There are about 20 different combinations in which you can take HRT, so it’s highly likely one of them will be right for you. It just requires a little patience and perseverance from both you and your doctor. Usually, changing to a different progestogen will get rid of the unwanted side-effects, but if that doesn’t work, then reducing the dosage should work, or possibly taking it for fewer days each month. However, there is a minim urn dose needed to ensure the lining of the womb is shed each month, so you shouldn’t have too low a dose or for too short a time. Many women find that vitamin B6 or evening primrose oil helps reduce unpleasant pre-menstrual symptoms brought on by progestogen.

The good news is that research is being done into new and better progestogens. Until recently, this hormone could only be taken in the form of tablets by mouth. As much of the progestogen gets lost as it passes through the digestive system, quite a large dose has to be taken so that you end up with the amount you need, and this large dose is what causes most side-effects. Progestogen is now also available in a combined progestogen and oestrogen patch. It is called Estracombi, and is manufactured by Ciba-Geigy. In this- form, the two hormones are absorbed through the skin, and because the digestive system is avoided, a much lower dose can be given to achieve the desired effect, thereby reducing the side-effects. Before long, a completely new generation of progestogens will be available which produce fewer side-effects.

If progestogen in any form really doesn’t agree with you, under certain circumstances it may be possible to cut it out altogether. Your doctor would probably only suggest this if you already had osteoporosis and needed to take oestrogen but were finding the side-effects of progestogen so intolerable that you had to give up. The big disadvantage of doing this, however, is that you would have a small but definite risk of developing cancer or other disorders of the lining of the womb. You would need careful counselling about this, and your doctor would probably suggest that every one to two years you had a biopsy: a small piece of the lining of the womb would be removed and sent for examination to see whether there was any sign of cancer or other disorders. Nowadays, for women who have osteoporosis of the spine but who really cannot take progestogen, a new non-hormone drug called etidronate might be the solution.

If it is the ‘withdrawal bleed’ that is putting you off HRT, there is a third alternative, known as ‘no-bleed HRT’ (because the aim of it is that it should eliminate distressing menopausal symptoms without producing periods), or ‘continuous/combined HRT’ (because you take combined oestrogen and progestogen continuously). No-bleed HRT involves taking a small dose of progestogen every day, instead of for just 10-12 days a month. The theory is that this method eventually leads to amenorrhoea (a complete absence of periods).

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bloodstream increases to ten or fifteen times that seen in the early part of the premenopausal menstrual cycle. The rise is gradual at first, then reaches a peak at which it stays for three to five years after menopause. It returns to the premenopausal range twenty or so years later.

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The pelvic floor muscles are like a safety net supporting all the organs of the lower abdomen. When the muscles are weak, any form of stress exerted on the bladder – such as a sudden jump, cough, laugh or lifting motion — can result in an outflow of urine. Increasing numbers of women are taught pelvic floor (Kegel) exercises, which they are encouraged to do daily. These exercises are designed to strengthen themuscles that support the bladder, uterus and bowel, in order to control stress incontinence and prolapse. You can alternate the exercises and use triggers, such as stops at red traffic lights or brushing your teeth, to remind you to do themmuscles that support the bladder, uterus and bowel, in order to control stress incontinence and prolapse. You can alternate the exercises and use triggers, such as stops at red traffic lights or brushing your teeth, to remind you to do them.

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Many studies show that women with a uterus who use oestrogen on its own for longer than six months experience an increased risk of cancer of the endometrium (lining of the uterus). By adding an adequate amount of progestogen for ten to fourteen days a month, we can make sure that the endometrium is protected.

Other concerns relevant to all women include the following.

The apparent benefit of oestrogen in reducing the risk of heart disease may be due, partly at least, to bias in the selection of the women studied. All the studies of the risks and benefits of HRT are overshadowed by a big question mark. Are women who use it somehow different from the remainder of the female population, and if so might this skew the results? Are they healthier and at less risk of heart disease to start with, for example? Are they more health-conscious at the outset? Are they careful about eating nutritious foods, not smoking, exercising regularly? And are they more likely to follow their doctor’s suggestions? To be sure that HRT really benefits the heart it would be necessary to give HRT to one group of women selected from the general population and a placebo (a harmless and inert substitute) to a comparable group. The results of three such trials, which are at an early stage in the US, will be of interest.

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The oestrogen is absorbed into the bloodstream through the cells lining the vagina, and its major effect is in the immediate vicinity of the vagina and bladder. It is also carried to other parts of the body, including the uterus. For this reason, if you have an intact uterus and use vaginal creams, tablets or pessaries more than three times a week, you should probably be taking an oral progestogen for ten to fourteen days every three months. This ensures that any build-up of endometrial tissue is shed as a withdrawal bleed or, if no bleeding occurs, it provides reassurance that the endometrium is not in any danger.

Hormone rings, which sit in the top of the vagina for three months before needing to be replaced, release a small and constant stream of oestrogen that is absorbed by the cells of the vagina and cervix. Once again, if your uterus is intact you should take a ten-to-fourteen-day course of progestogen every three months to ensure that stimulation of the endometrium does not occur. These devices are on trial in Australia at the time of writing.

Advantages of these forms of local therapy include a concentrated dose of oestrogen at the site of the symptom rather than its widespread dispersal through the body.

Disadvantages include the lack of effect on other menopausal symptoms (such as hot flushes and night sweats); the rare occurrence of unexpected spotting or bleeding or endometrial hyperplasia (excessive thickening of the uterine lining) if used too frequently without added progestogen; their messiness; and the embarrassment felt by some women about putting things into their vaginas.

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