Continuous combined hormone replacement therapy (HRT) tablets, capsules and patches

Continuous combined hormone replacement therapy (HRT) is a medicine used to treat hot flushes, mood swings, vaginal dryness and other symptoms of the menopause.

It can also prevent weakening bones (oesteoporosis) which is common after the menopause.

Menopause is when your periods stop due to lower hormone levels. It usually affects women between the ages of 45 and 55, but it can happen earlier. It affects anyone who has periods.

Your doctor will usually recommended continuous combined HRT if you are post-menopause (you have not had a period for 1 year or more).

It is not suitable if you have menopause symptoms but are still having periods (perimenopause), or within 12 months of your last period, because it may cause irregular bleeding. In these cases your doctor will usually recommend sequential combined HRT instead.

Menopause symptoms are caused by a drop in the levels of oestrogen and progesterone produced in the ovaries. There are different types of oestrogen and progesterone, called oestrogens and progestogens. Combined HRT uses both to raise the levels of these hormones in your body.

It's important to take both oestrogen and progestogen, unless you've had a hysterectomy (surgery to remove your womb). This is because taking oestrogen-based HRT on its own can thicken the womb lining. This slightly increases the risk of womb cancer. Taking progestogen together with oestrogen reduces the risk.

Continuous combined HRT is only available on prescription. It comes as tablets, capsules and patches.

If you still have a womb and have not had a period for a year (post-menopause) you can usually take continuous combined HRT.

If you've had a hysterectomy to remove your womb, you can usually take oestrogen without progestogen.

Continuous combined HRT is not suitable for everyone. To make sure it's safe for you, tell your doctor before taking it if you:

• have ever had an allergic reaction to oestrogen or progestogen, or any other medicine
• have ever had breast cancer, are having tests for breast cancer, or are considered high risk due to family history
• have a type of cancer that is sensitive to oestrogens, such as cancer of the womb lining (endometrium), or if you're having tests for this
• have thickening of the lining of the womb (endometrial hyperplasia) which has not been treated
• have any unexplained vaginal bleeding
• have ever had a blood clot in a vein (thrombosis), such as in your legs (DVT – deep vein thrombosis) or your lungs (pulmonary embolism)
• have problems with your blood which increases the likelihood of developing a blood clot (thrombosis)
• have ever had liver disease and your liver function tests are not back to normal
• have or recently had a condition caused by blood clots in the arteries, such as a heart attack, stroke or angina
• have a rare inherited condition called porphyria
• are pregnant or breastfeeding
• have high blood pressure (hypertension)
• have diabetes
• have an underactive thyroid
• have ever had migraines or severe headaches
• have lupus
• have epilepsy
• have asthma
• are very obese
• have dementia

If you get any of these conditions after you start taking continuous combined HRT, stop taking it and speak to your doctor.

Continuous combined HRT tablets and capsules contain an oestrogen called estradiol, and a progestogen. The doses of oestrogen and progestogen in your HRT will depend on the brand.

How to take continuous combined HRT tablets and capsules

The tablets and capsules include the brands Elleste Duet Conti, Kliofem, Kliovance, Femoston-conti, Indivina and Bijuve.

Take continuous combined HRT tablets or capsules once a day. It's best to take them at the same time each day.

Swallow the tablet or capsule whole with a drink of water. Check your medicine packet to see if you need to take it with food.

Take your tablet or capsule without a break between packs.

How to use continuous combined HRT patches

The patches include the brands Evorel Conti and FemSeven Conti.

Stick the patch onto an area of skin below your waist, such as on your thigh or buttocks. Do not put the patch:

• near your breasts
• on top of cuts, spots or irritated skin
• under elasticated or tight areas of clothing
• on creases or folds in your skin
• on your skin if you have recently used cream, talc or moisturiser
• on skin exposed to direct sunlight

Wait at least 1 hour after putting the patch on before you try any activity or exercise that will make you sweat as this can affect how the patch sticks to your skin.

Change the patch once or twice a week (depending on the brand you use). Try to do this on the same day or days every week. This may mean that 1 patch is on for 3 days and the next patch for 4 days. For example, if you put on a patch on a Monday, change it on Thursday, and again on the following Monday.

