Perimenopause, menopause and HRT: everything you need to know

What is menopause?

The usual definition of menopause is a year after a woman’s last menstrual period. However, it’s not this simple for many women, including those who no longer have periods as they have had a hysterectomy, have a Mirena coil or are using some types of contraception where they do not have a monthly bleed.

Menopause is related to a decline of the hormones oestrogen, progesterone and testosterone, which are produced in the ovaries and also other organs and tissues, including the brain. They have many important functions in the body.

Menopause should be recognised as a hormone deficiency which lasts forever (for life) regardless of whether or not a woman experiences symptoms. Hormones work as chemical messengers throughout your entire body – reaching and having an effect on every single cell.

The hormones oestradiol (the beneficial type of oestrogen), progesterone and testosterone have been shown to improve thousands of cellular actions which then improves function of your body systems and organs. In particular, they have many beneficial actions on bone, brain, circulation, urinary, genital and nervous systems.

When does menopause typically happen?

The average age a woman in the UK experiences menopause is 51 [1]. However, it can occur earlier or later than this – health conditions, medical treatment, genetics, ethnicity and your social economic background can influence the age you experience it.

Your menopause is described as early if it occurs before you are 45. If it occurs before the age of 40, it’s called Premature Ovarian Insufficiency (POI). Around 1 in 30 women experience their menopause when they are under 40 years [2].

What else can cause menopause?

Menopause can occur at an earlier age if you have a medical treatment such as having your ovaries removed (oophorectomy), breast cancer treatment, chemotherapy or radiotherapy.

If you have a hysterectomy (removal of your womb), then your ovaries are more likely to stop working properly earlier than they would do otherwise, which can lead to menopausal symptoms.

What is perimenopause?

Perimenopause is the duration of time from when you first start experiencing symptoms right up to the ‘menopause’ point in time. During menopause, levels of oestrogen and progesterone can fluctuate hugely on a daily, even hourly basis. Perimenopause can vary in length from a few months to around a decade. Symptoms of perimenopause and menopause are the same.

Often women start to have these symptoms when they are in their early 40s. Other women can be younger. Some women do not realise their symptoms are due to perimenopause – they may put them down to stress or being busy.

What are the symptoms of perimenopause and menopause?

Symptoms are commonly felt before actual menopause occurs (before your periods stop all together) and some women find that they have more severe symptoms during perimenopause.

The majority of women, around 80%, experience symptoms [3] and for around 25% of women, these symptoms are severe [4]. Symptoms affecting your brain (especially memory and mood symptoms) are more common than vasomotor symptoms (flushes and sweats). [5]

Symptoms vary between women and can change with time. Fluctuating hormone levels lead to many symptoms, including:

• Brain fog – symptoms such as poor concentration, slips, difficulty absorbing information
• Memory problems
• Reduced energy
• Low mood
• Anxiety
• Irritability
• Mood swings
• Poor sleep
• Lack of libido
• Muscle and joint pains
• Hair and skin changes (such as dry or itchy skin)
• Panic attacks
• Worsening headaches and migraines
• Worsening PMS (premenstrual syndrome)
• Vaginal dryness, itching or soreness
• Pain during sexual intercourse
• Urinary symptoms such as increased frequency passing urine
• Heart palpitations
• Changes to periods – lighter and more irregular or more frequent and heavier
• Hot flushes
• Night sweats

There can be other, often surprising symptoms of perimenopause and menopause, including dry eyes, brittle nails, dizziness, altered sense of taste and smell, mouth issues such as bleeding gums, and tinnitus.

Levels of hormones fluctuate during perimenopause then become, and stay, low during menopause and then stay low for ever. Lower levels of hormones are associated with an increased risk of developing other health conditions including osteoporosis (bone weakening disease) [6], cardiovascular disease (conditions affecting the heart and blood vessels) [7], type 2 diabetes [8], dementia and cognitive decline [9], auto-immune diseases [10] and some cancers [11].

