Confused by the likes of Elleste Duet Conti, Kliofem, Kliovance, Femoston Conti, Indivina, Premique, Novofem, Trisequens, Femoston and Tibolone? Find out more about combination HRT
• Replacement oestrogen and progesterone is prescribed during perimenopause and menopause to improve symptoms and future health
• Combination tablets contain both oestrogen, and a progestogen, which is a synthetic progesterone
• Understand the benefits and risk of combination tablets
During perimenopause and menopause, oestrogen and progesterone levels fluctuate and then decline, which can usually lead to symptoms as well as health risks. HRT is prescribed to relieve these symptoms - it works by replacing the oestrogen and progesterone that is lost. As well as reducing menopausal symptoms, taking HRT can reduce your future risk of diseases, including osteoporosis and cardiovascular disease.
In the UK, women are usually prescribed oestrogen, progesterone (and sometimes testosterone) separately - this allows the dose of each hormone to be adjusted to suit your individual needs. These are body identical hormones so the same structure as the hormones you make when you are younger.
However, there are combination tablets (and combination patches) available, which contain both oestrogen and progestogen (a synthetic type of progesterone).
Combination tablets are a type of systemic HRT, which means the oestrogen and progestogen enter into your bloodstream so they can travel through your entire body and improve symptoms.
What types of combination tablets are available?
Brands of combination tablet include Elleste Duet Conti, Kliofem, Kliovance, Femoston Conti, Indivina, Premique Low Dose, Novofem, Trisequens, Femoston and Femoston-Cont.
All of these brands, with the exception of Premique, contain oestradiol, which is a body identical oestrogen. Premique contains conjugated equine oestrogens, which is hormones derived from pregnant horses. They also all contain a type of progestogen. Some come in a range of doses.
Elleste Duet Conti contains 2mg oestradiol and 1mg norethisterone
Kliofem contains 2mg oestradiol and 1mg norethisterone
Kliovance contains 1mg oestradiol and 500mcg norethisterone
Femoston Conti contains 500mcg oestradiol and 2.5mg dydrogesterone; or 1mg oestradiol and 5mg dydrogesterone
Indivina contains 1mg oestradiol 1mg and 2.5mg medroxyprogesterone; or 1mg oestradiol and 5mg medroxyprogesterone; or 2mg oestradiol and 5mg medroxyprogesterone
Premique Low Dose contains 300mcg conjugated oestrogens and 1.5mg medroxyprogesterone
Novofem contains two types of tablet that are taken sequentially: red tablet of 1mg oestradiol and white tablet of 1mg oestradiol and 1mg norethisterone
Trisequens contains three types of tablet that are taken sequentially: blue tablet of 2mg oestradiol, white tablet of 2mg oestradiol and 1mg norethisterone, and red tablet of 1mg oestradiol
Femoston contains two types of tablet that are taken sequentially: 1mg oestradiol and then 1mg oestradiol and 10mg dydrogesterone. It is also available in 2/10mg dose: 2mg oestradiol and then 2mg oestradiol and 10mg dydrogesterone
Tibolone contains synthetic ingredients that work differently to natural hormones but can have effects similar to those of hormones. Tibolone is associated with more risks than natural body identical hormones, including increased risk of endometrial (womb) cancer, breast cancer, and stroke, particularly in older women [1, 2]. It can also cause side effects such as irregular bleeding and breast tenderness. Although Tibolone can still be prescribed during menopause, in an annual review it was recommended as a drug to avoid as it is more harmful than beneficial [3].
RELATED: HRT easy prescribing guide
What are the benefits of combination tablets?
Some women find that taking tablets is the simplest and most convenient way to take HRT.
What are the disadvantages of combination tablets?
For most people, the benefits of HRT outweigh any risks. However, there’s a small increased risk of blood clot or stroke if you take HRT in tablet form, and this is more likely if you are obese, a smoker, or have had a clot in the past.
The increased risk is associated with the synthetic progestogens more than the tablet oestradiol. There is no risk with body identical hormones.
There's less flexibility with combination preparations as you can't alter the amount of each hormone needed to relieve symptoms. In contrast, when you are prescribed the individual hormones - oestradiol, progesterone, and testosterone – separately, the dose of each can be individualised and your care is more holistic.
RELATED: Oestrogen in patches, gels or sprays
Can I expect any side effects?
There are more side effects with combination tablets, which is related to the synthetic progestogens.
It often takes a few months for your body to adjust to taking any HRT, so you may notice some mild side effects. The most common are breast discomfort, leg cramps, and breakthrough bleeding or spotting. These usually settle over time, but talk to your doctor if side effects persist for longer than the first six months.
You may also experience a lower libido when you take HRT tablets. This is because taking tablet hormones can block the way testosterone works in your body. If this becomes an issue, talk to your doctor about alternative preparations that don’t have this effect. You can still take testosterone with tablet HRT but some women find it does not work as effectively compared to other forms of HRT.
How do I take combination tablets?
Your healthcare professional will be able to advise the best way to take the combination tablet that is prescribed to you.
Elleste Duet Conti, Kliofem, Kliovance, Femoston Conti, Indivina and Premique Low Dose are continuous preparations where one tablet should be taken every day without a break.
Novofem, Trisequens and Femoston are continuous sequential preparations where tablets are taken in a particular order, without a break.
What else do I need to know?
Vaginal hormones, including oestrogen and prasterone, can be taken – instead of or as well as – combination HRT and can help alleviate symptoms associated with Genitourinary Syndrome of the Menopause (GSM), including vaginal dryness, discomfort or pain during sex, irritation or burning of the vulva or vagina, needing to go to the toilet more often and feeling very desperate to go, and urinary tract infections such as cystitis.
RELATED: Vaginal hormones: what you need to know
Resources
NHS: Continuous combined HRT tablets, capsules and patches
NICE: Estradiol with norethisterone
NICE: Estradiol with dydrogesterone
NICE: Estradiol with medroxyprogesterone
