What are the different types of HRT?

How to choose the right HRT for your body

HRT, hormone replacement therapy, is a type of medication regiment used to help balance levels of estrogen and progesterone in women. This is taken around the time a woman reaches menopause.

Menopause is normally part of a woman’s life and is experienced in a woman when her period stops. The woman’s body makes less estrogen and progesterone during menopause, leading to symptoms such as night sweats, hot flashes, vaginal dryness, and weaker bones.

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 either estrogen-only or both estrogen and progesterone. 

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, blood clots, and others. 
  • It can also cause painful and swollen breasts, vaginal discharge, headaches, and nausea. 
  • It may also increase cholesterol levels. 
  • Oral estrogen is harsh on the liver so any women with liver problems should refrain from oral estrogen therapy. 

Skin patches

Skin patches are another alternative to estrogen as a form of HRT. The patch is usually worn on the lower stomach below the waistline. The patch would be 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, it doesn’t help other menopausal symptoms)

Pros: 

  • It has all the benefits of oral estrogen therapy plus more. 
  • It is 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 blood.

Cons:

  • Skin patches pose the same risk as to the oral estrogen pill. 
  • When estrogen is combined progestin, there is an increased risk of breast cancer and heart attack.
  • 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 hence giving you 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

This is another type of estrogen treatment. It 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 shoulder on one arm. Estrasorb is applied to the legs and Evamist is sprayed on the arm. 

Pros:

  • They are safer on 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. 
  • Hence, assume it has the same risks are 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, and gel completely dry before putting on clothes. Make sure to apply it after you shower. 
  • As the cream, gel or spray is absorbed directly into the skin, it is important not to touch other people with it as it will then enter their bloodstream. It is also key to make sure to clean your hands and dry it after application.

Vaginal Suppositories, Rings and Creams 

These types of estrogen therapy are applied directly to the vagina. These types of therapy are specifically for 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 with some being used 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 only affect the local vaginal area to relieve the 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. The will not be able to help with hot flashes. 
  • The long term use of vaginal estrogen therapy is not recommended for women with 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
  • Thrombosis or blood clots
  • Stroke 
  • Heart Disease
  • Endometrial, ovarian and breast cancer

The decision to start taking HRT is a long one. 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 more. 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:

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