How is perimenopause and menopause diagnosed?

Most women over the age of 45 who have typical symptoms of perimenopause or menopause do not need any hormone blood tests to make the diagnosis.

If you are under 45 years old, hormone blood tests may be advised but they are not usually helpful as hormone levels can really vary. Sometimes other blood tests are recommended to ensure there is no other underlying cause for symptoms.

It can be very useful to keep a detailed account of all the symptoms you are experiencing so you can see how things are changing over time, look at what patterns there might be and consider what impact they are having on you.

What is HRT?

Hormone replacement therapy (HRT) is usually the first line treatment for the management of perimenopausal and menopausal symptoms [12]. The type of hormones you need and the doses you’re given vary between each woman – it is not a “one type fits all” prescription. HRT will usually contain oestradiol, progesterone and testosterone. These hormones are usually prescribed separately and it is important that you are given the right type and dose.

Women are prescribed hormones to both improve their symptoms as well as their future health.

Oestradiol: this hormone is produced predominantly by your ovaries, and levels fluctuate during perimenopause before declining in menopause and staying low for the rest of your life. Oestrogen helps to regulate your menstrual cycle, plays an important role in bone health, memory and cognition and cardiovascular health and is essential for many bodily functions.

Progesterone: if you still have your uterus (womb), taking oestrogen can cause the lining (endometrium) to thicken. To prevent this, you will usually need to take progesterone to keep the lining of your womb thin and regulate or stop bleeding. Progesterone can also relieve perimenopausal and menopausal symptoms such as sleeping problems, low mood and anxiety, and can be taken by women who’ve had a hysterectomy or use a Mirena coil as part of an individualised consultation for their symptom control.

Testosterone: this hormone is perhaps best known for improving libido, but you have testosterone receptors all over your body so the decline in levels can also lead to a loss of energy and brain fog, muscle and joint pains, low energy, poor sleep as well as other symptoms.

Who can take HRT?

For the majority of women, the benefits of HRT outweigh any risks. Most women can take HRT and usually natural, body identical hormones are prescribed. These are the same structure as the hormones you make in your ovaries, brain and other organs when you are younger. They are different to synthetic hormones that have been chemically altered and are associated with some risks.

There are often some misconceptions about HRT so it’s worth remembering:

• HRT can be started during perimenopause.
• You do not have to wait for your symptoms to become severe before taking HRT.
• There is no maximum length of time for which you can take HRT. Many women take HRT forever.
• Taking HRT reduces future risk of diseases.
• You can take natural, body identical HRT even if you have certain health conditions, such as migraine [13], high cholesterol [14], raised blood pressure [15] or if you’ve had a clot [16].
• Older women can start taking HRT.

What types of HRT are there?

There are numerous types of HRT, and it’s important to know what might be best suited to you.

Oestradiol (a type of oestrogen)

Transdermal preparations are those that are given through the skin as a patch, gel or spray. All types of transdermal oestradiol are natural (body identical) unless they are a combination patch, which also contains a synthetic progesterone. They are derived from yam plants and soy, and have the same chemical structure as your body’s natural hormones.

There are some oral oestradiol tablets that are body identical, such as Elleste Solo and Zumenon.

Other types of tablet oestrogen are synthetic – their chemical structure is different to that of oestradiol, which is the beneficial type of hormone produced by your body before menopause.

Progesterone

Like natural oestradiol, natural (body identical) progesterone in HRT is derived from yam plants or soy and has the same chemical structure as the progesterone your body produces.

Progesterone can be difficult to absorb through your skin and gut. It is therefore micronised (reducing the particles to a very fine powder and suspending in an oil) and putting it in capsule form so that it is easily absorbed. Utrogestan and Cyclogest are common brand names of natural progesterone. Utrogestan can be prescribed orally or vaginally and Cyclogest is given as a suppository (so can be used vaginally or rectally).

