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Appendix 7 – Side Effects

View HRT Guidance Flow Chart

Generally, most side-effects are due to the progestogen component of HRT.

Bleeding is one of the most important side-effects that cause poor update and continuation.

Cycle problems

See appendix 8 for more details.

  • Irregular/continuous bleeding
  • Heavy periods
  • Poor cycle control

PMS-like symptoms

  • Bloating
  • Irritability
  • Depression

Androgenic effects

  • Acne
  • Oily skin
  • Facial hair

A small amount of weight gain attributed to fluid retention can occur but weight gain is a side effect of the menopausal transition not of HRT.

It should be possible to determine whether the side-effects experience are estrogenic (ie. continuous) or only in the progestogen phase of the cycle. However, many women will not spontaneously volunteer side-effects as a potential problem, so it is very important to ask, especially within the first 3 months of commencing HRT.

Estrogenic Side-Effects

  • Fluid retention/bloating
  • Breast tenderness/enlargement (more common when starting in older women)
  • Nausea
  • Headaches
  • Leg cramps
  • Dsypepsia
  • Nipple sensitivity

Actions include:

  • Encourage perseverance – many will resolve over 2-3 months
  • Reduce the dose
  • Alternative estrogen
  • Change route of delivery

Device specific:

  • Skin irritation
  • Poor adhesion
  • Local sepsis/scars from implants
  • Tachyphylaxis

For information on heavy bleeding, see appendix 8.

Progestogenic Side-Effects

Progestogen usually presents more problems than estrogen (related to the type and dose/duration of progestogen).

  • Fluid retention
  • Breast tenderness
  • Headaches/migraines
  • Mood changes/depression
  • Acne
  • Lower abdominal pain
  • Backache
  • Bleeding problems

Actions include:

  • Encourage perserverance – many will resolve over 2-3 months
  • Change progestogen
  • Reduce dose, but not below recommended levels
  • Reduce duration
  • Consider continuous combined or Tibolone if 1 year post-menopause
  • Hysterectomy