Your patch should stay on while bathing or showering but if it does fall off, dry your skin and cool down before putting on a new one.

If your patch falls off or you need to replace it during the week, put the new patch in a different place.

If you're switching to patches from another type of HRT, such as tablets, when to start your patches will depend on which medicine you're switching from.

You can start to use your patches straight away if:

• your periods have stopped and you have not been taking HRT
• you're switching from another type of continuous combined HRT

If you have been using sequential combined HRT (taking your progestogen only on some days, and having a break), wait until the end of the cycle of your current medicine before using your new patches.

It's common to take HRT for between 2 and 5 years to treat menopause symptoms, but sometimes you may need to take it for longer. Talk to your GP about how long they recommend you take the treatment.

How long you take HRT for depends on the benefits and risks to you. Ask your doctor for advice.

If you have premature menopause (where your periods stop before the age of 40) or early menopause (where your periods stop before the age of 45), you'll usually be advised to take HRT at least until you're 51, which is the average age of menopause.

If you have a hysterectomy to remove your womb, you'll need to stop taking combined HRT. You may be able to take oestrogen-only HRT instead.

If you forget to take your continuous combined HRT tablet or capsule, take it as soon as you remember, unless it's less than 12 hours until your next dose. In this case, skip the forgotten dose and take the next dose at the usual time. You may have some vaginal bleeding or spotting.

Do not take 2 doses to make up for a missed dose.

If you forget to change your HRT patch, change it as soon as you remember and apply the next one at the usual time. If it's almost time for the next patch, skip the missed one and then change the patch on the usual day. You may have some vaginal bleeding or spotting.

If you often forget doses, it may help to set an alarm to remind you. You could also ask your pharmacist for advice on other ways to help you remember to take your medicines.

Taking an extra dose of continuous combined HRT is unlikely to harm you. If you're worried, talk to a doctor or pharmacist for advice.

Talk to your doctor if you're thinking of stopping taking continuous combined HRT. They may suggest that you reduce your dose gradually, to help prevent your menopause symptoms coming back.

If you're having problems with side effects, your doctor might suggest changing your dose, or switching to another type of HRT.

There are things you can do to help cope with these common side effects of continuous combined HRT:

Headaches usually only last for a few days after you start treatment as your body gets used to the medicine. Try taking a painkiller such as ibuprofen or paracetamol.

If headaches last longer than a week or are severe, speak to your doctor. You may need to change your dose or switch to a different type of HRT.

This usually improves after 4 to 6 weeks as your body gets used to the medicine. If it lasts for longer than this or becomes too painful, speak to your doctor. Your doctor may suggest that you try a different dose or change to a different type of HRT.

If after a few months of taking HRT you notice a lump or changes in your breasts, contact your doctor for advice.

Irregular bleeding is common for the first few months after starting continuous combined HRT.

If you get heavy bleeding or unexpected bleeding after you've been taking it for 6 months, talk to your doctor.

Take your HRT tablets or capsules with food. Try to stick to simple foods until your body gets used to the medicine.

Feeling sick should wear off after a few days as your body gets used to the medicine. If it lasts for more than a week, speak to your doctor as you may need to try a different dose or change to a different type of HRT.

This may last for the first few months after you start treatment as your body gets used to the medicine. Speak to your doctor if it lasts for longer than this. You may need to try a different dose or change to a different type of HRT.

This should only last for the first few weeks after you start treatment. Stretching and gentle exercise may help prevent leg cramps. If it keeps happening after the first few months, talk to your doctor as you may need a different treatment.

This is more likely to happen with HRT tablets or capsules, not patches.

Drink lots of fluids, such as water or squash, to avoid dehydration. Signs of dehydration include peeing less than usual or having dark, strong-smelling pee.

If the diarrhoea lasts more than a week, speak to your doctor as you may need to try reducing your dose or changing to a different type of HRT. Do not take any other medicines to treat diarrhoea without speaking to a pharmacist or doctor.

