HRT Archives - Balance Menopause & Hormones

HRT doses explained

Natalie Millman — Tue, 18 Mar 2025 09:23:27 +0000

What you need to know about hormone replacement during perimenopause and menopause

Hormone replacement therapy (HRT) is usually the first-line treatment to improve symptoms of perimenopause and menopause [1]. It works by topping up or replacing your missing hormones.

Types of HRT usually contain oestradiol (the beneficial type of oestrogen), progesterone and also testosterone.

But what are these hormones, why are there different doses and why do absorption rates vary from person to person? This article tackles these key questions and more.

What is oestradiol and what do I need it for?

Oestradiol is a hormone produced by your ovaries, adrenal glands, brain and other tissues. It helps to regulate your menstrual cycle and the development of female characteristics during pregnancy, such as breasts.

It also plays important roles in bone health, memory and cognition and cardiovascular health and is essential for many bodily functions, including:

temperature regulation
maintaining healthy and strong muscles and joints
helping your nerves work correctly
maintaining a healthy metabolism
improving the way your immune cells work and function
reducing inflammation throughout your body
improving the way other neurotransmitters (such as serotonin and dopamine) work in your brain
keeping the lining of your vagina and vulval tissues healthy and lubricated

Oestrogen is actually an umbrella term for three types: oestradiol, oestrone and oestriol. Oestradiol is the main type of oestrogen produced by your body in your reproductive years.

You have oestradiol receptors in cells throughout your entire body, so when levels fluctuate and fall, this can trigger wide-ranging and varying symptoms, including low mood, anxiety, memory problems, poor sleep, joint aches and pains, brain fog, hot flushes and vaginal dryness.

How is oestrogen given in HRT?

Oestrogen can be given either through your skin, known as transdermal oestradiol, or orally in the form of a tablet. Transdermal oestradiol can be given in the form of:

gel
patches
spray

Transdermal oestradiol is absorbed directly through your skin into your bloodstream. This means that it bypasses your liver and causes less side effects. In addition, your liver produces clotting factors, which means that if a tablet of oestrogen is taken, there is a small increased risk of a blood clot occurring. There is no risk of clot for women who use transdermal oestradiol.

Transdermal oestradiol can also be taken by women who suffer from migraines (women with migraine should not take oestrogen in tablet form) and women who have had a clot in the past.

Another benefit of transdermal oestradiol is that doses can be altered more easily, allowing you to be treated individually and have your dose and type tailored to your symptoms and health.

What is HRT made from?

In the past, oestrogen was only given as a tablet that was derived from pregnant horses’ urine.

However, the majority of oestrogen and progesterone in the HRT that is now prescribed is derived from yam plants and soy. When hormones have the same molecular shape as the hormones your body naturally produces itself, they are called body identical hormones.

The form of oestrogen most commonly used is called 17-β oestradiol. All types of transdermal oestradiol contain this type of oestrogen.

The brand of progesterone most commonly used is Utrogestan, which is another body identical hormone. There are some other brands of body identical versions of progesterone available. Sometimes, synthetic versions of this hormone are used, which are called progestogens. This will be discussed in more detail below.

Body identical testosterone is also derived from yam plants or soy and is either a gel or cream.

RELATED: Body identical hormones

I’ve started taking HRT. How will I know how much of each hormone I need?

A consensus statement by the British Menopause Society states that HRT dosage, regimen and duration should be individualised, with annual evaluation of advantages and disadvantages [2].

Doses are prescribed according to symptoms and some women have more symptomatic improvement with higher doses than other women. Prescribing HRT at the right dose improves symptoms and reduces future risk of heart disease, osteoporosis, clinical depression and type 2 diabetes.

Hormone blood tests are not usually needed to make a diagnosis of perimenopause or menopause, as they are unreliable, especially as the levels fluctuate so much during perimenopause. However, hormone blood tests can be useful for some women to monitor the absorption of hormones from your HRT.

As your hormone levels vary from day to day, it’s important to consider the whole picture, taking into account how you feel and if your symptoms have changed since starting to take HRT and this information will be considered to help decide if you need a change in your dose or type of HRT.

Oestradiol levels are most useful for monitoring how well a type of HRT is being absorbed. They are not that accurate if you take oestrogen as a tablet, as the oestrogen becomes metabolised into different types of oestrogen when it is digested. However, they can be helpful if you take transdermal HRT to confirm if it is being adequately absorbed through your skin into your bloodstream, especially if you are still experiencing symptoms. If you are having symptoms despite taking HRT, then it may be that there are other causes for your symptoms so it is important to discuss any symptoms with a healthcare professional.

Generally, to offer the health benefits of oestrogen replacement, oestradiol blood levels need to be over 250pmol/l. Few women need to have a level above 1,000pmol/l. Levels can alter rapidly during perimenopause and it can be common for women to transiently have higher levels. This is the usual range of oestrogen when you are menstruating. In comparison, during pregnancy levels of oestrogen can be around 65,000pmol/l.

However, the dose of oestrogen needed to relieve the symptoms of perimenopause and menopause can really vary between women. Studies have shown that younger women experiencing symptoms of perimenopause or menopause often tend to need higher levels of oestradiol (and therefore usually higher doses of HRT) than older women do.

A Newson Health study of 1,508 women found that almost one in three women using licensed doses had low blood oestradiol levels, including around one in four who were using the highest licensed dose [3]. These findings suggest that up to one in four women may need higher doses or a change in oestradiol formulations (eg from patch to gel) to achieve blood levels needed for optimal health.

It is important to have adequate oestrogen to improve symptoms as well as to improve future health. If amounts of oestrogen are too low, then it is likely you will experience symptoms and the health risks of menopause (such as increased risk of heart disease, osteoporosis, clinical depression and dementia) will still be present.

My friend is on a lower dose than I am. Does that mean my dose is too high?

Some women need higher doses than other women to achieve the same benefits, especially as oestrogen can often be absorbed differently through the skin. For example, some people find they absorb oestrogen much more effectively through gels rather than patches, whereas for other women they find they absorb more effectively using patches compared to gels. Other people find they absorb some brands of gels or patches better than others, despite them all containing the same type and dose of oestradiol.

Because of this, to achieve a specific oestradiol level, some women may only need a very low dose and some may need a higher dose.

Is it safe to use a higher than licensed dose of oestrogen?

The British National Formulary (BNF) states that doses of oestradiol should be adjusted according to response.

Some women need higher doses to achieve a physiological level of oestradiol. It is more common that younger women with premature ovarian insufficiency (menopause before the age of 40) need higher doses to achieve a physiological response.

While many women will respond well to lower doses of oestrogen, some will require higher doses such as 200mcg or 300mcg of oestradiol patches to provide adequate symptom control.

Why do some people absorb female hormones differently to others?

There are so many reasons why you may absorb hormones through your skin differently to others.

There are many tiny blood vessels, called capillaries, which supply blood and nutrients to your skin and absorb the hormones from the patches or gels. The depth and numbers of these capillaries varies between women [4].

Other factors that affect absorption of hormones through your skin into your body will be the thickness of the layers of your skin, how well hydrated it is and the temperature of your skin. The fact the skin works as a barrier is relevant too and some people’s barriers will be better than others even to hormones in patches and gels that are designed to penetrate your skin [5].

In addition, there are many proteins and enzymes that help make up the five layers of your skin. These enzymes can affect the amount of hormones that are available in your bodies (bio-availability) from the patches and gels and there is evidence this composition of proteins and enzymes alters with time too [6].

Some studies have found that your ethnicity can affect how much of a drug is absorbed through your skin. One study found people from a Hispanic background had the best absorption rate, followed by White people, Asian people and people from an Afro-Caribbean background [7].

In summary, there are many different factors affect the dose of oestradiol you need to ensure you have adequate oestrogen for your perimenopause or menopause. You should talk to a healthcare professional if you feel your dose or type of HRT needs changing.

Progesterone doses

If you still have your uterus (womb), taking oestrogen can cause the lining (endometrium) to thicken. To prevent this thickening, you will usually need to take either body identical progesterone (Utrogestan, Gepretix, Cyclogest or Lutigest) or a synthetic progestogen tablet or have the Mirena coil.

The regime in which you take this will depend on the type of progesterone and whether you are still having periods or not. If you are still having periods, the usual recommended dose is 200mg Utrogestan every evening for two out of four weeks. Once periods have stopped, the dose of Utrogestan is usually 100mg every evening.

If you experience progesterone intolerance symptoms (such as low mood), the capsules or an alternative progesterone can often be used vaginally.

The main aim of progesterone dosing is to keep the lining of the womb thin and to ensure bleeding does not happen outside of the expected times. The dose of progesterone needed to achieve this does not depend on your dose of oestrogen. There is no strong evidence to suggest that if you are prescribed a higher dose of oestrogen that you also require a higher dose of progesterone.

Prescribing higher doses of progesterone on this basis is off label with no evidence of safety. The dose of progesterone at initial consultation will be determined by personal history, whether there are risk factors for thickening of the womb and any previous side effects from taking progesterone which would suggest intolerance. This decision is reviewed at all subsequent follow-up appointments.

