What is body identical HRT?
The term ‘body identical HRT’ means that the hormones that are used are identical in molecular structure to your own hormones. This means that they are very safe to use and in particular do not have the slight risk of clot that the older synthetic HRT is linked to. This means that many people who may have been told that they can’t have HRT due to circumstances such as being older, being overweight, having migraine can safely use it. They are derivatives of the yam plant.
We will generally prescribe hormones separately rather than in combined preparations as this allows greater dose variation and symptom control. It also means that if you do experience any side effects we only have to change one element of your regime.
Oestrogen
Fluctuations or an overall decrease in oestrogen can be responsible for many of the well known symptoms of perimenopause and menopause as well as many that you may not have been aware of. We have oestrogen receptors throughout our brains and bodies and once this is understood it becomes easier to see why suddenly you may experience anything from frozen shoulder (called ‘menopause shoulder’ in Japan) to sudden anxiety and tearfulness.
Common symptoms are included on our menopause symptom checker and this is by no means an exhaustive list. This can be particularly useful if you are unsure whether you could be perimenopausal or are on hormonal contraception including the Mirena coil which suppress your natural cycle.
The oestrogen that we generally prescribe is delivered through the skin (transdermal) and takes the form of gels/patches or a spray. These will be discussed during your consultation to assess which form would be the most suitable for you.
Things to consider:
Gels such as Oestrogel and Sandrena which come in either a metered dose pump or small sachets are applied daily to the outer arms or inner thighs. They can be useful when first starting HRT as the dose can be changed easily.
Patches either come as oestrogen only (eg. Evorel or Estradot) or in combination as oestrogen and progestogen (eg. Evorel conti). The latter are in a fixed dose so we tend to use the oestrogen only ones and add a separate progesterone if you have a womb, but for some women the combination ones can work well. Patches are generally applied below the waist and changed twice a week which can make them very convenient. They come in different doses which can be altered depending on your symptoms.
Progesterone
If you still have a womb (ie. have not had a total hysterectomy) then you will also need progesterone to protect the womb lining. Micronised progesterone (Utrogestan) is used in and the regime that you need will be discussed with you during your consultation. Progesterone can also have added benefits as it can help with several menopausal symptoms such as anxiety and sleep. In approximately 1 in 20 women there can be an intolerance to progesterone and instead of going down the pathway that gives a nice quality of sleep and calms mood it can cause effects such as irritability. Often this starts to settle down as your body adapts to the HRT, but if not there can be other options to help with this.
Localised vaginal oestrogens
Urogenital symptoms can be very common during times of low oestrogen. As well as menopause this can also occur after childbirth and with breastfeeding. Symptoms can include itching, dryness, discomfort whilst penetrative sex or having a cervical smear. Skin can become more thin and split easily making activities such as cycling/horse riding and sometimes even sitting uncomfortable. The collagen around the bladder neck and vaginal walls can decrease and the ‘good bugs’ can also decrease causing a tendency to urinary urgency, frequency and cystitis or urine infections.
Lubricants and moisturisers can be really helpful and we would advise avoiding those with additives such as glycerine or strong scents. We would also avoid perfumed soaps/shower gels and bath products as these can be really irritating for the skin in this area.
There are several low dose oestrogen preparations that can be used to restore the normal balance of the skin, collagen and natural lubrication. The absorption of these is absolutely minimal so they can safely be used by the majority of cis women, trans men and non binary people. They can also be used by the majority of those who have undergone or are undergoing treatment for cancers including breast cancer. In this scenario we sometimes need to discuss this with your Oncologist, but not always.
Depending on dexterity and lifestyle factors we can discuss the type or combination most appropriate for your needs during the consultation.
Testosterone
Testosterone is produced by the ovaries and the adrenal glands. It is an important hormone for libido and many will notice a decrease in desire and ability to climax during menopause. This can be particularly significant with a sudden drop in hormones due to surgical or medical menopause and also in those with Premature Ovarian Insufficiency.
Not everyone will find the addition of testosterone beneficial but many do and 'a trial of testosterone' is something that we may discuss during your consultation if appropriate. It is important to optimise your other HRT first and also to make sure that any symptoms of vulvovaginal atrophy are treated adequately.
At present there isn't enough clinical data to support the use of testosterone for symptoms such as brain fog, word finding difficulties, low mood and decreased energy but hopefully there will be Randomised Controlled Trials to assess these aspects in the near future.
All testosterone is prescribed as ‘off license’ in the UK at the moment and we are hoping that this will change soon and a wider range of products for designated female use will be available.
Androfeme is a testosterone cream that is produced and licensed for female use in Australia. It can be prescribed in the UK on private prescription. A small dose is applied daily to the skin of the outer thigh or buttock.
Testogel is available in sachets and a small amount depending on your dose is applied daily to the outer thigh or buttock.
Testim is available in small resealable tubes and again a small dose can be applied daily to the outer thigh or the buttock.
Blood tests are used to monitor the dose and ensure that it stays within range.
It can often take several months for symptoms to start to resolve, but many who have started this treatment report that it has felt like the ‘missing piece’ or that ‘I feel myself again’.