Estrogen-Only vs Combined HRT: Which Is Appropriate for You?
Estrogen-only and combined HRT serve different situations. Learn which type is recommended based on your uterine status, symptoms, and health history.
The Fundamental Difference
The single most important factor in determining which type of HRT you are offered is whether you have a uterus. Estrogen-only HRT (also called unopposed estrogen) is appropriate for women who have had a hysterectomy, because without a uterus there is no uterine lining to protect. For women who still have a uterus, taking estrogen without a progestogen causes the uterine lining (endometrium) to thicken over time, which significantly increases the risk of endometrial cancer. Combined HRT adds a progestogen to estrogen precisely to prevent this thickening and keep the endometrium safe. This is not a matter of preference. It is a clinical requirement determined by anatomy.
Estrogen-Only HRT: Who It Is For
Women who have had a total hysterectomy (removal of the uterus and usually the cervix) can take estrogen alone without needing a progestogen. This simplifies the regimen and removes the progestogen-related side effects that some women find difficult, including mood changes, bloating, and breast tenderness. Estrogen-only HRT is delivered in the same ways as combined HRT: patches, gels, sprays, or tablets. The dose can be adjusted to achieve symptom relief while keeping the dose as low as needed for effectiveness. Some women with a hysterectomy who also had their ovaries removed (bilateral oophorectomy) may need higher doses of estrogen initially, particularly if they entered surgical menopause at a younger age.
Combined HRT: What It Involves
Combined HRT delivers both estrogen and a progestogen. The progestogen element can be taken in different ways depending on the chosen regimen. In sequential combined HRT, progestogen is taken for 10 to 14 days each month, producing a monthly withdrawal bleed. In continuous combined HRT, both hormones are taken every day with no break, which suppresses bleeding entirely. The continuous combined approach is generally recommended only for women who are fully postmenopausal, to avoid irregular breakthrough bleeding. Women in perimenopause with an intact uterus usually begin on sequential combined HRT.
Comparing Side Effects
Estrogen-only HRT tends to have a more straightforward side effect profile because progestogen-related symptoms are absent. Common estrogen side effects, particularly when starting, include breast tenderness, bloating, nausea, and headaches, most of which settle within the first two to three months. Combined HRT carries all of these potential estrogen effects plus potential progestogen effects, which include mood changes, bloating, breast tenderness, and in some women, low mood or anxiety, particularly in the progestogen phase of sequential regimens. Choosing body-identical micronised progesterone (Utrogestan) rather than synthetic progestogens significantly reduces these progestogen-related side effects for many women, though access varies by country and prescriber.
Risk Profiles: What the Evidence Shows
The breast cancer risk associated with HRT has been widely discussed, and it differs between estrogen-only and combined HRT. Estrogen-only HRT does not appear to carry a meaningful increase in breast cancer risk for most women using it at standard doses and for typical durations, and some analyses have suggested it may be associated with a slight reduction in risk. Combined HRT is associated with a small increased breast cancer risk that becomes measurable after around five years of use. This risk is considered small in absolute terms and should be weighed against the significant benefits of HRT for bone health, cardiovascular protection, and quality of life. The risk figures vary by progestogen type, with micronised progesterone associated with lower risk than synthetic progestogens.
The Role of Testosterone
Testosterone is sometimes prescribed alongside either estrogen-only or combined HRT, particularly for women who experience persistent low libido, fatigue, or cognitive difficulties despite adequate estrogen treatment. Testosterone is not part of the estrogen-versus-combined debate but it is worth mentioning because it is an addition that many women are not told about. It is typically delivered as a gel or cream and used in small doses designed to bring testosterone levels to the normal physiological range for women. Women who had a surgical menopause through oophorectomy often have a more pressing need for testosterone replacement because the ovaries produce around half of a pre-menopausal woman's testosterone.
Getting the Right Prescription for Your Situation
The conversation about which type of HRT to start requires a clear picture of your medical and surgical history, your current symptoms, your risk factors, and your preferences regarding bleeding. If you have a uterus, combined HRT is the only safe estrogen-based option, and the choice within that category is between sequential and continuous combined based on where you are in the menopause transition. If you have had a hysterectomy, estrogen-only is simpler and avoids progestogen-related side effects. In either case, tracking your symptoms carefully before and after starting HRT helps both you and your prescriber assess whether the current regimen is working and whether adjustments are needed. PeriPlan lets you log symptoms and track patterns over time, which makes those review appointments far more productive.
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