If you are experiencing bleeding when you shouldn’t be bleeding, regardless of your dose of hormones, you should discuss this with your healthcare provider to see if any other investigations are needed. Bleeding commonly occurs in the first 3-6 months after starting or altering the dose of HRT and can occur with both higher and lower doses of oestrogen. Sometimes a higher dose of progesterone is recommended to reduce any bleeding.

A recent audit of patients at Newson Health found that abnormal vaginal bleeding occurs in fewer than 1% of our patients. Moreover, there was no correlation between oestradiol dose levels and the incidence of problem bleeding.

RELATED: Changes in bleeds: your FAQ

Testosterone doses

When commencing testosterone replacement, the starting dose is usually 5mg of cream or gel daily. Generally, after 3-6 months a blood test is done to check the level of testosterone and often also your sex hormone binding globulin (SHBG) to determine your Free Androgen Index (FAI).

If your levels are low despite treatment with testosterone and you are still experiencing symptoms of testosterone deficiency (reduced libido, low energy, reduced motivation), then you may be recommended to increase the amount of testosterone gel or cream you are using and then repeat the blood test again after a few months.

Side effects due to testosterone are very rare if levels of testosterone and Free Androgen Index remain in the female range.

Resources

HRT is not a “one size fits all” treatment

References

NICE Guideline NG23 (2024) Menopause: identification and management
British Menopause Society (2020), ‘BMS & WHC’s 2020 recommendations on hormone replacement therapy in menopausal women’
Glynne S., Reisel D., Kamal A., Neville A., McColl L., Lewis R., Newson L. (2025), ‘The range and variation in serum estradiol concentration in perimenopausal and postmenopausal women treated with transdermal estradiol in a real-world setting: a cross-sectional study’, Menopause. 32(2) pp103-111. doi: 10.1097/GME.0000000000002459. Epub 2024 Dec 17. PMID: 39689249.

Tinhofer I.E., Zaussinger M., Geyer S.H., Meng S., Kamolz L.P., Tzou C.H., Weninger W.J. (2018), ‘The dermal arteries in the cutaneous angiosome of the descending genicular artery’, J Anat, 232(6) pp.979-86. doi: 10.1111/joa.12792.
Singh I., Morris A.P. (2011), ‘Performance of transdermal therapeutic systems: effects of biological factors’, Int J Pharm Investig, 1(1):4-9. doi: 10.4103/2230-973X.76721.
Liu, P., Higuchi, W.I., Ghanem, A.H., Good, W.R. (1994), ‘Transport of beta-estradiol in freshly excised human skin in vitro: diffusion and metabolism in each skin layer’, Pharmaceutical Research, 11(12), pp.1777–84. doi.org/10.1023/a:1018975602818
Leopold C.S, Maibach H.I, (1996), Effect of lipophilic vehicles on in vivo skin penetration of methyl nicotinate in different races, International Journal of Pharmaceutics, 139, 1–2, pp.161-67, doi.org/10.1016/0378-5173(96)04562-0.

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Endometriosis and hormones

Natalie Millman — Wed, 12 Mar 2025 09:46:54 +0000

How hormones can affect endometriosis and advice on how to treat and improve symptoms

Endometriosis affects around one in ten women
Hormones, oestrogen, progesterone and testosterone, can play important roles in endometriosis
Various hormone treatments are available, as well as surgery for some women

Endometriosis is the second most common gynaecological condition after fibroids – it is estimated that two million women in the UK have endometriosis [1]. Yet it has been referred to as “the missed disease” [2], and there is still much to learn.

What is endometriosis?

The word endometriosis comes from the Greek words ‘endos’ (inside), ‘metra’ (womb) and ‘-osis’ (disease). With this in mind, endometriosis is a condition where tissue similar to the lining of your womb grows elsewhere in your body. This tissue can grow on your ovaries, fallopian tubes and around your bowel and bladder. It can also grow in other organs such as your lungs.

While some women with endometriosis do not experience symptoms, for others it can cause heavy, painful periods, pain in your abdomen, pelvis, and other organs, and for some women, problems with fertility. For women who have symptoms, there are many different treatments available to manage the condition and reduce the symptoms and associated pain.

RELATED: Endometriosis and hormones

Some women who have endometriosis may also have adenomyosis – a condition where endometrial tissue grows into the muscular wall of your womb. Adenomyosis is more likely to cause heavy period bleeding than endometriosis.

How is endometriosis treated?

Treatment often varies between women. It can be effective and really improve symptoms.

Treatment may involve limiting or stopping the production of the hormone oestrogen. This is because oestrogen can encourage the tissue to grow, both those inside and outside of your womb. It is the presence of the cells elsewhere in the body that usually causes the unwanted symptoms.

There are different types of oestrogen and there is very little research about the effects of different oestrogens (such as oestradiol, oestrone and oestrogens in synthetic contraceptives) on endometriosis.

There are various treatments available, including hormones and painkillers. In more severe cases, or when those treatments have not improved symptoms, you may need surgery.

Surgery aims to remove or destroy the tissue found outside of your womb, known as endometriotic lesions or deposits. Keyhole surgery using a camera (laparoscope) inserted through small incisions in your abdomen is a common procedure used to destroy these endometrial deposits. In some cases an operation, such as a hysterectomy (removal of your womb) or removal of your ovaries is needed. Although these operations are often successful in improving endometriosis symptoms, they can lead to a surgical menopause occurring.

Surgical menopause is when hormones (oestradiol, progesterone and testosterone) suddenly stop being produced in your body, due to such types of operations (or certain medications). It can cause a sudden onset of menopausal symptoms, which can be severe and disabling and have a negative impact on the quality of your life as well as your future health. Having the right type and dose of hormones is really important for women who have had a surgical menopause, and often improves menopausal symptoms considerably, as well as improving your health in the future.

Can I have HRT and testosterone if I have or have had endometriosis?

If you have had an early surgical menopause (under the age of 45 years), it is very important that you consider taking hormones as without hormones you have a greater risk of developing conditions such as heart disease, osteoporosis and diabetes [3]. If you are perimenopausal or menopausal, or experiencing symptoms related to PMS or PMDD, then taking the right dose and type of hormones is likely to both improve your symptoms as well as your future health.

Replacement oestradiol comes in the form of a tablet, patch, gel or spray. The safest types are ones that are absorbed through your skin, as there is no risk of clot or stroke with these preparations. Natural progesterone is usually prescribed as an oral capsule but can also be used as a pessary for some women and testosterone is a cream or gel.

For the majority of women, the benefits of HRT outweigh any risks.

RELATED: HRT doses explained

Currently, there is a lack of high-quality research looking into the specific benefits and risks of HRT in women with endometriosis. There is a possibility that oestrogen can reactivate endometriosis, giving rise to symptoms of endometriosis occurring in a some women.

Oestradiol and oestrone work differently in your body so some women find that the synthetic oestrogen in contraceptives and some types of HRT can flare up and worsen their endometriosis whereas taking oestradiol in body identical HRT does not have these effects. Synthetic and natural hormones have very different effects in the body.

Which types of HRT may I be offered?

If you naturally enter perimenopause or menopause (rather than due to medical or surgical intervention), you should be offered combined HRT – this contains both oestradiol and progesterone (or progestogen).

If you are thought to have some endometriosis remaining after a hysterectomy, for example around your bowel or bladder, you will usually be given progesterone with oestradiol, to reduce the risk of any endometriosis tissue being stimulated by the oestradiol. Women with endometriosis are usually given progesterone daily, which helps to reduce any symptoms and the chances of endometriosis recurring.

The safest type of progesterone is micronised progesterone or Cyclogest (progesterone pessary), which is body identical and derived from the yam plant and soy.

Some women with endometriosis are prescribed a type of hormone-blocking drug, which is a GnRH analogue. This blocks hormones so leads to a chemical menopause. This can improve symptoms of endometriosis but lead to menopausal symptoms occurring, so it is often advisable to have add-back hormone replacement therapy – where HRT (sometimes with testosterone) is given at the same dose each day, which does not usually flare up endometriosis [4].

However, very occasionally endometriosis can reactivate spontaneously without taking any oestrogen. It is therefore important to report any recurrence of endometriosis symptoms such as pelvic pain, or bleeding from your vagina, bladder or bowel.

Taking testosterone can often really help improve your energy levels, mood, concentration and libido. Some women find that they have more benefits starting testosterone and progesterone before oestrogen. Both testosterone and progesterone can reduce inflammation so can be beneficial for some women. Testosterone does not stimulate the endometrium in the way that oestradiol does [5].

It is important for your dose and type of hormone treatment to be individualised for you.

RELATED: My story: endometriosis

Resources

ESHRE Endometriosis guideline

Endometriosis | Treatment summaries | BNF | NICE

References

UCLH Endometriosis Centre
Overton C., Park C. (2010), ‘Endometriosis. More on the missed disease’, BMJ, 341:c3727. doi: 10.1136/bmj.c3727
Langer, R. D. (2021), ‘The role of medications in successful aging’, Climacteric, 24(5), pp505–512. https://doi.org/10.1080/13697137.2021.1911991
Edmonds D.K. (1996), ‘Add-back therapy in the treatment of endometriosis: the European experience’, Br J Obstet Gynaecol. Oct;103 Suppl 14:10-3. PMID: 8916980.
Zang H., Sahlin L., Masironi B., Eriksson E., Lindén Hirschberg A. (2007), ‘Effects of testosterone treatment on endometrial proliferation in postmenopausal women’, J Clin Endocrinol Metab, 92(6) pp2169-75. doi: 10.1210/jc.2006-2171.

