A Doctor’s Guide To Coming Off HRT
If you are looking to transition from HRT, suddenly stopping can bring on withdrawal symptoms so Dr Tony Coope tells you how to do it simply and easily.
This is a question that comes up frequently, and since there are so many different types of HRT I wanted to ask an expert for their opinion.
If you are looking to transition from your current HRT then my colleague Dr Tony Coope shares his view on how to do this safely and effectively.
Dr Tony Coope M.B; Ch.B; D.Obst.R.C.O.G.
Since the Women’s Health Initiative study ending in 2002, there has been an increasing number of studies confirming that bio-identical hormones are safer than their synthetic counterparts.
The important aspect of this is not so much the oestrogen component, as ‘synthetic’ versions of this are not dissimilar to the body’s own 17beta oestradiol, but in the progestin components, which are different in their molecular structure to bioidentical progesterone.
I have found that women respond better to the bioidentical form, with far fewer side effects. Many women have no difficulty in deciding against synthetic hormones, either because of their experience of the contraceptive pill, or because of side effects (very common in women with a degree of ‘oestrogen dominance’ – a deficiency of progesterone in relation to levels of oestrogen). Others have had no such problems, but are uneasy about the accumulating evidence.
However, for those women already on HRT for menopausal symptoms or bone density problems, there is often a dilemma. They may be uncertain of the effectiveness of the alternatives, and unsure of how to change from one to the other.
Their GP may have limited knowledge of these, or even be actively against them. What to do?
Before coming off HRT
Some women are able to stop their HRT suddenly prior to going on to their new regime, but in the main these are women who have not previously had severe symptoms, or are using it for bone protection.
Those who have had symptoms would be best advised to come off slowly, cutting tablets in half, then spacing them out, according to how they feel.
With patches you can then put a waterproof plaster between your skin and the patch to leave only a small part of the patch in direct contact with the skin so it is absorbing less hormone.
Types of HRT
Just to clarify, the main types of HRT are:
1. Continuous combined HRT; where either a patch or tablet containing both oestrogen and a progestin such as Femoston Conti, Climest, Premique and Evorel Conti. This type is used straight through a repeated 28 day cycle.
2. Sequential combined HRT; where an oestrogen patch or tablet is used to cover the 28 days of a cycle, and a progestin tablet added for the second half of it. A slight variation on this is with the former used only for the first 14 days, then a combined tablet or patch for the second 14 days. Examples of this type are Evorel Sequi, Prempack-C and Trisequens.
3. Combined HRT with oral progesterone: although the NHS is now beginning in a welcome change of direction to replace the synthetic progestins in HRT with Utrogestan or generic equivalents, which are bioidentical progesterone in tablet form, there do appear to be potential problems for sensitive women.
This is because the oral form has to go through the digestive system and liver before being distributed via the circulation, a variable and significant portion of the dose of progesterone will be metabolised into its break-down products.
This means the initial dose has to be higher, and also that there is the possibility of unwelcome reactions such as undue drowsiness or gastro-intestinal effects, – problems that do not occur when using the progesterone cream via the skin.
4. Oestrogen alone HRT; as either patch or tablet continuously, or an implant, prescribed for women who have had a hysterectomy. Examples of this type are Elleste Solo, Estradot, Sandrena and Evorel.
Many doctors now believe, however, that these women should be given the same protection as those with an intact uterus, as ‘unopposed’ oestrogen also has an unwanted effect on sensitive breast and ovarian tissues.
Getting started
Whatever the form of HRT, the practical way to come off it is not so difficult as it might first appear.
The important principle is to first add bioidentical progesterone to support the withdrawal and reduce the withdrawal symptoms from the HRT.
Generally, women who have been on HRT find it best to start using 20 to 1, which has the majority ingredient of progesterone with two natural oestrogens.
After a week or so on this they can begin to reduce their high-dose HRT supported by continuing with 20-1.
I find this can usually be done over one or two cycles of 28 days, rarely more than three, and it significantly reduces both the long-term cancer risk and that of cardiovascular events such as heart disease, stroke and blood clots.
In addition it may well improve other factors such as energy levels, depression, anxiety, mood swings and sense of well-being.
Without going into detail for each form of HRT, it is possible to keep the oestrogen part going continuously for each 28 day cycle, (eg by using oestrogen tablets or patches ‘borrowed’ from supplies for following months), while introducing progesterone as in 20-1.
In the case of combined HRT, because both the progestin and oestrogen components are at a fixed dose in the same patch or tablet, you need to gradually reducing the dose (by spacing out the tablets or reducing the size of the patches) while at the same time starting on 20 to one, the combined progesterone and oestrogen cream.
Begin on a low dose of this while gradually tailing off the HRT; as the full dose of 20 to one is reached, the HRT is stopped.
If necessary on combined/sequential forms of HRT, it is possible to use the 20 to one together with the synthetic progestin for a month or two.
The two forms act on the same cell receptors, so the natural form will not exert its full effect while this is done, but stores will build up in the body and help to prevent ‘rebound’ symptoms occurring when the progestin is stopped.
Oestrogen only is perhaps the simplest, as you just reduce the amount of oestrogen gradually once using bioidentical hormones.
Once off HRT
Once off HRT, and if symptoms are then coming under control with 20 to one, you can make the decision as to whether to continue with the combined cream, if you still need a small amount of oestrogen, or you could then switch to Serenity if you feel your symptoms need progesterone only.
As natural bioidentical progesterone is the precursor to oestrogen, and so can be converted into oestrogen in the body, this may be an added source.
Women who have been deficient in progesterone may also not need additional oestrogen as the adrenals and fat cells continue to produce it as their ovarian function declines.
If needed, supplementation can be considered in the form of natural progesterone only cream Serenity, or a bioidentical combination cream such as 20-1, containing both progesterone and oestrogen.
You could also consider adding phytoestrogens, supported by Vitamin E, omega fatty acids and a regime of bone support, which will have received a positive boost with the addition of progesterone itself.
However if dealing with conditions where additional oestrogen is essential, such as vaginal atrophy, then combining either Serenity or 20 to one with Wellsprings oestrogen cream is also an option.
Helpful information
One of the things that I have noticed is that many women tell me that they are having progesterone, when in reality what they are having is a synthetic progestin.
These are found in the pill, coil and HRT and mimic the action of the natural hormone but do have their own side effects.
It is important to know the difference between progesterone and progestins so this article will be helpful.