Sometimes, synthetic versions of progesterone are used, which are called progestogens or progestins. They have a slightly different chemical structure to natural progesterone and are associated with small risks, including a risk of clot [17] and heart disease [18].

The Mirena (and Levosert) coil is another option to protect the lining of your womb as part of HRT. It contains a hormone called levonorgestrel, which is slowly released into your womb. Although it is a synthetic progestogen, it is a much lower dose and usually just works locally on the lining of your womb.

Combined patches and pills

Combined HRT is oestrogen and progesterone and is available in patches and tablets. Patches contain natural (body identical) oestradiol but the progestogen part is synthetic. Many combination tablets contain natural oestradiol but the progestogen is synthetic. However, one tablet, branded in the UK as Bijuve, contains both natural oestradiol and progesterone.

Testosterone

Testosterone comes in gels (Testogel) and a cream (AndroFeme). They are all body identical and are derived from the yam plant or soy.

How do I take my HRT?

Oestrogen

Patch

Oestrogen patches are usually changed twice a week – for example if you put one on a Monday, you change it on a Thursday. They should be stuck onto your skin below your waist. Most women stick them on their bottom or upper thigh.

Gel

Oestrogen gel usually comes in a pump-­action bottle called a ‘pump pack’. The gel should be applied to the outer part of your arm, from your shoulder to your elbow, and to your inner thigh. It can also be rubbed on other sites of your body (although not advisable on your breasts). Some women use the gel in the morning, others in the evening and some women use it in both the morning and evening. You can watch a video that explains how to apply the gel at https://www.balance-menopause.com/menopause-library/how-to-apply-oestrogel

Oestrogen gel is also available in small sachets.

Spray

The spray should be applied to clean, dry, healthy skin of the inner forearm, in areas that do not overlap. If that is not possible, it should be applied on your inner thigh. The manufacturer of the spray suggests absorption may be lower if you apply it to your abdomen.

Tablet

Oestrogen-only tablets should be taken daily at a similar time of day, with or without food.

Progesterone

If you are still having periods when you take HRT, then the type of HRT you will be given (sequential HRT) will lead to you having regular periods. If it has been more than a year since your last period or you have been taking HRT for around six months to a year, then the type of HRT usually prescribed is one where you will not have periods (continuous HRT).

Sequential HRT

Also known as cyclical HRT, this involves taking oestrogen all the time, and then adding in progesterone for only part of the month. It’s generally used if you are still having periods, or if they have only stopped in the past few months.

With sequential HRT you will typically take oestrogen every day, and then for 12 to 14 days each month you take progesterone as well. After you finish the progesterone part of your HRT, you will usually have a period-like bleed, which is due to the hormones stopping rather than an actual period.

Continuous HRT

Continuous HRT is when you take your oestrogen and progesterone all the time without a break. If you take tablets, this will be every day, while patches are changed once or twice a week. Continuous HRT is usually used from about a year after your last period or if you have been taking sequential HRT for around 6-12 months.

The Mirena Coil (or IUS)

The Mirena coil can be left in place for five years (or longer if you are over the age of 45 when it is inserted, and just using it for contraception). This works locally on your womb, usually resulting in periods stopping. It also works as a contraception. Some women also take additional progesterone (as a capsule), which can have beneficial effects throughout your body. This is outside of the product licence and is recommended on an individual basis.

Testosterone

This is usually given as a gel or cream and should be rubbed on to clean, dry skin; usually on your upper outer thigh or buttocks. Applying it at the same time each day will usually have the best effect.

What dose will I need?

Every woman is woman is different so your dose of HRT will be decided with your healthcare professional. The dose and type of HRT may need to change with time.

There may be a noticeable improvement initially but then not as much as you were hoping for, or there may be a return of some symptoms. You may need a higher dose, to try a different way of taking the hormone or a different brand. You might benefit from adding in testosterone, as well as oestrogen (and progesterone). This is something your healthcare professional will work with you on to determine your optimum dose and balance of hormones.

