There are several different types of hormone replacement therapy (HRT) available to treat menopause symptoms. These include: oestrogen-only and combined (progestogen and oestrogen) hormone; low, medium and high doses; and continuous and sequential doses. HRT can also be given in different forms: for example as a pill (such as Elleste Duet or Kliofem), a gel, or a transdermal (skin) patch.
The option someone uses will depend on a range of circumstances, such as: what stage of the menopause they are at; what symptoms they are experiencing; whether or not they have had a hysterectomy; whether or not they have stopped having menstrual bleeds (and if they have, how long ago their last one was); and what treatments they have used before (and whether or not these were effective).
On this page, we’ll discuss the different cases in which each type of HRT is used, and what the benefits of each type are:
This type of HRT contains two different active ingredients: a synthetic version of oestrogen and a synthetic version of progesterone. They are distributed into the body at a steady rate over the course of a month.
So for example, a packet of 28 pills of continuous combined HRT will all the contain the same amount of each active ingredient. One pill is taken per day, without a break, so the levels of each hormone supplementing the body stays constant.
When continuous combined HRT is given through a skin patch, again, this releases hormones at a steady rate across the month.
Evorel Conti is an example of a patch which is changed twice weekly; whereas FemSeven Conti is changed once weekly.
Who should use continuous combined HRT?
Combined continuous HRT can be used by women who:
- are post-menopausal and have not had a menstrual bleed for more than one year, and have not had a hysterectomy; or:
- are aged 54 and over, and have not had a hysterectomy.
It can be used by women who started HRT on a sequential therapy while still having periods, but in such cases it should not be used before the age of 54.
Women will usually commence continuous combined HRT on a low dose, and this may be increased over time in order to manage symptoms accordingly.
- Femoston, Angeliq and Kliovance are low dose forms;
- Indivina and Premique are available as low and medium dose;
- Elleste Duet Conti and Kliofem are higher dose options.
What are the benefits of combined continuous HRT?
This type of HRT is sometimes referred to as ‘period free’ HRT. This is because women who are still bleeding when starting this form of HRT will usually stop within a few months.
Taking combined HRT means that the user does not have to remember to take two pills (or apply two patches), each containing a different ingredient. Both progesterone and oestrogen are included in one pill (or patch).
Because they contain the same dose in each, it doesn’t matter as much on what day someone takes each pill; as long as they remember to take one every day at the same time.
Women who use continuous combined therapy are not as likely to develop a problem called endometrial hyperplasia (thicker womb lining) as women who use sequential therapy. (Endometrial hyperplasia can cause heavy menstrual bleeding and spotting, and pain during intercourse.)
The risk of endometrial cancer is also lower in women who use combined therapy as opposed to single hormone (or oestrogen-only) therapy.
This type of HRT also contains two different hormones; man-made versions of progesterone and oestrogen. These are delivered into the body in varying amounts throughout a one-month cycle of treatment.
For example, some 28-day pill packets might contain:
- 16 oestrogen-only tablets to be taken on days 1-16 of the 28-day cycle
- and 12 combined oestrogen and progesterone tablets to be taken on days 17-28 of the 28-day cycle.
The duration of sequences can vary too. Some pills, such as Trisequens or Femoston 1/10, may have 10 or 14 progesterone pills, to be taken on days 19-28 or 15-28 of the menstrual cycle, respectively.
Other courses, such as Tridestra, may mean that the user only takes progesterone for a couple of weeks at the end of every quarter (3-monthly period). It’s progesterone intake that essentially determines how often someone can expect to have a menstrual bleed (so either every month or every three months).
Some pill packs may have a separate progesterone and oestrogen pill for the combined days; so for instance, a user may need to take one pill per day for the first 16 days of their cycle, then two pills per day (one of each hormone) for days 17-28.
The amount of oestrogen taken may also change across the month, and there might be a 7-day break or tablet free period in some cases (such as with Cyclo-Progynova).
Sequential or cyclical therapy is also available as a transdermal patch. So, if a patch is applied once weekly (FemSeven Sequi) or twice weekly (Evorel Sequi), the patches they apply towards the second half of the month will contain different levels of hormones than those they apply at the start of the month.
Who should use sequential combined HRT?
Sequential HRT can be used by women who:
- are perimenopausal (going through the menopause) and still having some menstrual bleeding; and:
- have not had a hysterectomy.
Starting on the lowest dose and increasing as required is recommended. Side effects most commonly occur during days where progesterone is delivered into the body. If someone experiences these, a doctor may suggest changing to a therapy containing a different type of progesterone.