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Urinary incontinence in menopause: are you ignoring the symptoms?

Natalie Millman — Mon, 10 Mar 2025 01:01:00 +0000

How to spot symptoms and manage urinary incontinence during perimenopause and menopause

Urinary incontinence and bladder problems affect around six million people in the UK
Risk factors include falling hormones in perimenopause and menopause, pregnancy and obesity
Advice on how to spot symptoms, plus management strategies

If you have noticed more urine leaks and accidents since you hit perimenopause and menopause, then you are not alone. Declining levels of hormones, especially oestradiol (oestrogen) and testosterone, can affect your continence, which is the ability to control your bladder and when you urinate. The impact can range from inconvenience to a devastating effect on quality of life.

‘Urinary incontinence can be a difficult thing to talk about,’ says Newson Clinic GP and Menopause Specialist Dr Clair Crockett. ‘But it is incredibly common, especially around perimenopause and menopause. It can be really upsetting and distressing and have a big impact on women’s lives, leading to lots of planning, worrying and anxiety.’

Here we look at what can lead to incontinence during perimenopause and menopause, signs to look out for and where to seek help.

What is urinary incontinence?

Urinary incontinence is when you unintentionally pass urine. There are a number of different types, and they can all occur in a range of severity, from small leaks to larger volumes. It is estimated that around six million people in the UK are affected with bladder and incontinence problems – so if you have symptoms, please know you are not alone.

What are the symptoms of urinary incontinence?

There are number of different types of incontinence – here we look at the most common.

Stress incontinence is when you leak urine when your bladder is put under extra pressure, and could happen when you laugh, sneeze, lift something heavy or exercise. While it is normally small amounts of urine that leak, it can be larger volumes, especially if your bladder is very full. This happens when the pressure inside your bladder is greater than the strength of your urethra (the tube which carries urine out of your body) to stay closed.

Urgency urinary incontinence is urine leakage after a sudden, compelling need to urinate that is difficult to delay while you find a toilet.

Mixed incontinence is when you have both symptoms of stress incontinence and urgency.

Overactive bladder (OAB) is defined as urgency that occurs with or without urgency urinary incontinence, which comes with the need to frequently wee, especially at night.

What can put me at higher risk of urinary incontinence?

Factors which stretch, injure or put extra pressure on the muscles in and around your bladder and pelvis all contribute to a higher risk, including:

ageing: as you get older your muscles can weaken – although this doesn’t mean you should accept it as a natural part of ageing – and this risk starts to increase around the time of perimenopause and menopause, as your hormone levels begin to drop
pregnancy and childbirth: if you’ve been pregnant, your risk of bladder incontinence increases, and it can increase more if you had a vaginal delivery
having a hysterectomy
cancer treatments in the pelvic area
prolapse: a common problem when some of the tissues from your pelvis slip down slightly and bulge into your vagina
family history of incontinence
Obesity, and smoking now or in the past, can increase the risk of having bladder weakness [1]

RELATED: Pelvic floor and hormones

How common is incontinence in women?

Research has suggested the issue is incredibly common. One study looking at women aged around 35 to 55 years of age found that 30% to 40% said they sometimes leak urine [1].

Around 70% of menopausal women have genitourinary syndrome of the menopause (GSM) – this covers a range of symptoms, including an increase in the need to urinate and the urgency to do so [2]. Many young women also experience these symptoms, which are often related to low hormones in the genitourinary system but are often not diagnosed as being associated with changing hormone levels

Why can urinary incontinence occur in perimenopause and menopause?

During perimenopause, your levels of oestradiol, progesterone and testosterone, which are produced in your ovaries and brain, as well as other organs and tissues, start to decline until they reduce further during menopause. The loss of these hormones, particularly oestradiol and testosterone, causes the muscles that help support your bladder, known as your pelvic floor, and the muscles that close your urethra to lose strength. This loss of strength and tone can diminish your bladder’s ability to securely carry urine, says Dr Clair.

At the same time, the loss of these hormones also can affect the epithelium, the cells that form the top covering of your bladder, your urethra and your vulva, making them more sensitive, thinner, less flexible and less robust. This extra sensitivity can increase overactive bladder symptoms and bring on strong feelings of urgently needing to urinate.

‘Often perimenopause and menopause can exacerbate a problem that was already there,’ says Dr Clair. ‘A lot of women struggle with continence after pregnancy, and then when their hormone levels start to decline in their 40s, it can start to worsen.’

Can HRT help urinary incontinence?

First of all, make an appointment with your GP or a clinician who specialises in hormones to get a proper diagnosis and treatment advice. ‘Make sure you seek help as soon as possible, as there are lots of things that can be done,’ says Dr Clair.

Replacing low hormones by taking HRT, often with testosterone and/or using vaginal hormonal preparations, can help restore strength and tone to your muscles and tissues in your pelvic area. Vaginal oestrogen, applied topically in low doses to your vagina, and HRT via skin patches, skin gels or tablets, can lead to significant improvements, says Dr Clair. Vaginal DHEA (also known as prasterone) pessaries, which convert into both oestrogen and testosterone, can also be beneficial [3]. Using vaginal hormones can increase the concentration of hormones in your urinary system and pelvic floor muscles.

You may benefit from having both vaginal hormones and systemic HRT, or may start with a single approach depending on your symptoms, personal preferences and medical history. Adding in testosterone, which has a role in the strength of your pelvic floor, and which also declines as you age, can help some women improve their continence [4].

What other treatments are available for urinary incontinence?

While HRT can have an impact on symptoms for many women, there are several lifestyle factors that can help reduce your leakages whether or not you use hormones.

Pelvic floor exercises can help, and seeing a specialist physiotherapist for personalised advice can also be beneficial
Moderate weight loss (5-10%) has been shown to significantly reduce urinary incontinence episodes in overweight women [5]
Reduce caffeine intake from drinks such as coffee, tea and some soft drinks, and avoid fizzy carbonated drinks, which can irritate your bladder and bring on feelings of urgency. Aim to be hydrated
Limit or avoid alcohol and spicy food as these can irritate your bladder
Avoid irritation of the delicate skin of your vulva and around your urethra. Perfumes, powders, soaps, deodorants, spermicides and many brands of lubricants often contain chemicals that can irritate and should be avoided [6]
Tight-fitting clothing and long-term use of sanitary pads or continence pads, which can seem part of solution, can worsen symptoms by rubbing your delicate skin
Treat and manage vaginal and vulval dryness as this can irritate your urethra. As well as vaginal hormones, vaginal moisturisers and lubricants, which are available over the counter, can help bring you relief. Avoid intimate washes or intimate products as these can dry out these delicate areas – use a simple emollient to wash with such as Cetraben or Hydromol.

‘It’s important to make lifestyle changes alongside exploring hormonal treatments to get the maximum relief from symptoms,’ says Dr Clair. ‘Receiving the right treatment can be a journey, there may need to be different preparations and types of hormones tried along with lifestyle changes to find the combination that works best for you.’

If non-surgical treatments for urinary incontinence are unsuccessful or unsuitable, surgery or other procedures may be recommended [7].

Resources

NHS: Urinary incontinence

References

1. Danforth K.N., Townsend M.K., Lifford K., Curhan G.C., Resnick N.M., Grodstein F. (2006). ‘Risk factors for urinary incontinence among middle-aged women’, American Journal of Obstetrics and Gynecology, 194(2), pp.339–45. doi.org/10.1016/j.ajog.2005.07.051

2. Nappi R.E., Kokot-Kierepa M. (2012), ‘Vaginal Health: Insights, Views & Attitudes (VIVA) – results from an international survey’ Climacteric 15 (1): 36-44. Doi: 10.3109/13697137.2011.647840

3. Collà Ruvolo C., Gabrielli O., Formisano C., Califano G., Manna P., Venturella R., Di Carlo C. (2022), ‘Prasterone in the treatment of mild to moderate urge incontinence: an observational study’, Menopause, 29(8) pp957-962. doi: 10.1097/GME.0000000000002007. PMID: 35881944.

4. Kim, M.M., Kreydin, E.I. (2018), ‘The Association of Serum Testosterone Levels and Urinary Incontinence in Women’, The Journal of Urology, 199(2), pp522-27. doi.org/10.1016/j.juro.2017.08.093

5. Wing R.R., Creasman J.M., West D.S., Richter H.E., Myers D., Burgio K.L., Franklin F., Gorin A.A., Vittinghoff E., Macer J., Kusek J.W., Subak L.L. (2010), ‘Program to Reduce Incontinence by Diet and Exercise (PRIDE). Improving urinary incontinence in overweight and obese women through modest weight loss’, Obstet Gynecol, 116(2 Pt 1):284-292. doi: 10.1097/AOG.0b013e3181e8fb60

6. British Society for Sexual Medicine (2023), ‘Position Statement for Management of Genitourinary Sydrome of the Menopause (GSM)

7. NHS.uk (2022), ‘Surgery and procedures – Urinary incontinence’

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Managing your menopause during Ramadan

Natalie Millman — Fri, 28 Feb 2025 01:00:00 +0000

Tips on HRT, hydration and managing menopause symptoms

Ramadan is one of the holiest months in the Islamic calendar and marks four weeks of fasting, prayer, reflection and community.