If you are using patches, and the rash or itchiness is only affecting the area where you put on the patch, talk to your doctor as you may need a different treatment.

If this affects a large area of skin, talk to your doctor.

Speak to a pharmacist or doctor if the advice on how to cope does not help and a side effect is still bothering you or does not go away.

Serious side effects from continuous combined HRT are rare.

Call a doctor or call 111 for advice now if you have pain, redness or swelling in one of your legs, usually in your calf – this could be a sign of deep vein thrombosis (DVT).

Speak to your doctor if you have:

• a lump or changes in your breasts, especially dimpling of the skin, changes in the nipple or any lumps you can see or feel – this could be a sign of breast cancer
• any changes in vaginal bleeding after you have been taking HRT for more than a few months – this could be a sign of womb cancer

It's important to attend your breast screening (mammogram) appointments while you're taking HRT.

• you have pain in your chest and breathlessness – this could be a sign of a blood clot in your lungs (pulmonary embolism) or heart problems
• you have difficulty speaking or moving your arm or leg, or your face has dropped on one side – this could be a sign of a stroke

Do not drive to A&E. Ask someone to drive you or call 999 and ask for an ambulance.

Bring all the medicines you take with you.

In rare cases, it's possible to have a serious allergic reaction (anaphylaxis) to continuous combined HRT.

Call 999 now if:

• your lips, mouth, throat or tongue suddenly become swollen
• you're breathing very fast or struggling to breathe (you may become very wheezy or feel like you're choking or gasping for air)
• your throat feels tight or you're struggling to swallow
• your skin, tongue or lips turn blue, grey or pale (if you have black or brown skin, this may be easier to see on the palms of your hands or soles of your feet)
• you suddenly become very confused, drowsy or dizzy
• someone faints and cannot be woken up
• a child is limp, floppy or not responding like they normally do (their head may fall to the side, backwards or forwards, or they may find it difficult to lift their head or focus on your face)

You or the person who's unwell may also have a rash that's swollen, raised, itchy, blistered or peeling.

These can be signs of a serious allergic reaction and may need immediate treatment in hospital.

These are not all the side effects of continuous combined HRT. For a full list see the leaflet inside your medicines packet.

Continuous combined HRT is not known to be harmful in pregnancy, but if you think you might be pregnant, stop taking it and speak to your doctor.

Levels of oestrogen and progesterone are naturally high during pregnancy and HRT is not needed.

Most of the information about taking oestrogen and progestogen while breastfeeding comes from research into the combined contraceptive pill. The combined contraceptive pill uses different types of oestrogen. There is no information about taking combined HRT while breastfeeding.

If you are breastfeeding, combined HRT is not usually prescribed, unless a specialist recommends it.

Taking continuous combined HRT is unlikely to affect your fertility.

Although continuous combined HRT contains progesterone it does not act as contraception.

Even if you think that you have gone through the menopause, there's a small chance that you could become pregnant. You are advised to use contraception for at least 1 year from your last period if you are over 50 and for 2 years if you are under 50. Discuss this with your doctor or family planning practitioner.

Tell your doctor if you're:

• trying to get pregnant
• pregnant
• breastfeeding

There are some medicines that may affect how continuous combined HRT tablets and capsules work because they can sometimes cause irregular bleeding. HRT can also affect how some medicines work by making them less effective. For example, some HRT can cause epilepsy to be less well controlled.

Tell your doctor or pharmacist if you're taking any other medicines, including:

• epilepsy medicines
• some antibiotics
• medicines for tuberculosis
• medicines for HIV

HRT skin patches are less likely to be affected by other medicines.

St John's wort may stop HRT tablets and capsules from working as well. HRT patches will be less affected by this.

It's not possible to say that other herbal remedies and supplements are safe to take with HRT. They're not tested in the same way as pharmacy or prescription medicines. They're generally not tested for the effect they can have on other medicines.

Any herbal product may affect other medicines you're taking, so it's important to check with your doctor or pharmacist before starting to take them.

Tell your doctor or pharmacist if you're taking any other medicines, including herbal remedies, vitamins or supplements.