- Novofem is an example of a low dose sequential combined HRT.
- Climagest, Elleste Duet and Femoston are available as sequential combined HRT in both low and medium dose preparations.
- Evorel Sequi, FemSeven Sequi, Trisequens and Cyclo-Progynova are medium doses.
Some forms of progesterone, such as norgestrel, norethisterone and levonorgestrel, are derived from testosterone, which is an androgen (or male hormone). This type of progesterone may be more likely to cause side effects in some people; and in such cases, a treatment containing a progesterone which works less in the body like testosterone. (Examples of these are medroxyprogesterone and Utrogestan.)
What are the benefits of sequential combined HRT?
This type of HRT is more suited to women who are younger than 54, but are still having some bleeding; and for whom continuous combined therapy isn’t likely to be suitable.
Unlike in continuous combined therapy, where periods stop completely after a few months, sequential HRT enables the user to continue to have a period for as long as they naturally would, before eventually moving on to continuous therapy once they have completely stopped menstruating for a year.
And as it is a combined therapy, the risk of developing cancer of the womb lining is thought to lower than it is in oestrogen-only therapy.
This type of HRT does not contain a progesterone hormone; it only contains an oestrogen. In this therapy, oestrogen is distributed into the body at a steady rate over the course of the month (continuously).
Oestrogens are available as oral pills which are taken every day, as patches applied to the skin, and as topical gels. Vaginal rings and pessaries (tablets inserted into the vagina) are also available.
Who should use oestrogen-only HRT?
Single hormone or oestrogen-only therapies are indicated for:
- women who are experiencing menopause symptoms who have had their womb surgically removed (hysterectomy).
An oestrogen-only product can be also used as part of a combined programme of treatment, with an additional progesterone given.
As with other forms of HRT, there are different doses on offer. A doctor will recommend using the lowest possible dose as a starting point and increasing to alleviate symptoms where necessary.
- Elleste Solo, Progynova and Zumenon are available as low and medium dose pills.
- Premarin (pills), Estraderm MX (patch), Evorel (patch) and Estradot (patch) are available in low, medium or high doses.
Oestrogel and Sandrena are topical gels containing oestrogen.
Vaginal gels and pessary tablets are available too. However these only work to alleviate symptoms local to the vagina, such as dryness, and won’t help with other symptoms such as flushes.
What are the benefits of oestrogen-only HRT?
It tends to be more suitable for women who have had a hysterectomy than combined therapy.
As well as alleviating symptoms, such as hot flushes, oestrogen can help to lower the risk of osteoporosis (loss of bone density). People who develop osteoporosis are more likely to sustain a fracture or break if they fall or get injured. (However, combined therapies also containing oestrogen can also help to lower the risk of osteoporosis.)
Previously, combined HRT has been linked with a higher risk of breast cancer than oestrogen-only therapy.
Conversely, oestrogen-only therapy carries a higher risk of endometrial cancer than combined HRT in women who haven’t had a hysterectomy; so it will only be used in cases where a woman has had her womb removed.
Available under the brand name Livial, tibolone is a ‘gonadomimetic’ HRT pill containing one ingredient (called tibolone) which is synthesised into hormones in the body. These hormones work in a similar way to progesterone, oestrogen and testosterone. They are distributed into the body continuously, so the drug is essentially a combined continuous form of HRT.
It is only currently available in one dose (2.5mg).
Who should take tibolone?
Tibolone is indicated for use by women who:
- are postmenopausal, and have not had a menstrual bleed for at least one year.
Because it contains a testosterone mimetic, it can be useful in alleviating reduced libido (sex drive), in addition to the other symptoms of menopause (loss of bone density, hot flushes, vaginal dryness and so on).
It can also be prescribed to women who have had a hysterectomy.
What are the benefits of tibolone?
Tibolone may be better for users wishing to take continuous combined HRT who are experiencing loss of libido. It is also not thought to pose the same risk of breast cancer as other combined treatments; instead carrying a risk which is comparable to that of oestrogen-only therapy.
A slight drawback compared to other forms of HRT is that it is only currently available as an oral pill (and not a patch).
Which HRT is best for me?
If you haven’t taken HRT before or are not sure, it’s better to speak to your doctor in the first instance, so that they can review your symptoms and help you decide on the most suitable treatment. They will also be able to discuss the different forms of HRT, and help you weigh up the benefits and risks of each depending on your circumstances.