From the evening of Friday 28 February to the evening of Sunday 30 March 2025, many Muslims will observe the month by not eating or drinking in daylight hours.

Here Dr Hina Shahid, a GP and chair of the Muslim Doctors Association, offers advice on managing the menopause during this special month.

What about my hormone replacement therapy (HRT) medication?

Some medication can be affected by the Ramadan fast, so here is what you may need to change if you take HRT.

If you replace hormone levels using skin patches, skin gels, an intrauterine device such as a Mirena coil, or a vaginal pessary or cream, then you don’t need to make any changes during Ramadan.

‘Continue as normal with these forms of HRT,’ says Dr Shahid. ‘These are absorbed through the skin, they are not ingested and have no nutritional value, so they don’t break your fast.’

However, oral HRT does break your fast, so move them to before or after daylight hours.

‘Most women take their HRT tablets first thing in the morning, so just move it back earlier to your suhur, the predawn meal. If you normally have them in the evening, just wait until the sun goes down.’

These small tweaks shouldn’t disrupt their effectiveness, Dr Shahid says. ‘If you just move it by a short amount of time it won’t have an impact on your hormone levels, and as they tend to be taken once a day they are not hard to move.’

RELATED: HRT doses explained

I’m perimenopausal. What if I’m on my period during Ramadan?

Women on their period do not fast during Ramadan, so if you’re in perimenopause and still having periods, Dr Shahid says the exemption to not fast applies, and you can make it up at a later date.

‘If you’re having irregular bleeding, and you have already seen a doctor about this, then you may still be able to fast and it would be advisable to speak to an Islamic scholar who can give specific advice around this,’ she says.

Don’t be tempted to skip suhur

Your menopause is unique to you, but many women can find their sleep is poor and they are tired as hormone levels decline.

Dr Shahid says it can be easy, especially when you’re tired, not to get up early and leave time for suhur before dawn.

‘But I would always recommend women, especially those experiencing menopause, to get up and have a good healthy meal,’ she adds.

‘Aim for lean protein, like meat, fish or vegetarian options, wholegrains and fruit and vegetables. These will help give a continuous, steady supply of energy that stabilise your sugar levels. Oatmeal is a good option. Make conscious choices about what will work best for your body and provide the nutrients you need.’

Drink plenty of water at night

Keeping hydrated is important for energy and wellbeing and can be tricky for those observing Ramadan as the fast includes not drinking any liquid.

Ensure you drink two litres of water during non-fasting hours, so you are topped up for the day and eat plenty of hydrating foods, such as fruit and salad vegetables, before dawn and after sunset, Dr Shahid says.

Choose evening foods that won’t aggravate perimenopausal or menopausal symptoms

When breaking the fast after sunset, it can be easy to be drawn to a large, rich options for iftar, which can be geared towards unhealthy food.

‘You might really want a samosa, but try and avoid fried and fatty foods,’ Dr Shahid says. ‘They can disrupt your energy levels, give you heartburn, make it harder to sleep and worsen night sweats. It’s really important to pay attention to your nutrition, especially if you are going through menopause. Again, focus on lean protein, wholegrains and a balanced diet.’

Try to stick to a routine

Find a new routine during Ramadan, keeping your meals at similar times every day and following the steps that usually help you manage your symptoms, like not getting too hot in bed.

Many women will go to the night prayers at a mosque, which are often busy and warm. Wear layers of cool natural fabrics to these sessions to minimise hot flushes, Dr Shahid says.

‘You are not going to be perfect every day of the month, but try and have some structure,’ she says. ‘Ramadan is meant to challenge you but within limits. If you can get a daytime nap, and some people take time off during Ramadan to really concentrate on it, then this can help.’

Focus on the positives and joy that Ramadan brings

A month of fasting can bring emotional up and downs, and when mixed with menopause, when declining levels of hormones can affect your mood, this can be a difficult combination.

While some days will be harder than others, there are many positives to take from Ramadan, says Dr Shadid.

‘For women experiencing fluctuating moods due to perimenopause and menopause, it may become more noticeable during Ramadan when you are hungry and tired,’ she says.

‘This is when lifestyle measures are really important, and Ramadan is a really supportive month with a focus on community and family. A lot of people do extra prayers, it is a spiritual time with an emphasis on gratitude. This can lead to an amazing positive synergy between Ramadan and mood.’

Reaching out into the community and talking to other women who are going through the menopause during this time can be a great source of support, says Dr Shahdid.

And if you are really struggling on some days and break your fast, don’t feel you have failed.

‘There are all sorts of reasons that people need to break their fast, and people are encouraged to stop if they need to,’ says Dr Shahid.

‘You can make it up at another time. It is important for women not to feel bad and beat themselves up, it is absolutely fine.’

The post Managing your menopause during Ramadan appeared first on Balance Menopause & Hormones.

Vaginal dryness: why you don’t need to suffer

Natalie Millman — Fri, 21 Feb 2025 09:58:36 +0000

This painful condition can have a big impact on your life and be linked to other symptoms during perimenopause and menopause, but treatments are available

Falling hormone levels can cause the tissues around your vulva and vagina to thin and become more sensitive
Applying local oestrogen is effective at relieving symptoms
Numerous preparations are available – your healthcare professional can help determine what’s best for you

Vaginal dryness is a well-recognised symptom of perimenopause and menopause but despite this, its impact has sometimes been underestimated. Oestrogen and testosterone are natural lubricants and cells that respond to these hormones are present in your vulva, vagina, urinary tract, pelvic floor muscles and surrounding tissues. Falling hormone levels during perimenopause and menopause can leave the tissues around your vulva and vagina more dry and less flexible.

While this used to be referred to as vaginal atrophy or atrophic vaginitis, this term only refers to vaginal and vulval changes. In fact, the lack of oestrogen and testosterone can also affect your bladder and the tube running from it (urethra) – they thin and become weaker, which can cause you to need the toilet more often and feel very desperate to go, without much notice. Oestrogen helps cells to fight off harmful bacteria, so a lack of this hormone can make you more prone to urinary tract infections, such as cystitis.

The term genitourinary syndrome of the menopause (GSM) now tends to be used to acknowledge that vaginal and vulval changes can also be associated with urinary symptoms.

What problems does vaginal dryness cause?

A lack of oestrogen to your vagina and vulva can cause symptoms that, although very common, are often not mentioned due to embarrassment. In a survey of women in the UK aged 55 and over, 33% did not seek professional advice for their symptoms of vaginal dryness and/or painful sex, while 36% resorted to an over-the-counter remedy [1].

Symptoms can present in the earlier years of perimenopause or may not occur at all until years after your last period. Around 65%-84% of women experience some of these symptoms after their menopause [2].

It is not just a problem for women who are sexually active – in more severe cases, discomfort can be present all the time and affect normal everyday activities, such as what clothing you wear or how long you can sit down for.

As mentioned, a common feature of vaginal dryness is for the tissue to thin and become more sensitive. This often feel sores and itchy, and can become red and inflamed. Scratching leads to more soreness, redness and inflammation, further exacerbating the problem. There may also be more frequent episodes of thrush.

You might experience intermittent, or even constant, pain at any time of the day, regardless of what you are doing. Or you may only feel discomfort when your vaginal tissue is stretched, such as during sex or when using tampons. This is because, as well as being drier, the tissue around your vagina has become less flexible and doesn’t expand as easily as it did before.

The good news is that there are effective treatments for vaginal dryness, which can be taken alongside HRT if necessary, and some remedies are available over the counter.

What are the treatments for vaginal dryness?

Local oestrogen

Because these symptoms are due to a lack of oestrogen, a very effective solution is to put oestrogen directly on the affected area. This is known as ‘local’ or ‘topical’ oestrogen. It is not the same as the oestrogen you take as part of your HRT.

Local oestrogen is available via a prescription and your healthcare professional can advise which type would be best for you. There are two types of oestrogen used – oestradiol and oestriol – and three main ways to absorb the oestrogen directly from the vagina and surrounding area:

Pessary

The most common choice of vaginal oestrogen is to use a pessary. This is a small tablet you insert into your vagina. Women usually insert the pessary at nighttime so it can stay in place for several hours. Your healthcare professional will advise you on how best to use it, but it’s commonly used daily for the first two or three weeks, then twice a week after that.

There is another type of pessary that is different to other preparations - Intrarosa contains DHEA (also known as prasterone), a hormone that your body naturally produces. Once positioned in the vagina, the DHEA is converted to both oestrogen and testosterone. It can be used with or without an applicator and the usual dose is one pessary every night.

