Sequential combined hormone replacement therapy (HRT) tablets and patches

Sequential combined hormone replacement therapy (HRT) is a medicine that contains the hormones oestrogen and progestogen. It's used to treat menopause symptoms.

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.

As you reach the menopause your ovaries gradually begin to produce less oestrogen and progestogen. This can cause symptoms such as hot flushes, mood swings and vaginal dryness.

Taking HRT can help these symptoms and help prevent other conditions such as weakening of the bones (osteoporosis), which is common after the menopause.

A doctor will usually recommend sequential combined HRT if you have menopause symptoms but you're still having periods, or your last period was less than 12 months ago.

Sequential combined HRT involves taking oestrogen every day and taking progestogen for 10 to 14 days of each 28-day cycle. You'll usually have withdrawal bleeding at the end of each course of progestogen.

This is different to continuous combined HRT, where you take both oestrogen and progestogen every day with no monthly bleeding. Continuous combined HRT is usually prescribed after you have not had a period for 1 year or more.

You'll need to take combined HRT if you still have a womb. This is because taking oestrogen on its own can thicken the womb lining, which slightly increases the risk of womb cancer. Taking progestogen together with oestrogen reduces the risk.

Sequential combined HRT is only available on prescription. It comes as tablets or skin patches.

Brands include Elleste Duet, Clinorette, Femoston, Novofem, Tridesta and Trisequens tablets, and Evorel Sequi and FemSeven Sequi patches.

If you're still having periods (perimenopausal) or had your last period less than 1 year ago you can usually take sequential combined HRT.

Sequential combined HRT is not suitable if you've had a hysterectomy to remove your womb.

Sequential 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 any medicine containing oestrogen or progestogen, or anything contained in the patches or tablets
• have ever had breast cancer, are having tests for breast cancer, or are at high risk due to family history
• have a type of cancer that is sensitive to oestrogens, such as cancer of the womb lining (endometrium), if you're having tests for this, or if you're at high risk of getting it
• have vaginal bleeding with no known cause
• have ever had a blood clot in a vein (thrombosis), such as in the legs (deep vein thrombosis) or the lungs (pulmonary embolism)
• have problems with your blood which may cause a blood clot
• have a rare inherited condition called porphyria
• have or have recently had a problem caused by blood clots blocking the arteries, such as a heart attack, stroke or angina
• have thickening of the lining of the womb (endometrial hyperplasia) that has not been treated, or fibroids or endometriosis
• have ever had a problem with your liver
• have high blood pressure
• have diabetes
• have an underactive thyroid
• have ever had migraines or severe headaches
• have lupus
• have epilepsy
• have asthma
• are living with obesity
• have dementia

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

Sequential combined HRT is taken in 28-day cycles. This means that you take oestrogen every day, but you only take it with progestogen for 10 to 14 days of your cycle. You then repeat the cycle without a break.

You'll usually have withdrawal bleeding at the end of each course of progestogen.

The tablets and patches come in different strengths. Your doctor will prescribe the right dose for you, depending on your symptoms, your age and any other health conditions you have.

Changes to your dose

You'll usually start on a low dose, and it may be increased later, depending on how well it works and whether you get any side effects.

If you're having side effects from taking HRT and think you may need to change your dose, speak to your doctor.

How to take sequential combined HRT tablets

You take sequential combined HRT tablets every day without a break.

Try to take them at around the same time each day.

You can take them with or without food.

Each pack contains 2 or 3 different types of tablets, in different colours. It's important to follow the instructions on the pack and in the leaflet to make sure you take them on the correct days.

How to use sequential combined HRT patches

You put sequential combined HRT patches on your skin, and change them once or twice a week, depending on which type of patch you have.

Each pack contains 2 different types of patch, containing either oestrogen only, or oestrogen and progestogen. It's important to follow the instructions on the pack and in the leaflet to make sure you use the patches on the correct days.

Put the patch on skin below your waist, such as your buttocks, hips or thighs. Do not put them near your breasts.

Put them on skin that is clean, dry and healthy.

Each time you change your patch, put the new one in a different place below your waist.

You can leave the patch on while you have a bath or shower. If it falls off, wait until your skin has cooled down, then put on another patch. If a patch falls off early for any other reason, put a new patch on straight away. Then continue to change the patches on the usual day.

It's common to take or use HRT for between 2 and 5 years to treat menopause symptoms, but sometimes you may need to take it for longer. How long you take it 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 years old. This 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 sequential combined HRT tablet, 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're using patches and forget to change it, change it as soon as you remember and then change it again on the usual day. 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.

Taking an extra dose of HRT is unlikely to harm you.

If you take too many tablets, you may feel sick or be sick.

If you're worried, or have any unusual symptoms after taking too much HRT, talk to a doctor or pharmacist for advice.

Talk to your doctor if you're thinking of stopping taking sequential combined HRT. They may suggest 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 cope with these common side effects of sequential 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.

It's normal to have withdrawal bleeding at the end of each course of progestogen.

Irregular bleeding is common for the first few months after starting sequential 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 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, not patches.

If this happens, 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're using a patch, and the rash or itchiness is only affecting the area where you put on the patch, talk to your doctor. 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 sequential 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 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 sequential 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 sequential combined HRT. For a full list see the leaflet inside your medicine's packet.

Do not take sequential combined HRT if you're pregnant or might become pregnant.

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

If you're pregnant then your levels of oestrogen and progesterone will be high and you will not need to take HRT.

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 and sometimes different types of progesterone.

There is no information about taking sequential combined HRT while breastfeeding.

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

Sequential combined HRT does not affect your fertility.

There's a chance that you could become pregnant while taking HRT as it does not act as contraception.

Even if you think that you've gone through the menopause, there's a small chance that you could become pregnant. You're advised to use contraception for at least 1 year from your last period if you're over 50 years old and for 2 years if you're under 50 years old. 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 your HRT works because they can sometimes cause irregular bleeding.

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

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

There are several different herbal products sold to help relieve menopause symptoms. These include evening primrose oil, soya, red clover, black cohosh, ginseng and St John's wort.

Herbal remedies containing St John's wort may affect the way your HRT works and make it less effective.

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.