
• Keep doing this until you fill the tube to the top line. If you cannot get enough blood to fill the tube, use the extra lancets on another finger, repeating the steps above
• Once you’ve finished, use the plaster to cover your fingertip
• Put the lid on the collection tube and screw it on tightly
• Write your details on the sticky label. This is an important step as the lab need these details to be able to do your test
• Put the label on the collection tube and put the tube into the wallet. Then put the wallet into the prepaid envelope
• Post the sample to our lab
• Your results, along with advice from our doctors, will be in your account two to three days after your sample arrives at the lab

The best time to take the menopause test is on day 3 of your period if you’re still experiencing them. Otherwise you can test on any day.

In the peri-menopause, while your periods are becoming more irregular, your FSH levels can change a lot day by day, so it is possible to get a normal result even if you are having some of the symptoms of menopause.

The test cannot tell you when your periods are going to stop, but can be helpful in diagnosing early menopause.

The test can also be useful if you’re over 50 and have been using progesterone-only contraception. If your contraception means that you do not have periods anyway, the test is a useful way to find out if you’ve gone through the menopause already.

We don’t recommend taking the test if you’re using the combined contraceptive pill, or you’re already having HRT.

Hormone Replacement Therapy (HRT) is a well known and effective treatment for women with symptoms of menopause.

HRT replaces the hormones that your body starts to make less of during menopause. For many women, it provides an important and positive improvement to their quality of life. It can also help to prevent developing osteoporosis.

HRT does come with some risks and it is important to discuss both the benefits and possible side effects with a doctor.

There are two different types of HRT: systemic and local (vaginal) treatments. Local treatments are applied directly to the vagina and treat vaginal dryness. Systemic treatments affect all of the body (your whole system) and treat more of the symptoms that menopause can cause.

Local vaginal treatments are oestrogen-only and usually come in the form of a cream or pessary.

With systemic treatments, you can be prescribed either oestrogen-only (no progesterone) or combined HRT (oestrogen and progesterone).

Oestrogen-only This is used if:

• you’ve had your womb removed (a hysterectomy) as you do not need progesterone which protects the lining of the womb

Combined HRT This is given in two different ways (if you still have your womb):

• continuous combined HRT – oestrogen and progesterone are taken together daily and continuously
• sequential or cyclical HRT – oestrogen-only, usually for about half a cycle then both hormones for the other half

Non-HRT menopause treatments

There is a new treatment available for menopause that isn’t HRT. This is called Veoza and contains the active ingredient fezolinetant. It can be used to treat hot flushes (also called hot flashes) and is recommended for women with moderate to severe symptoms. It’s a prescription-only medication available privately from January 2024. It may take a little longer to be available on the NHS.

Veoza doesn’t contain any hormones. Instead, it works on the parts of your brain that regulate body temperature, which can prevent hot flushes. Veoza may be suitable if:

• you can’t take HRT
• you’re getting unpleasant or ongoing side effects from HRT
• you want a non-hormonal alternative treatment for menopause
• hot flushes are your primary menopause symptom

You can order Veoza with ZAVA.

HRT comes in tablets, patches, creams, gels, pessaries, or vaginal rings.

ZAVA offers a range of these treatments:

• continuous combined tablets
• continuous combined patches
• vaginal oestrogen (local HRT)
• tibolone
• continuous and cyclical patches and tablets

The current indications for HRT are:

• If you have menopausal symptoms and the benefit of using HRT outweighs the risks
• If you suffer from early menopause (before the age of 45) *Please note our service may not currently provide HRT to women suffering from early menopause
• For women under 60 who have a strong family history or at risk of osteoporosis

There are 2 main types of HRT:

• Cyclical
• Continuous

Cyclical HRT

This is recommended for you if your last menstrual period was less than a year ago, or if you are still having periods, but have significant symptoms of the menopause.

This HRT allows you to have a monthly bleed not too different from being on the contraceptive pill.

Continuous HRT

This is recommended for you if your last menstrual period was more than a year ago, or if you have been on cyclical HRT for more than a year.

This HRT may cause irregular bleeding but will eventually lead to no bleeding.

We offer the following types of HRT:

Continuous HRT as combined patches

These are patches worn on the skin.

• Evorel Conti, each patch contains 3.2mg of estradiol hemihydrate (oestrogen) and 11.2mg norethisterone acetate (progesterone). Available in pack sizes of 8 (1 month), 16 (2 months), or 24 (3 months) patches
• The patch should be applied to a clean, non-hairy area of skin below the waist and replaced with a new patch every 3—4 days using a different site.

This is for women who have not had a period for at least a year and are suffering significant symptoms. It may also be advised for women who are at high risk of osteoporosis. It should only be continued for as long as the benefits outweigh the risks.

