What are the different types of HRT?

Hormone replacement therapy (HRT), is a type of medication regiment used to help balance levels of estrogen and progesterone.  It is administered to women as a treatment for the symptoms of menopause.

Menopause is a normal part of a woman’s life which occurs when menstruation stops.  A woman’s body makes less estrogen and progesterone during menopause, leading to symptoms such as night sweats, hot flashes, vaginal dryness, and decreased bone density.

HRT is used to relieve the symptoms of menopause, such as sweating and hot flashes. It is also used to reduce the risk of osteoporosis which is associated with diminished levels of estrogen. HRT takes many forms. It can contain estrogen-only or both estrogen and progesterone. 

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Pills

The estrogen pill is the most common form of HRT. Most estrogen pills are taken once a day without food while others have a more complicated dosing schedule. Examples of estrogen pills include:

• Premarin 
• Estrace

Pros: 

• Estrogen pills reduce the symptoms of menopause and lower the risk of osteoporosis. 

Cons: 

• Estrogen therapy can cause an increased risk of strokes and blood clots.
• HRT can also cause painful and swollen breasts, vaginal discharge, headaches, and nausea. 
• It may also increase cholesterol levels. 
• Oral estrogen ican be toxic to the liver, so any women with liver problems should refrain from oral estrogen therapy. 

Skin patches

Skin patches are an HRT alternative to estrogen pills. The patch is usually worn on the lower stomach below the waistline. The patch is replaced once or twice a week. Examples of estrogen skin patches include:

• Alora
• Climara
• Estraderm
• Vivelle-dot
• Climara Pro - a combination patch of estrogen and progestin
• Combipatch  - a combination patch of estrogen and progestin
• Menostar - only contains estrogen but at a lower level than other patches (only used to reduce the risk of osteoporosis and does not help other menopausal symptoms)

Pros: 

• All the benefits of oral estrogen therapy plus more. 
• Convenient - you do not have to worry about taking the pill every day.
• Patches are not dangerous for women with liver problems, unlike oral estrogen. The patch is safe as the estrogen bypasses the liver and is absorbed directly into the bloodstream.

Cons:

• Skin patches pose the same risk as oral estrogen pills aside from liver damage. 
• When estrogen is combined with progestin, there is an increased risk of breast cancer and heart attacks.
• The patch itself might irritate the skin. 
• Skin patches are sensitive to heat and should not be exposed to high heat or direct sunlight. The heat causes the patch to release the estrogen too quickly, releasing too high of a dose in the beginning, and later too low a dose. This is why tanning beds or saunas should not be used when wearing the estrogen patch. 

Topical Estrogen Creams, Gels and Sprays

Another type of estrogen treatment which is absorbed into the bloodstream directly through the skin. 

Estrogen gels include:

• Estrogel
• Divigel 

Estrogen creams include:

• Estrasorb 

Estrogen sprays include:

• Evamist 

The specifics on how to apply each of these vary, however, they are usually applied once a day. Estrogel is applied from wrist to the shoulder on one arm. Estrasorb is applied to the legs and Evamist is sprayed on the arm. 

Pros:

• They are nontoxic to the liver as the estrogen is absorbed straight into the bloodstream. 

Cons:

• The effects of sprays, creams, and gels have not been well studied by scientists. 
• Likely have the same risks as oral estrogen. 
• This type of estrogen therapy can be rubbed or washed off before it is fully absorbed. It is important to make sure the cream, spray or gel completely dry before putting on clothes. Make sure to apply it after you shower. 
• While the cream, gel or spray absorb into the skin, it is important not to touch other people with it, as it can then enter their bloodstream. It is therefore, very important to clean and dry your hands after application.

Vaginal Suppositories, Rings and Creams 

These types of estrogen therapies are applied directly to the vagina, specifically targeting women who are struggling with vaginal dryness, itching, burning or pain during intercourse. 

Vaginal tablets include:

• Imvexxy
• Vagifem

Vaginal creams include:

• Estrace
• Estradiol

Vaginal insertable rings include:

• Estring 
• Femring 

Vaginal rings are generally replaced every 3 months. Vaginal tablets are often used on a daily basis for the first couple of weeks and then used twice a week. Creams have varying schedules from daily to several times a week.

Pros:

• These treatment types are more effective in treating vaginal dryness than other forms of estrogen therapy. 
• They do not need to be taken daily like the estrogen pill. 
• The vaginal rings act locally to relieve vaginal symptoms without exposing the whole body to high doses of estrogen. 

Cons:

• Vaginal rings that contain low doses of estrogen only help with symptoms caused by surgical menopause. They will not be able to help with hot flashes. 
• Long-term use of vaginal estrogen therapy is not recommended for women with a uterus as it increases the risk of endometrial cancer. 

Who should not use HRT?

HRT may not be suitable for women who have:

• High blood pressure
• Severe migraine
• A history of thrombosis or blood clots
• A history of stroke 
• Heart Disease
• Endometrial, ovarian or breast cancer

The decision to start taking HRT is complicated. Even after deciding to start HRT, further decisions need to be made regarding the type of HRT. The estrogen-only therapy comes in several forms such as pills, patches and gels. When deciding which type of HRT is best for you, several factors need to be taken into account. These factors depend on your health, symptoms, personal preference and what you want to get out of the treatment. 

References:

• Menopause: Medicines to Help You". 2020 [accessed 24 March 2020].
• HRT: Benefits and risks | Women's Health Concern". 2020 [accessed 24 March 2020].
   

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