Cream or Gel

Oestrogen creams are inserted inside your vagina, usually on a daily basis for the first fortnight, and then twice weekly after that. An applicator can be used to insert the cream in your vagina and it can be applied with your fingertips on and around your vulva area, which can be useful if you are experiencing itching or soreness of your external genitalia too.

Blissel gel is a newer product – it contains a lower dose of oestrogen and has an applicator to insert the gel inside your vagina. It is used every night for three weeks, then twice a week after that. Some women prefer the gel formula as it is less messy than cream.

Ring

This is a soft, flexible, silicon ring you insert inside your vagina, called an Estring. The ring’s centre releases a slow and steady dose of oestradiol over 90 days, and it needs to be replaced every three months. A health professional can insert the ring if you do not feel confident or able to do so. You can leave the ring in position to have sex, or you can remove and reinsert it yourself, if preferred.

Vaginal moisturisers and lubricants

As well as vaginal oestrogen treatments, there are non-hormonal moisturisers and lubricants that act to keep the tissues well hydrated and feeling less sore. Moisturisers such as YESTM VM, Sylk Intimate, and Regelle are longer lasting, so you might only need to use it every two or three days.

Lubricants are for using just before having sex. Sylk moisturiser can also be used as a lubricant and YES has lubricants known as YES OB or YES WB. If you are using condoms for contraception, and use a lubricant when having sex, make sure it is a water-based lubricant as this type will not dissolve the latex in the condom.

HRT

Many women find that using the right type and dose of HRT can really improve their symptoms. It is quite safe to take HRT with the other treatments mentioned in this article.

How long does it take to improve vaginal dryness?

Your symptoms of vaginal dryness and discomfort should improve after about three months of using vaginal hormone treatments or moisturisers. Some women see significant improvement using products containing oestradiol and not with oestriol – for other women, it is vice versa. Some women see good results with either type of oestrogen or with prasterone. Many women experience more improvements with prasterone as the cells in this area respond to oestrogen as well as testosterone with this preparation. It can also be very beneficial for women with recurrent UTIs and urinary symptoms [3].

It can be a case of trying a few preparations before finding the one most suitable for you. On occasion, it may be necessary to use one type inside your vagina and a different type for your external genitalia. While some symptoms of menopause become less severe as you get older, vaginal dryness is unlikely to resolve by itself – most women will benefit from continuing a maintenance dose of vaginal oestrogen or vaginal moisturisers.

If you have still not had an improvement after three months, you should see your doctor, as sometimes these symptoms can be due to other conditions or medications, for example the contraceptive pill and antidepressants. It is also very important to see your doctor if you have any unusual bleeding from your vagina.

These treatments are usually continued for ever as if they are stopped then symptoms usually return. It is quite safe to continue using them.

References

Barlow D.H., Cardozo L.D., Francis R.M. et al. (1997), ‘Urogenital ageing and its effect on sexual health in older British women’, Br J Obstet Gynaecol 104(1) pp87-91. Doi: 10.1111/j.1471-0528.1997.tb10655.x
Palma, F. et al. Vaginal atrophy of women in postmenopause. (2016), ‘Results from a multicentric observational study: The AGATA study’, Maturitas, 83, pp40-44. Doi: 10.1016/j.maturitas.2015.09.001
Rubin R., Sanaee M., Yee A., Moyneur E., Dea K., Dury A.Y. (2025), ‘Prevalence of urinary tract infections in women with vulvovaginal atrophy and the impact of vaginal prasterone on the rate of urinary tract infections’, Menopause, Jan 7, doi: 10.1097/GME.0000000000002485

The post Vaginal dryness: why you don’t need to suffer appeared first on Balance Menopause & Hormones.

Vaginal hormones: what you need to know

Natalie Millman — Fri, 21 Feb 2025 09:57:47 +0000

Vaginal hormones are an effective treatment for menopausal and postmenopausal women, but others may benefit too

Vaginal hormones include oestrogen and prasterone
They are available in cream, gel, pessary and silicone ring formats
Your healthcare professional can help to determine the right dose and type to manage your symptoms

Around 80% of menopausal women vulvovaginal symptoms and lower urinary tract symptoms related to low hormone levels [1]. Genitourinary Syndrome of the Menopause (GSM) is a collective term to describe symptoms, which can include vaginal dryness, discomfort or pain during sex, irritation or burning of the vulva or vagina, needing to go to the toilet more often and feeling very desperate to go, without much notice, and urinary tract infections such as cystitis.

NICE menopause guidelines recommend vaginal oestrogen to help manage GSM in menopausal and postmenopausal women [2]. Vaginal DHEA (prasterone) can also help to alleviate symptoms. You don’t need to have all the symptoms to be prescribed vaginal hormones – some women may be prescribed them to treat recurrent UTIs and not suffer from vaginal dryness, for example.

It’s important to note that it’s not just menopausal women who can benefit from using vaginal hormones if they are experiencing these symptoms. Younger women, especially those taking contraceptives, and some women with diseases such as diabetes and inflammatory bowel disease, can also experience these symptoms, which often improve with vaginal hormones.

Most vaginal hormones are prescribed by a healthcare professional, and they will be able to advise you on how to take them. However, there are two over-the-counter preparations – Gina, a vaginal oestrogen tablet, and Ovesse, a vaginal oestrogen cream – that are available to some women without a prescription.

If you have been prescribed vaginal hormones to treat or manage your symptoms, it can be confusing to see all the different brands available, and the different hormones and formulations available. This overview can help.

Vaginal creams

In the UK there are two brands of vaginal oestrogen cream available – Estriol and Ovesse. Both contain oestriol, which is a type of oestrogen made naturally in your ovaries. While Estriol is a prescription-only cream, Ovesse is available over the counter – it can be bought by women aged 50 and above who have not had a period for at least a year. A pharmacist will ask you a few questions from a checklist to make sure that it’s suitable and some women may still need a prescription from a healthcare professional. This includes women who have had breast, endometrial or ovarian cancer, blood clots, heart disease, liver disease or stroke. Also, younger women will need a prescription.

Estriol

Estriol cream is available as a 1mg/g cream preparation and each applicator contains 0.5g of cream, which is 0.5mg oestriol. You screw the clear plastic applicator onto the neck of the tube, which makes it easy to squeeze the cream into the applicator up to the red ring mark. To dispense the cream, it’s best to lie down, put the applicator into your vagina and slowly push the plunger all the way in.

Ovesse

Ovesse contains 1mg of oestriol per 1g of cream. Like with Estriol, you apply the cream directly in your vagina using a reusable applicator. Fill the applicator up to the red ring mark with Ovesse, then apply as you would a tampon. Again, usually a good time to do this is before going to bed.

Vaginal Gel

Blissel

Blissel is a clear, water-based gel. It contains a lower dose of oestriol than most other creams or pessaries (50 micrograms of oestriol per gram of gel). This makes it a gentler option – it is less likely to cause irritation and can be used to treat external soreness.

It comes with an applicator that you can screw onto the neck of the tube of gel. You squeeze the tube to fill the applicator up to the filling mark. To apply the gel, simply lie down, insert the applicator into your vagina, and push the plunger all the way in to release the gel. It’s usually best to do this before you go to bed. Alternatively, you may be recommended to use the gel externally on your vulva or other areas in which case you gently apply with your fingertips.

As it’s water based, Blissel is not as thick and sticky as creams so is often less messy to use. The water-based formulation means it’s safe to use if you rely on latex condoms or a diaphragm for contraception.

Vaginal Pessaries

In the UK, there are numerous brands of vaginal hormonal pessaries. Most of these contain the hormone oestrogen (which will appear on the leaflet as either oestriol or oestradiol), but pessaries containing prasterone are also available.

Imvaggis

Imvaggis pessaries contain 30 micrograms of oestriol, which makes it the lowest-dose topical oestrogen product available in the UK. The pessaries are small, waxy and bullet shaped. Unlike other pessaries, Imvaggis doesn’t come with a plastic applicator – it’s designed to be inserted with your finger, which reduces plastic waste. The waxy texture makes it easy to insert, and adds some extra moisture to your vagina as it melts. As Imvaggis is oil-based, it shouldn’t be used alongside condoms or a diaphragm as it could damage the latex.

Vagifem

Each dose of Vagifem, which contains 10 micrograms of oestradiol, comes in a foil-wrapped, pre-dosed, single-use applicator, which looks similar to a tampon applicator. You can insert it when you’re standing up or lying down, and it’s best to use it before you go to bed. As Vagifem pessaries stick well to the vaginal walls, they aren’t as messy to use as some other creams and pessaries and don’t leave a sticky residue.

The main downside is that Vagifem can only be used internally, unlike creams and gels which can be used around the vaginal opening and vulva. You should avoid having sex straight after using Vagifem as your partner will be exposed to the oestrogen from the pessary.

Vagirux

Vagirux is a similar product to Vagifem. Each pessary contains 10 micrograms of oestradiol but unlike Vagifem, it comes with a single reusable applicator in each pack, which should be cleaned after each use. Simply load the pessary into the applicator before use, then insert it in the same way that you would when using a tampon, either standing up or lying down.

It’s best to use Vagirux before you go to bed, so the pessary stays in place for several hours and you should avoid having sex straight after using Vagirux as your partner will be exposed to the oestrogen from the pessary.