Continuous HRT as an oestrogen patch and progesterone capsule

As an alternative to Evorel Conti, we also offer a combination of Estradot patches and Utrogestan capsules.

Estradot contains various strengths of Estradiol, an oestrogen absorbed via a transdermal patch.

It can come in the following strengths:

• 25 microgram/24 hrs
• 37.5 microgram/24 hrs
• 50 microgram /24 hrs,
• 75 microgram/24 hrs
• 100 microgram/24 hrs

It is available in a 1 month (8 patches), 2 months (16 patches) or 3 months (24 patches) supply. The patch should be applied to a clean, non-hairy area of skin below the waist and replaced with a new patch every 3—4 days using a different site.

Utrogestan is a progesterone-only capsule. It comes in 100mg capsules and is available as a pack of 30. For Continuous HRT it is taken at a dose of 100mg every night.

Cyclical HRT as an oestrogen patch and progesterone capsule

Estradot contains various strengths of Estradiol, an oestrogen absorbed via a transdermal patch.

It can come in the following strengths:

• 25 microgram/24 hrs
• 37.5 microgram/24 hrs
• 50 microgram /24 hrs
• 75 microgram/24 hrs
• 100 microgram/24 hrs

It is available in 1 month (8 patches), 2 months (16 patches) or 3 months (24 patches) supply. The patch should be applied to a clean, non-hairy area of skin below the waist and replaced with a new patch every 3—4 days using a different site.

Utrogestan is a progesterone-only capsule. For cyclical use where you continue to have a vaginal bleed, it is usually taken at a dose of 200mg daily at night for 12 days per month. It should be taken on the same 12 days each month.

This treatment works in a similar way to Evorel Conti but the progesterone is taken via a pill while the patch contains oestrogen only. With this treatment option, there is likely to be less of a risk of breast cancer and thrombosis.

We offer this treatment as both continuous treatment and cyclical treatment as described above.

Continuous combined tablets

These are taken as one oral tablet daily (preferably at the same time each day) without any break. This means that you will not have a monthly bleed. Each tablet contains a synthetic version of both oestrogen and progesterone. They are prescribed for treating symptoms in post-menopausal women with a womb.

• Elleste Duet Conti
• Kliovance, 1mg of estradiol hemihydrate (oestrogen) and 0.5mg of norethisterone acetate (progesterone). Available in pack sizes of 84 tablets (3 months)
• Premique, low dose 0.3mg of conjugated oestrogens (a mix of ten types of synthetic oestrogen hormones) and 1.5mg of medroxyprogesterone acetate (progesterone). Available in pack sizes of 84 tablets (3 months)

Elleste Duet Conti and Kliovance are also prescribed for the prevention of osteoporosis in menopausal women who are likely to have bone problems and where other treatments are not tolerated or not safe to take.

Continuous combined patches

These are patches worn on the skin.

• Evorel Conti Each patch contains 3.2mg of estradiol hemihydrate (oestrogen) and 11.2mg norethisterone acetate (progesterone). Available in pack sizes of 8 (1 month), 16 (2 months), or 24 (3 months) patches

Vaginal oestrogen (local HRT)

Local HRT works for specific symptoms such as vaginal dryness. It will not improve other symptoms such as hot flushes or protect against longer-term effects of the menopause, like osteoporosis. These can be used for women with or without a womb, to help with vaginal symptoms.

• Vagifem, inserted into the vagina, these tablets contain estradiol hemihydrate equivalent to 10mcg of estradiol (oestrogen). The initial dose is one vaginal tablet daily for two weeks. After the first two weeks you use a maintenance dose of one vaginal tablet twice a week.
• Ovestin, a vaginal cream. Each gram contains 1mg of estriol (oestrogen). It’s applied with an applicator that provides a 0.5g dose. It’s prescribed for vaginal dryness in peri- and post-menopausal women. It is also prescribed before surgery for vaginal operations. The initial dose is usually one applicator-dose daily for two to three weeks. After this you use a maintenance dose of one applicator-dose twice a week.
• Estriol Cream, this is the generic version of Ovestin. It contains the same hormones in the same strength and can be used in the same way as Ovestin.

Tibolone

• Tibolone, a synthetic steroid (with the brand name Livial) that works similarly to taking a combined HRT. It’s prescribed for symptoms in post-menopausal women or to prevent osteoporosis in post-menopausal women who are likely to have bone problems and where other treatments are not safe. Each tablet contains 2.5mg of tibolone and is taken daily by mouth, preferably at the same time each day. Available in pack sizes of 28, 84, and 168 tablets.

Women can consider using HRT at any point, if their menopause symptoms are affecting their daily life. The type of HRT that is recommended for you might be different depending on when you had your last period and what kind of symptoms you’re having. It’s generally recommended to use HRT at the lowest dose for the shortest time possible.

