Roberta Bass (00:00)
 Hello, I am Roberta Bass, a women's health physiotherapist, Pilates instructor, remedial hypnotist, and a menopause mentor. And I want to welcome you back to Making Sense of Women's Health. Today, I'm going to be talking about HRT and hormonal support. What it is, the different types, how it's used, and what the latest evidence actually says.

There's still a lot of confusion, fear and outdated information out there and my aim with this episode is to give you a clearer understanding so you can make informed choices.

So just a quick note before we begin, I am not a doctor and I do not prescribe HRT. What I will be talking about today is based on published research, national guidelines and the work of experts such as the British Menopause Society and NICE guidelines. This episode is for educational purposes only and is not medical advice. It's always best to speak to a GP or a menopause specialist that can prescribe about what's right for you.

Firstly, what is HRT? Now, HRT stands for hormone replacement therapy, used to replace the hormones that your body naturally reduces the production of during menopause. And that's mainly estrogen and progesterone and sometimes testosterone too. Now the goal of HRT is to reduce menopause symptoms and to support long-term health, particularly in areas like hot flushes and night sweats, sleep issues, mood and anxiety, joint aches, vaginal dryness or bladder symptoms, bone health and heart health. Now, HRT isn't a cure-all, but for many women it can be life-changing, especially when it is combined with good lifestyle support.

But let's break down the different types of HRT. Now you may have estrogen only HRT if you've had a hysterectomy and you don't need progesterone to protect the womb lining. Otherwise you would need to have some combination HRT which is estrogen and progesterone. Now this is needed if you still have a uterus because the progesterone is needed to prevent endometrial overgrowth which can increase the risk of cancer.

So within both of these categories, there are different types of HRT further. So our body identical HRT, now this is our regulated prescription treatments and it is match the molecular structure of the body's own hormones. Estradiol and micronized progesterone, now these are widely available in the NHS and considered the safest form of HRT and are actually made from yams. Bioidentical are compounded HRTs. Now this version is often promoted privately, however, it is not regulated, it is not monitored for quality and is not recommended by the British Menopause Society.

If you still have a uterus, you'll need that combined HRT. There are several different ways that it can be delivered. Now micronized progesterone, the trade name is Utrogestan, taken alongside a patch, gel or spray of the estrogen. Now this is the body identical hormone and is generally considered the safest and most well tolerated options. Combined oral tablets and combined patches, which include both the estrogen and a synthetic progesterone. Now these are maybe more convenient but they do have a slightly higher risk because of that synthetic progesterone and some women experience more side effects like bloating, mood changes or breast tenderness. The Mirena coil is another good option because it releases progesterone directly into the uterus and this can be used as the progesterone part of the HRT and is often well tolerated, especially for women who also want some contraception or if they're having heavy bleeding, this can help reduce that. It is also worth knowing that combined forms, whether that's the tablets or the patches, it doesn't allow as much flexibility when it comes to adjusting that balance between the estrogen and progesterone. But using separate components gives more control, particularly during perimenopause when symptoms can vary. I'll talk a little bit about safety and risk in a moment, but it is useful to know that the micronized progesterone and the Mirena coil are typically the preferred options in terms of long-term safety and women being able to tolerate them.

We've mentioned this but there are several different ways to take HRT and choosing the right one does depend on your symptoms, preferences and your health history. Now transdermal estrogen, that means taking it through the skin, is generally considered the safer option and this could include patches, gels or sprays and this form is safer because it bypasses the liver, so they don't increase the risk of blood clots in the way that oral tablets can. So women with a history of migraines, high blood pressure or clotting risks having transdermal estrogen is usually the recommended route. Tablets are still available and may be convenient for some, but they do come with that slightly increased risk of clotting and may not be suitable for everybody, especially those with existing cardiovascular risk factors. It is also worth noting though that absorption will vary between women and one woman might respond well on a low dose patch while another may need a gel or a different delivery method entirely. Tracking your symptoms and reviewing with a clinician helps make sure that your treatment is effective and it can take several months to get the right dosage and balance of the HRT.

Finally, there is vaginal estrogen, which is used locally for vaginal dryness, bladder irritation, discomfort with intercourse, and even prolapse related symptoms. This is very low-dose, it doesn't increase systemic hormone levels and it is considered safe for most women, even those who can't use standard HRT. And I would recommend this for a lot of the women that come to see me with pelvic health issues if they have any dryness, they have prolapses or bladder issues, it can be really helpful.

Testosterone plays an important role in women's health too, particularly if things like libido, sexual function, energy, motivation and mental clarity. And while testosterone isn't a license for women in the UK, it can be prescribed off label by menopause specialists if there is a clear deficiency. It's not for everyone and it's not a first line treatment, but for some women it can make a noticeable difference, particularly if they've been on normal HRT for some time and it's not quite giving them the results that they are hoping for. Blood testing is usually required before and during treatment to keep the levels within the female range.

So let's talk about the elephant in the room, the fear that HRT is dangerous. All stems from a large study that was done back in 2002, called the Women's Health Initiative. And they reported an increased risk of breast cancer, stroke and heart disease in women taking HRT. And the media ran with it and as a result many women stopped treatment overnight and many doctors became really reluctant to prescribe it. But here's what we now know. The WHI used older synthetic forms of HRT often given to women who were already over 60 when they started. The results were misinterpreted and overgeneralized. Further analysis has shown that body identical transdermal HRT started under the age of 60 or within 10 years of menopause is safe and beneficial for most women.

Current guidelines from NICE and the British Menopause Society support this and for most women the benefits of HRT for symptom relief and bone health outweigh the risks. There are some cases however where HRT may not be suitable including if a woman has a history of hormone sensitive cancers, especially breast or endometrial. If there's undiagnosed vaginal bleeding, if there's active liver disease, a history of blood clots or certain clotting disorders, but that doesn't mean you can't have any treatment, but those situations need specialist advice and in some cases, non hormonal alternatives or vaginal estrogen only may still be safe.

If you're someone that can't take HRT or you've decided not to, there's still a lot that you can do. And that's exactly what I talked about in the episode on the SENSSE method, which is the method that I have created to help support menopausal women. I'll link that in the show notes.

So whether or not you're on HRT, your day-to-day choices still play a key role in your health. Think of it like building a house, your lifestyle, things like stress management, sleep, nutrition, movement and mindset is the foundations. Things like HRT, supplements or complementary therapies are the walls, helpful supports, but they rely on the foundation being solid and your overall well-being is the roof. If the foundation is unstable, the walls won't hold the roof properly, but if the base is strong, everything else works better too. This is what the SENSSE method is all about, those fundamentals in place so whatever you add on top has the best chance to help.

If you're not sure whether HRT is right for you, or you're trying to weigh up the options and make sense of your symptoms, I do offer a Menopause MOT session either online or in person. This is where we look at your journey, what symptoms you are dealing with and explore your options, including what to talk to your GP about in order to get HRT if that is the route that you are going down. You'll also get support with lifestyle changes based on the SENSSE method to help you feel more in control. And you can find the link in the show notes or just visit the website thriveandshinewomenswellness.co.uk.

So that's it for this episode of Making Sense of Women's Health. I know that HRT can feel overwhelming or even controversial, but the goal here is simply to help you understand what's available and what's safe so you can make decisions that are right for you. If this helped clarify anything, feel free to share it with a friend or leave a review. It really helps others find the podcast too. Take care.