Vagirux pessaries aren’t as messy to use and don’t leave a sticky residue. However, it can only be used internally, unlike creams and gels that can be used around the vaginal opening and vulva.

Intrarosa

Intrarosa is one of the newest treatments available in the UK and is the only vaginal non-oestrogen treatment available. It contains plant-derived form of the hormone dehydroepiandrosterone (DHEA, also known as prasterone), which your body produces naturally. Each pessary contains 6.5mg of prasterone, and once inserted into your vagina, this hormone is released and converted to both oestrogen and testosterone. These hormones lubricate and improve the condition of affected vaginal and surrounding tissues, and research has shown that women using Intrarosa have a lower future risk of developing urinary tract infections and symptoms too [3].

Vaginal tablet

Gina

Gina is a small vaginal tablet that contains 10 micrograms of oestradiol, and you insert it into your vagina using a pre-loaded, single-use applicator. This is the same as Vagifem. Gina is available without a prescription in the UK to women aged 50 and over, who haven’t had a period for at least a year. As it’s available over the counter, stricter rules apply when buying Gina. The pharmacist will need to ask you a few questions to make sure that it’s suitable, and some women will still need a prescription of this preparation from a healthcare professional.

Vaginal silicone ring

Estring

Estring is a soft, flexible, silicon ring that contains 2mg of oestradiol. Once inserted into the upper third of your vagina, Estring slowly and continuously releases oestradiol (at an average amount of 7.5micrograms per 24 hours) directly to the area where it’s needed most to relieve symptoms. It works for three months, at which point it needs to be replaced.

You shouldn’t be able to feel Estring once it’s in place – if you can, this means it’s too low in your vagina and needs to be inserted a little higher up. If you’re not confident about inserting Estring yourself, a healthcare professional can do it for you.

There’s no need to remove it before sex. If you prefer to take it out, it should be rinsed in lukewarm water and reinserted as soon as possible. If you rely on barrier forms of contraception such as condoms or a diaphragm, there’s no risk of Estring damaging the latex, unlike oil-based creams and pessaries.

Some people prefer Estring to creams, gels and pessaries, which can be messy to use as they leave a sticky residue when they leak out of your vagina.

What other vaginal treatments are there?

Women with vaginal dryness can also use non-hormonal vaginal moisturisers and lubricants alone or in addition to vaginal oestrogen.

Are vaginal hormones safe?

Vaginal hormones are different to HRT as they are very low dose and do not get absorbed into your body. Vaginal oestrogen is safe to use and can usually safely be prescribed for women who have had any type of breast cancer [4,5,6,7].

Vaginal hormones are safe to use alongside other forms of HRT, including gels, sprays and patches.

Resources

NHS: About vaginal oestrogen

BNF: Estradiol

BNF: Estriol

BNF: Prasterone

References

Genitourinary Syndrome of Menopause: Epidemiology, Physiopathology, Clinical Manifestation and Diagnostic. Sarmento ACA, Costa APF, Vieira-Baptista P, Giraldo PC, Eleutério J Jr, Gonçalves AK. 2021, Front Reprod Health., p.15; 3:779398. doi: 10.3389/frph.2021.779398. PMID: 36304000; PMCID: PMC9580828.
NICE: Menopause: identification and management (ng23)
Rubin R., Sanaee M., Yee A., Moyneur E., Dea K., Dury A.Y. (2025), ‘Prevalence of urinary tract infections in women with vulvovaginal atrophy and the impact of vaginal prasterone on the rate of urinary tract infections. Menopause. doi: 10.1097/GME.0000000000002485. Epub ahead of print. PMID: 39774900.
Agrawal P. et al. (2023), ‘Safety of vaginal estrogen therapy for genitourinary syndrome of menopause in women with a history of breast cancer’, Obstet Gynecol,142(3):660-668. doi: 10.1097/AOG.0000000000005294
McVicker L. et al (2024), ‘Vaginal estrogen therapy use and survival in females with breast cancer’, JAMA Oncol, 10(1):103-108. doi: 10.1001/jamaoncol.2023.4508
The 2022 hormone therapy position statement of the North American Menopause Society advisory panel (2022), ‘the 2022 hormone therapy position statement of The North American Menopause Society’, Menopause, 29(7):767-794. doi: 10.1097/GME.0000000000002028
Hussain I., Talaulikar V.S. (2023), ‘A systematic review of randomised clinical trials – the safety of vaginal hormones and selective estrogen receptor modulators for the treatment of genitourinary menopausal symptoms in breast cancer survivors’, Post Reprod Health, 29(4):222-231. doi: 10.1177/20533691231208473

The post Vaginal hormones: what you need to know appeared first on Balance Menopause & Hormones.

Easy HRT prescribing guide

Caroline Roberts-Garth — Thu, 13 Feb 2025 01:00:00 +0000

Managing people with symptoms of the perimenopause and menopause is a very rewarding aspect of clinical practice.

There are now excellent guidelines available, both national and international, for healthcare professionals on the management of the menopause.

However, worldwide, only a minority of perimenopausal and menopausal people are prescribed HRT despite these guidelines stating that for the majority of women the benefits of HRT outweigh any risks.

Developed by Newson Education, this Easy HRT prescribing guide covers what you need to know about HRT prescribing.

The post Easy HRT prescribing guide appeared first on Balance Menopause & Hormones.

10 FAQ about HRT

Natalie Millman — Wed, 05 Feb 2025 12:59:08 +0000

Want to find out more about hormone replacement therapy? Here’s what you need to know

1. How does HRT work?

Hormone replacement therapy works by topping up or replacing your missing hormones. During perimenopause, levels of oestradiol (a type of oestrogen) and progesterone often fluctuate hugely on a daily, even hourly basis and then gradually reduce. During menopause, levels of oestradiol, progesterone and testosterone decline and remain low. These hormones work as chemical messengers throughout your entire body, influencing every single cell and organ. Women are prescribed hormones to both improve their symptoms as well as their future health. HRT will usually contain oestradiol and progesterone, and sometimes testosterone. These hormones are usually prescribed separately, and the type and dose will be individualised to help control your symptoms as well as your future health.

RELATED: HRT doses explained

2. Do I have to wait until my symptoms are bad/my periods have stopped before starting HRT?

Symptoms are commonly felt before actual menopause occurs (before your periods stop all together) – during perimenopause. Many women find that they have more severe symptoms during this time than when they are menopausal. You don’t have to wait for your periods to stop before starting HRT. You also do not have to wait for your symptoms to become severe before taking HRT. In fact, the health benefits (including reduction of heart disease and osteoporosis risk) with taking HRT are greater if HRT is started earlier. However, there are still benefits of taking HRT at any age.

3. Which HRT is best?

HRT comes in numerous formats, which means it can be individualised to suit your needs, taking into account your health and preferences. However, with so many different types of HRT available it can be confusing so you should discuss your options with a healthcare professional. The safest and most regulated type of HRT – and that prescribed by the NHS – is body identical (natural) HRT. This includes oestradiol you take through your skin in a patch, gel or spray, and micronised progesterone, usually known as Utrogestan in the UK and testosterone as a gel or cream. These are usually made from soy or yam plants.

RELATED: Body identical hormones

4. What are the side effects of HRT?

HRT is usually really well tolerated and few people have side effects. The most common side effects that can occur in the first few weeks after starting HRT are sometimes known as the “four Bs”:

Bleeding: this may come and go or last for a few weeks. If you are perimenopausal when you start HRT, your bleeding pattern may alter initially and may take three to six months to settle into a regular pattern. If you are menopausal when you start HRT (are no longer having periods), bleeding may occur, but this usually settles within three to six months.

Breasts: your breasts may become tender, painful and more sensitive. This can be due to the oestradiol or progesterone and usually settles with time.

Bloating: if your HRT regimen includes progesterone or a synthetic progestogen, you may experience a bloating feeling, which usually improves.

Blues: You may find that your mood is affected, or you feel more emotional than usual. If these feelings persist then you may need to change your dose or type of HRT.

Side effects usually settle over time. If side effects have not settled after 3-4 months, discuss them with your health professional. You may find that changing brands, the delivery method (eg, from tablets to patches) or type of hormone might help improve side effects.

5. Can HRT cause weight gain or help with weight loss?

There’s little evidence that taking HRT can lead to weight gain. You may gain some weight during menopause due to the metabolic changes that occur [1].

Many women find that they lose weight when they are prescribed the right dose and type of HRT [2]. In addition, you may find that replacing your missing hormones improves symptoms – such as joint and muscle pains, poor sleep and low mood – resulting in you being more able to exercise and eat a balanced diet, leading to weight changes.

6. Can HRT cause cancer?

For most women the benefits of HRT outweigh the risks. When assessing risk and reading headlines about HRT and cancer risk, it’s important to know what type of HRT studies are referring to – many involve older, synthetic types rather than the body identical (natural) types that are more commonly prescribed now.

For instance, while combined synthetic HRT may slightly increase the risk of breast cancer (an additional four cases per 1,000 women), oestrogen-only HRT slightly decreases it (four fewer cases). There is no evidence that women who take oestradiol with body identical progesterone have an increased risk of breast cancer [3].