Current research shows that you should start thinking about HRT treatment before the age of 60, or within 10 years of your menopause, as this time frame indicates the most benefit in comparison to the risks.

Women over 60 do not usually start HRT as the likely benefit is limited. Speak to your doctor for more advice as you may be able to use a low dose HRT patch.

How long you should use HRT for depends on how persistent your symptoms are. If you’re taking HRT for the sole purpose of treating your symptoms, then a duration of two to three years is common.

How long symptoms last for also varies greatly though. Some symptoms appear a few months before your periods stop and some symptoms can last for years after.

As menopause can also lead to osteoporosis, you may have to take it for longer if that’s a concern.

It’s important to have regular reviews with your doctor and to discuss how long you should be taking HRT.

Oral HRT

You can fill out a questionnaire for systemic HRT if:

• you’ve been using these forms of HRT for three months with your doctor’s supervision
• you’ve had no complications or problems
• you’re happy with the results

Local HRT

You can get assessed for your first vaginal-only HRT through our online doctor service.

Transdermal HRT

You can also be assessed for starting transdermal HRT online through ZAVA if you’re over 45 or you’re already on a repeat prescription for oral HRT.

HRT may not be suitable for you if you have:

• a history of breast, ovarian or womb cancer
• a history of blood clots or a blood clotting disorder (such as protein C, protein S or antithrombin deficiency)
• a blood problem called porphyria
• a recent diagnosis of angina
• a recent heart attack
• untreated high blood pressure – your blood pressure would need to be controlled before you can start HRT
• liver disease, where liver function tests have failed to return to normal
• undiagnosed vaginal bleeding
• untreated endometrial hyperplasia (abnormal and excessive thickening of the womb lining)

You cannot use HRT if you’re pregnant, and it’s not a form of contraception. You should use contraception until two years after your last period if you’re under 50 or for one year after the age of 50.

You may not be able to take HRT if you’re taking the following medications:

• medicine for epilepsy like phenytoin, phenobarbital and carbamazepine
• medicine for tuberculosis like rifampicin and rifabutin
• medicine for HIV infection like nevirapine, efavirenz, nelfinavir and ritonavir
• medicines used to treat chronic hepatitis
• herbal preparations containing St John’s Wort (Hypericum perforatum)
• bosentan (used for high blood pressure in the lungs) – if you’re using Evorel Conti patches
• anticoagulants – this is if you’re using Tibolone as it can enhance the effects of anticoagulants, particularly warfarin

It is possible to get some side effects from HRT, as with any other medicine. Each treatment is different and the information leaflet with your HRT medicine will provide more detail on:

• how to take your HRT
• risks
• what medication you can and cannot take with it
• side effects

Most side effects go away quickly – it takes some time for your body to get used to HRT. If you do experience any side effects, they usually settle within the first few weeks.

Speak to your doctor if they persist for more than three months or are particularly troublesome. Your doctor may suggest a different type of HRT or change your dose.

Some possible side effects are:

• (feeling sick) nausea
• irregular bleeding or spotting
• premenstrual symptoms
• headache
• breast tenderness and enlargement
• acne or greasy skin
• bloating
• water retention
• pain in the lower stomach
• backache
• leg cramps

Visit your nearest A&E department if you experience any of these rare but serious effects:

• sudden increase in blood pressure
• dizziness, confusion, or loss of consciousness
• sharp chest pain, sudden breathlessness, or pain and swelling in the legs – this could be a blood clot
• chest pain or tightness radiating to the arms, face or jaw, fainting, shortness of breath – these are symptoms of a heart attack
• sudden numbness of one side of the body, sudden trouble seeing, speaking, or walking, unexplained migraine-type headache with or without disturbed vision – this could be a stroke
• face, mouth or throat swelling or difficulty breathing – this is likely to be an allergic reaction
• yellow eyes or skin – this could indicate a liver problem
• a rash (urticaria)

Studies have shown that HRT can increase your risk of:

• certain types of cancer
• stroke
• blood clots

The Medicines and Healthcare products Regulatory Agency (MHRA) released a report in August 2019 on new findings on the increased risk of breast cancer on HRT. These findings show that the risk is higher than originally thought. The MHRA's patient information leaflet covers this in more detail.

You should talk to your doctor if you have concerns about any of these risks at your annual review. If you have any questions about the MHRA’s new findings in the meantime, you can message our doctors through your account. They’ll be happy to answer any concerns you may have. You should also make sure that you’re going to your national breast cancer screening appointments, and do the breast cancer self-checks as well.

Studies have also suggested that starting HRT in women going through the menopause, provides a reduction of the risk of:

• osteoporosis and hip and vertebrae fractures
• overall mortality