Benefits and risks of HRT

HRT is a safe and effective treatment for the vast majority of healthy women with symptoms who are perimenopausal and menopausal. The benefits and risks of HRT often vary according to your age, your medical history and any existing conditions you may have – your healthcare practitioner will discuss this with you and personalise your HRT.

Benefits

Simply put, the main benefit of HRT is that the right dose and type can improve symptoms of perimenopause and menopause. Many women find their symptoms improve within a few months of starting HRT and feel like they have their ‘old self’ back, improving their overall quality of life. Hot flushes and night sweats usually stop within a few weeks of starting HRT. Many of the vaginal and urinary symptoms usually resolve within a few months, but it can take longer. You should also find that symptoms such as mood changes, difficulty concentrating, aches and pains in your joints, and the appearance of your skin will also improve.

HRT also benefits your future health. Around one in two women over the age of 50 will develop a fracture due to osteoporosis – a condition when the loss of bone density is severe and there is a greater risk of bones breaking [19]. Taking HRT can help prevent and repair bone loss and reduce the risk of fractures by around 50% [20]. 

There are also heart benefits – taking HRT will lower risk of developing heart disease and a lower risk of death from heart disease compared to women who do not take HRT [21].

Women who take HRT also have a lower risk of developing type 2 diabetes, bowel cancer and some studies have shown a lower risk of dementia [22].

Risks

The risks of HRT depend on the type of HRT you are given and factors such as your age, your family history, your general health and medical history. This is why it is so important to have an individualised consultation where you can discuss your actual risks.

Women who take synthetic types of HRT as tablets have a small increased risk of developing a clot in their veins or a stroke. You are more likely to develop a clot or have a stroke if you have other risk factors for these conditions. These include being obese, having a clot or stroke in the past or being a smoker.

This risk of clot or stroke is not present for women who use oestrogen as patches or gel rather than tablets. This risk is not associated with taking natural progesterone or testosterone.

Many women worry about breast cancer when taking HRT. Taking combined synthetic HRT (oestrogen and progestogen) may be associated with a small risk of developing breast cancer [23]. However, the Women’s Health Initiative study (WHI) showed that this risk was not even statistically significant [24]. The risk of breast cancer is reduced if micronised progesterone is used [25]. Any risk of breast cancer is very low; to put this in perspective the risk of breast cancer is greater in women who are overweight, do no exercise or drink moderate amounts of alcohol compared to taking any types of HRT [26].

The WHI study found that women who took oestrogen only HRT actually had a lower future risk of developing breast cancer.

There have never been any studies showing that taking HRT increases the risk of death from breast cancer. In addition, there is no increased risk of breast cancer in women who take HRT under the age of 51 years.

What can I expect when I start HRT?

While every woman is different, symptoms such as hot flushes and night sweats should subside within a few weeks of starting HRT, while other symptoms, such as low mood, muscle and joint pains and vaginal dryness, may take longer to resolve.

There are some temporary side effects that can happen in the first few weeks after starting HRT, including bleeding, tender breasts, bloating and you may find your mood is affected or you may feel more emotional. These side effects should settle and improve with time. If you experience side effects that are unexpected or persistent, it’s important you consult your clinician.

Is there anything else I need to know?

It’s worth remembering that HRT isn’t a contraceptive and it doesn’t work by delaying your menopause.

A holistic approach to your perimenopause and menopause, which incorporates a balanced diet and exercise, as well as considering hormone treatment, is the most effective way to manage your symptoms and future health.

There is a wealth of evidence-based information on the balance website and app, and your healthcare professional can help decide what is the right treatment choice for you, depending on your individual circumstances.

Resources

Understanding the benefits and risks of HRT downloadable visual aids

Easy HRT prescribing guide

The influence of oestrogen, progesterone and testosterone posters

References

1. NICE: CKS: Menopause
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