There is no evidence of a negative effect of taking HRT on prognosis of other cancers [4].

7. Can HRT stop periods?

If you are perimenopausal (still having periods), taking HRT may have an effect on your periods, depending on the type. Cyclical/sequential HRT (where you take oestradiol all the time and progesterone for only part of the month) can often help regulate your periods and many women find their periods become lighter too. Continuous HRT (where you take oestradiol all the time and also progesterone every day) can usually completely stop your periods. This can take a few months.

The Mirena coil can make periods lighter and shorter, and usually causes them to stop altogether.

8. Does it matter where I apply my patches/gel/spray?

Licensed directions are to rub oestradiol gel into the outside of your upper arm or inside of your upper thigh. Some women prefer to rub it in other places such as the shoulder blades or lower abdomen. Use the spray on the inner part of your forearm or the inner part of your thigh. Patches should be stuck onto the skin below your waist – on your bottom or upper thigh. Rub testosterone cream/gel into the lower part of your tummy or your outer thigh. You may want to vary the place you rub the cream or gel every few days to avoid possible growth of a few dark hairs.

HRT is licensed to be applied on these areas, but your skin is used as a vehicle for delivery of the hormone oestradiol through your skin so sometimes women use different areas of their bodies. Absorption of oestradiol through your skin can really vary in different areas of your body and between different women [5].

9. What do I do if I miss a dose?

If you take or apply your medication a couple of hours later now and then, it shouldn’t make any difference. Missed doses of progesterone can lead to breakthrough bleeding. If you forget to take your progesterone capsule one evening, it’s not a good idea to take it in the morning if you find it usually makes you drowsy. Missing the occasional dose is not a huge issue but if you are regularly missing doses then speak to your healthcare professional about how to make your medicines fit more easily into your daily routine. Don’t double up on the dose as this may cause worse side effects than the missed dose, such as a headache or breast tenderness.

10. What do I do if HRT stops working?

Many women need their HRT treatment regime altered over time. You may experience 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; you may need to try a different way of taking the hormone or to try a different brand or type. You might benefit from adding in testosterone. Whatever the reason, discuss it with your health professional or see a menopause specialist if you are not satisfied.

References

Lobo R.A., Gompel A. (2022), ‘Management of menopause: a view towards prevention’, Lancet Diabetes Endocrinol. 10(6): PP457-470. doi: 10.1016/S2213-8587(21)00269-2
Lovre D., Lindsey S.H., Mauvais-Jarvis F. (2016), ‘Effect of menopausal hormone therapy on components of the metabolic syndrome’, Ther Adv Cardiovasc Dis. 11(1): pp33–4310.1177/1753944716649358
Women’s Health Concern. Understanding [NM5] the risks of breast cancer.
MacLennan A.H. (2011), ‘HRT in difficult circumstances: are there any absolute contraindications?’, Climacteric. 14(4): pp409-17. doi: 10.3109/13697137.2010.543496
Glynne S., Reisel D., Kamal A., Neville A., McColl L., Lewis R., Newson L. (2025), ‘The range and variation in serum estradiol concentration in perimenopausal and postmenopausal women treated with transdermal estradiol in a real-world setting: a cross-sectional study’, Menopause. 32(2): pp103-111. doi: 10.1097/GME.0000000000002459

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Oestrogen in patches, gels or sprays

Natalie Millman — Tue, 04 Feb 2025 16:43:15 +0000

A guide to understanding the different ways of taking oestradiol (oestrogen) so you can decide what’s best for you

Oestradiol is the main part of HRT and is available in different formats
Transdermal oestradiol – through a patch, gel or spray – is generally recommended as it’s released directly into your bloodstream
Doses can be tailored through patches, gels or sprays

Oestradiol (oestrogen) is the main hormone in hormone replacement therapy (HRT). Levels of oestradiol fluctuate during perimenopause then become low during menopause and remain consistently low. Lower levels of hormones (oestradiol, progesterone and testosterone) can cause perimenopausal and menopausal symptoms, plus are associated with an increased risk of health conditions.

The oestradiol in HRT can be given as either a tablet or as a transdermal preparation, this means oestradiol is delivered through the skin as a patch, gel or spray. Transdermal options are natural (body identical) – they are derived from yam plants or soy and have the same chemical structure as your body’s own oestradiol. Body identical HRT is the type of HRT recommended by the National Institute of Health and Care Excellence (NICE) guidelines [1].

RELATED: Body identical hormones

What are the benefits of transdermal oestrogen?

As well as being body identical, oestradiol in a patch, gel or spray is usually the preferred method of application for numerous reasons:

It is systemic HRT, which means oestradiol is released directly into your bloodstream and does not have to be digested or metabolised. It can travel through your body where it can relieve a wide range of symptoms as well as improving the function of various organs, tissues and cells in your body.
There is no increased risk of clot or stroke using transdermal oestradiol.
Taking oestrogen as a tablet leads to the liver clotting factors being activated, so there is a small increased risk of clot and stroke in women who take oestrogen in tablet form.
Transdermal oestradiol can be used by women with migraines. Migraines can often become more severe and more frequent in perimenopause and menopause – HRT usually improves migraine symptoms. As there is a small increased risk of stroke in some women who have migraine, it is safer and advisable to take oestradiol as a patch, gel or spray.
Transdermal oestradiol does not worsen libido. Taking oestrogen as a tablet, however, can increase levels of Sex Hormone Binding Globulin (SHBG), which binds to testosterone – this effect can then reduce amount of testosterone and then result in a lower libido. Taking oestradiol in a patch, gel or spray does not have this effect.
The dose of transdermal oestradiol can be adjusted easily. It is very common that younger women need to have higher doses of oestradiol than older women [2]. Many women find that their oestradiol requirements change with time. It is very easy to either adjust the dose of the patch, or the amount of gel or spray used.

RELATED: HRT doses explained

Once you have decided to take transdermal oestradiol, you can choose which preparation might suit your best.

How do I use oestrogen patches?

Oestrogen (oestradiol) patches should be stuck onto your skin below your waist. Most women stick them to the skin on their bottom or upper thigh.

They are usually changed twice a week - for example, if you put one on a Monday then you change it on a Thursday.

The patches usually stick on well and stay in place in the shower, bath or when exercising. A plaster mark sometimes occurs when they are removed. Using baby oil or eye makeup remover and a dry flannel is effective at removing these marks.

RELATED: How to apply HRT patches

How do I use oestrogen gel?

Oestrogen (oestradiol) gel usually comes in a pump-action bottle called a ‘pump pack’. It also comes in small sachets. 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).

Despite what the leaflet insert says, it is preferable to rub the gel into the skin as this aids absorption. The gel usually gets absorbed into your body very easily. You should avoid using other products on your skin for up to an hour after you have rubbed in the gel and ensure you wash your hands well after applying it.

RELATED: How to apply Oestrogel

Your doctor will recommend how many pumps of the gel or how many sachets you need to use. Most women use between two and four pumps of gel each day, but the actual amount varies between women. Some women use the gel in the morning, others in the evening and some women use it in both the morning and evening.

RELATED: Oestrogel and Sandrena

How do I use oestrogen spray?

Oestrogen (oestradiol) spray should be applied to clean, dry, healthy skin of your outer arm or inner thigh, in areas that do not overlap. Absorption may be lower if you apply it to your abdomen, and oestrogen in patches, gels or sprays should not be applied to your breasts.

Your doctor will recommend how many sprays to use and how often.

You can get dressed a few minutes after applying the spray when your skin is dry but you should leave around 60 minutes before bathing or washing. There is no need to rub the spray in.

RELATED: Lenzetto: Oestrogen-only spray

What else do I need to consider?

If you still have your uterus (womb), you will also need to take progesterone to protect the lining of your womb. This is because taking oestrogen by itself can increase the thickness of the lining of your womb – taking progesterone reduces this effect. Progesterone is usually given as an oral capsule (known as micronised progesterone), but it can also be given in the form of a coil inserted into your womb (uterus). The Mirena coil can be beneficial to women who also need contraception.

Women who have had a hysterectomy can still often benefit from taking progesterone as it has many beneficial effects throughout your body.

Remember, there are many different preparations of HRT and if one type does not suit you, it is very likely that another type or dose will. Talk to your healthcare professional to help determine the best option for you.

References

National Institute for Health and Care Excellence (NICE), Menopause: identification and management (NG23)
Baber R. J., Panay N., & Fenton A. (2016) ‘IMS Recommendations on women’s midlife health and menopause hormone therapy’, Climacteric, 19(2), pp109–150. https://doi.org/10.3109/13697137.2015.1129166

The post Oestrogen in patches, gels or sprays appeared first on Balance Menopause & Hormones.

The Mirena coil: everything you need to know

Natalie Millman — Tue, 04 Feb 2025 16:21:48 +0000

Confused by coils? The Mirena can form an important part of an HRT regimen

The Mirena can be used as the progestogen part of HRT
It can also be used as a contraception or to treat heavy, painful periods
It’s effective for five years as a part of an HRT regimen so is a convenient option

First of all, let’s clarify what is the Mirena coil is exactly.

