Hormone Replacement therapy is the most effective treatment for menopausal and perimenopausal symptoms . Some women have poor relief of symptoms inspite of increase in dose of HRT.
Oestradiol, a type of oestrogen is the main hormone in HRT. This is derived from natural yam and is available as tablets, patches, gel or spray. If you have a uterus oestrogen is combined with progestogen to prevent cancer of the womb.
Oestrogen patches, gels and spray are directly absorbed through the skin. When given this way, it is termed “transdermal body identical HRT”.
A. Why and when does HRT not work for some women?
- Compliance issues : Forgetting to apply Oestrogel/Sandrena gel or Lenzetto spray daily or Oestradiol patches twice a week or to take oral HRT tablets daily
- Incorrect application of Oestrogen gel : I have seen women applying gel on both wrists , upper back or applying 2 pumps on one arm , instead of one pump on each arm . This can result in poor absorption of gel and lower levels of hormones in the blood. Applying moisturiser just before applying gel, patch or spray can reduce absorption.
- Patches not sticking well or causing irritation
- Drug interactions : Liver enzyme inducers such as medicines to treat epilepsy and HIV and others interact with oral HRT tablets making them less effective.
- Prescribed oral HRT instead of transdermal : If women are on thyroxine tablets and are given oral oestrogen, they may find their mood has deteriorated further or they are gaining weight as oral oestrogen increases thyroxine binding protein which binds thyroxine resulting in less free thyroxine and symptoms of underactive thyroid . Malabsorption due to Crohn’s disease will make oral HRT tablets less effective .
- Prescribing higher doses of transdermal oestrogen can result in higher blood oestrogen levels . This phenomenon is called tachyphylaxis in which women will continue to have symptoms inspite of taking higher doses. These high levels can instead cause worsening of mood.
- Symptoms may not be due to menopause: Severe depression , thyroid disorders, some medications cause hot flushes (e.g. Tamoxifen, Aromatase inhibitors for breast cancer , nitrites used to treat angina , some antidepressants, Type 2 Diabetes, Carcinoid syndrome ( carcinoid tumour secretes extra hormones), infections, some cancers like pancreatic, thyroid, or lung cancer.
- Life style factors: such as excess alcohol, weight gain, spicy food, increase in caffeine consumption and smoking can trigger hot flush.
- Increase in PMS like symptoms such as low mood or fatigue : This could be due to the type of progesterone hormone in your HRT such as norethisterone or medroxyprogesterone acetate. Progestogens like Dydrogesterone , Micronized Progesterone or Mirena coil reduce PMS side effects.
- Symptoms of fatigue due to taking Micronised progesterone in the morning or with food instead of bedtime or 2-3 hours after evening meal.
B. What can be done ?
Speak to your GP or Menopause Specialist. The dose of oestrogen must be carefully individualised, and should be taken as advised by your doctor.
Women are started on low dose of oestrogen and at 3 month follow up the dose is increased in most cases if there is inadequate symptom control.
If women are on doses above standard licensed dose for their age, blood oestradiol levels are checked before increasing the dose .
Oestrogen absorption varies in women, some absorb better from a patch and others from a gel.
Some women on oral HRT may require dose of estrogen to be increased or change of HRT to transdermal as estrogen absorbed via skin is more effective with release of the hormone directly into circulation without being broken down by the liver when taken orally.
The dose of HRT may require a change depending on where women are in their menopause journey and their age .Younger women under age 40 require higher doses of oestrogen than women in age group of 45+.