There are two main types of coil: the hormonal coil, which is known as an intrauterine system (IUS) and is a plastic T-shaped device, and the intrauterine device (IUD), which is made of copper and plastic.

The Mirena is a type of hormonal coil (other types include Levosert, Benilexa, Kyleena and Jaydess). It’s very small and is inserted into your womb (uterus) where it gradually releases a hormone called levonorgestrel, a type of progestogen, into your womb.

There are two threads attached to the Mirena coil that pass out through the neck of your womb (cervix) and lie in your vagina. These allow you to check the coil is still there. They also mean it can be easily removed. They do not hang outside the body and your partner does not usually feel them during sexual intercourse.

RELATED: What is a Mirena coil? [Video]

How does the Mirena coil work and what are the benefits?

As the progesterone part of HRT

HRT is the first line of treatment for women experiencing perimenopausal and menopausal symptoms. The Mirena coil replaces the progesterone your body produces less of during perimenopause and menopause with a progestogen (a synthetic version of progesterone). If you still have your womb, taking oestrogen can cause the womb lining (endometrium) to thicken. To prevent this, you will usually need to take progesterone, which thins the lining.

Progesterone also ensures bleeding does not happen outside of the expected times, and has other health benefits, which you can read about here. While the Mirena is a synthetic progestogen, it is a much lower dose than the tablet versions of progestogen. It delivers the hormone directly to your uterus – this localised effect means potential side effects that can occur in some women who take progestogen tablets are minimised.

A treatment for heavy and painful periods

During perimenopause, it’s not unusual for women to experience heavy bleeding [1]. Although “normal”, heavy periods can cause disruption, distress and difficulties in every area of life, including work, exercise, social life and sex life.

The Mirena is recommended as a first‐line treatment for heavy bleeding by NICE [2] because the low dose of progestogen controls the development of the lining of the womb – it makes it thinner, which usually leads to periods becoming lighter and shorter or stopping. One study found that the levonorgestrel-releasing IUS (such as Mirena) can reduce blood loss by more than 90% over 6 months for most women with heavy menstrual bleeding [3].

A very reliable contraceptive

The Mirena thickens the cervical mucus, making it difficult for sperm to get to the egg, and keeps the lining of the womb too thin to support a pregnancy. It’s therefore a highly effective form of contraception – it is over 99% effective [4]. It is safe, easy to use – once it is fitted, you don’t need to do anything – and it is useful for those who may struggle to remember to take a tablet. It is also a reversible method of contraception.

How long does the Mirena coil last?

The amount of time a Mirena coil can be left in place depends on its reason for use.

If you use the Mirena for contraception only, it is now licensed for eight years. If you use the Mirena purely for heavy menstrual bleeding, it is licensed for five years.

If you are using the Mirena as part of your HRT, for endometrial protection, it can be used for five years before you need to get it replaced. While the product license for Mirena is for four years for endometrial protection, the Faculty of Sexual & Reproductive Healthcare supports its use for five years.

What are the risks of the Mirena coil?

There are very few risks associated with insertion of the Mirena coil. These include:

In a small number of women there can be difficulties with the insertion of the Mirena coil. This can be due to uterine malformation such as a bicornate uterus (heart-shaped uterus), large fibroids distorting the shape of the womb or a narrow entrance to the womb (cervical canal). On rare occasions it may not be possible to fit the device within a clinic, so alternative options will be discussed with you.
Very rarely (in about 1-2 in every 1,000 cases), during insertion the Mirena coil can make a tiny hole in your womb called a perforation and an operation may be needed to remove the coil [5].
Occasionally the Mirena coil may fall out of your womb (expulsion). This happens in approximately one in 20 women [6].

There are very few risks associated with use of the Mirena coil. These include:

Pelvic infection, usually within 3 weeks of having an IUS fitted
Ectopic pregnancy if the IUS fails
A small increased breast cancer risk (14 extra cases of breast cancer per 10,000 women) in women aged 15 to 49, compared to those not using contraceptive medication [7]. By way of comparison, the contraceptive pill is thought to be linked to less than 1 in every 100 breast cancer cases in the UK [8].

Are there any side effects?

The Mirena coil can cause some irregular, light bleeding. It can lead to spotting or having a brown discharge that may continue for up to six months. After this time, it usually settles down and then there is usually no further bleeding.

Side effects are more common within the first few months of the Mirena coil being inserted; these may include breast tenderness, headaches, acne and symptoms similar to premenstrual syndrome (PMS), they usually settle after the first few months.

Are there any alternatives?

There are other types of hormonal coil (such as Kyleena and Jaydess) that can be used for contraception only, not as a part of HRT. They do not contain enough hormone to protect the womb lining.

There are hormonal coils which, like the Mirena, also contain 52 mg of levonorgestrel (Benelixa and Levosert). The FSRH supports the use of these coils for protection of the womb lining as part of a HRT regimen for five years as well as the Mirena.
There are also types of coils (IUD) that do not contain any hormones. Whilst these can work well for contraception, they cannot be used to protect the lining of your womb as part of HRT; they also do not lead to periods reducing or stopping.

Body identical progesterone capsules (such as Utrogestan) can be used as the progesterone part of HRT.

How can I prepare for having a coil fitted?

You do not need any special preparation beforehand, although Clair Crockett, GP and menopause specialist at Newson Health recommends that you take your usual painkiller (for example paracetamol or ibuprofen) around one hour before your appointment time.

To ensure that there is no risk of pregnancy before the coil you are having inserted is fitted, ensure that you use adequate contraception or do not have sexual intercourse between your last period and having the coil fitted.

What will happen at my fitting?

‘You will usually be asked to sign a consent form,’ says Dr Clair. ‘This states that you agree to have the coil inserted and you understand what it involves. The clinician fitting the coil will spend time talking you through what is in the form and give you opportunity to answer questions.’

How is a coil fitted?

‘Much like when you have a cervical smear test, you will be asked to lie on an examination couch and a speculum will be used so as the clinician fitting your coil can see your cervix,’ explains Clair. ‘At this point, if you are having any form of local anaesthetic, this will be applied. A small measuring device is passed through your cervix and into your womb. This measures the length of your womb to ensure that the coil is fitted correctly. The coil is then passed into your womb within a small tube (an introducer), and the coil is released once it’s in the correct position. The introducer is removed, and the threads of the coil are then visible in the vagina. These are trimmed so they fit neatly, without you being able to feel them unless actively seeking to.’

Will I feel any pain?

Many women do not feel any pain when having a coil inserted. However, some women feel ‘periodlike’ discomfort during, and after the fitting. Sometimes this can be quite severe around the time of the fitting, but is usually very short lived.

What do I need to do after I go home?

When you leave the clinic, you can return to your normal activity. You should not use tampons for the next four weeks. If you are using the Mirena coil for contraception, it will be effective seven days after insertion so additional contraception (such as condoms) will be needed if you have sexual intercourse in the first week. ‘This advice is the same for any hormonal coil,’ says Dr Clair. ‘A non-hormonal (copper coil) is effective immediately.’

You may experience some bleeding, which is normal. If you have period pains, you can take your usual painkillers, such as paracetamol or ibuprofen. ‘If pain is not relieved by painkillers, or you are continuing to experience pain more than a week after the coil was inserted, I would advise that you see your GP or contact the clinic where the coil was fitted for advice,’ says Dr Clair.

Will I have a follow-up appointment?

Most women do not need a follow up appointment. ‘In the past it was common practice to be invited for a coil check after six weeks, however, this is no longer recommended routine practice as most women will be able to feel their coil threads when they insert a finger into their vagina,’ says Dr Clair. ‘If the coil threads are felt, and there is no ongoing pain, then this would suggest all is well. However, if you would like a review appointment to have a coil check then this can be arranged on request.’ This will involve passing a speculum to check the coil threads can be seen, which confirms the coil is in position.

RELATED: The Mirena coil: your FAQ

References

Paramsothy P., Harlow S.D., Greendale G.A., Gold E.B., Crawford S.L., Elliott M.R., Lisabeth L.D., Randolph J.F. Jr. (2014), ‘Bleeding patterns during the menopausal transition in the multi-ethnic Study of Women’s Health Across the Nation (SWAN): a prospective cohort study’, BJOG. 121(12):1564-73. doi: 10.1111/1471-0528.12768
NICE (2018): heavy menstrual bleeding: assessment and management
Creinin MD, Barnhart KT, Gawron LM, Eisenberg D, Mabey RG Jr, Jensen JT. Heavy Menstrual Bleeding Treatment With a Levonorgestrel 52-mg Intrauterine Device. Obstet Gynecol. 2023 May 1;141(5):971-978. doi: 10.1097/AOG.0000000000005137
NHS: Methods of contraception: IUS hormonal coil
FSRH Clinical Guideline Intrauterine Contraception
NICE: CKS: Contraception – IUC: Risks, adverse effects, associated problems
Mørch LS, Meaidi A, Corn G, Hargreave M, Wessel Skovlund C. (2024), ‘Breast Cancer in Users of Levonorgestrel-Releasing Intrauterine Systems,’ JAMA, 332(18) pp1578–1580. doi:10.1001/jama.2024.18575
Breast Cancer Now

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