Frequently Asked Questions

At Clinic 51 we offer evidence-based advice and treatment in line with guidance from the British Menopause Society and the UK National Institute of Clinical Excellence.

As a team, we keep up to date through regular meetings where we share learning, current changes in guidance and difficult cases. We ensure we prescribe according to the current majority medical consensus view of best practice for menopause care by attending conferences and liaising regularly with other recognised menopause specialists.

We practice holistically, looking at all the factors that affect wellbeing including psychological, familial and societal factors. Our treatment, where appropriate, will offer hormone therapy but we will also guide you through lifestyle advice, talking therapies and other medical options.

As generalists, we are able to assess your symptoms and advise when symptoms are not in keeping with perimenopause / menopause. In these circumstances, we may suggest that you seek further investigation to exclude other medical problems.

We will review your symptoms, your personal risk factors and your personal preferences to decide on the most appropriate dose, and formulation, of oestrogen and progesterone. We generally start with low doses and will increase the dose according to your symptoms, as necessary.

We will help to guide you to the correct dose for you; the most important indicator of dosing is symptom control. If you feel well, then this is usually the correct dose.

If your symptoms do not improve on maximum licensed doses, we may organise blood tests to help guide our treatment.

If your symptoms do not improve on licensed doses of oestrogen, and the blood tests confirm you are absorbing the treatment well, then we may look for a different cause of your symptoms or suggest an alternative treatment plan, rather than just increasing your HRT.

We are always happy to discuss any side-effects you are experiencing. It is normal to experience some side-effects on first starting HRT though these will often settle with time. These can include bloating, nausea and heartburn, headaches, breast tenderness and swelling, fluid retention, pelvic pain, mood swings and vaginal bleeding.

Vaginal bleeding is common in the first 3 to 6 months after starting or changing dose of HRT. We will discuss this at your 3 month review. If the initial bleeding is getting lighter with time then we will often wait for this to settle. Depending on your individual circumstances, we may increase the dose of your progesterone, change your progesterone, reduce your oestrogen or, sometimes, we will refer you for further investigation.

If you are getting persistent heavy bleeding, your bleeding pattern is getting heavier or you start bleeding after 3 months of HRT use, contact us and we will discuss this with you.

British Menopause Society guidance states that high dose oestrogen is anything 100mcg and above.

This is equivalent to a 100mcg patch or 4 pumps of Oestrogel. Oral oestrogen is licensed for 2mg, but the equivalent of 100mcg is 4mg of oral oestrogen. Lenzetto is licensed for 3 sprays, but the dose equivalent of 100mcg is 6 sprays).

However, we also know that women absorb oestrogen through the skin (transdermal) differently, and that for a few, this high dose is not enough to return their oestrogen levels to a normal level. If we have confirmed that blood oestrogen levels are still low, even at a dose of 100mcg, we would consider increasing the dose to an unlicensed level. The General Medical Council recognises that doctors may sometimes prescribe unlicensed doses of medications to meet the specific need of an individual patient.

At this dose we will advise you to increase your progesterone dose. When making prescribing decisions at all doses of oestrogen we will take into account your underlying risk factors for thickening of your endometrial lining (endometrial hyperplasia). 

High dose oestrogen is any dose equivalent to or greater than 100mcg, which is also described as an unlicensed dose, since it is not officially approved for treating your health condition at present. The General Medical Council recognises that doctors may sometimes prescribe unlicensed doses of medications to meet the specific needs of an individual patient.

A 100mcg dose of oestrogen is a licensed dose and we will prescribe this dose if needed to control symptoms.

We will very occasionally prescribe a higher than licensed dose (>100mcg), though we will generally only do this after checking your oestrogen levels to confirm that they are low. We will consider swapping to an alternative preparation prior to increasing to a higher than licensed dose. We will always recheck your blood levels to ensure they remain in the female range.

If we prescribe higher than licensed doses, we will always discuss this with you in advance and explain our rationale for doing this. When we prescribe higher than licensed doses, we will increase the progesterone dose to ensure that the lining of your womb is well protected.

Young women with premature ovarian Insufficiency (POI) or surgical menopause sometimes require higher than licensed doses of HRT. Again we will discuss this with you.

The safety data available to all practitioners only applies to doses of 100mcg or less. As a result, when prescribing at higher doses, there is no reliable safety data to support this.

We know that prescribing high dose oestrogen, or insufficient progesterone, can put you at risk of endometrial thickening and endometrial cancer and will always discuss this with you.

Please also note, however, that use of continuous combined regimes (daily progesterone with oestrogen) at licensed doses is associated with a significantly lower risk of endometrial cancer in women compared with those not taking HRT.

We will ALWAYS discuss this with you.

In line with British Menopause Society guidance we prescribe progesterone proportionate to oestrogen dose.

If we are prescribing a high dose of oestrogen we will advise you to increase the dose of your progesterone or suggest a Mirena coil. The Mirena coil offers excellent endometrial protection. 

If you are bleeding or have personal risk factors, such as your body mass index (BMI), a history of diabetes or polycystic ovaries, or a family history of colorectal, ovarian and endometrial cancers we may advise an increased dose of progesterone at lower doses of oestrogen. 

If you are sensitive to progesterone, and we are not able to increase this, we will discuss a plan tailored to your specific needs to monitor your endometrial lining, usually with ultrasound scans.

No, vaginal oestrogen preparations do not result in significant absorption so there is no concern about their safety.

We will continue to review your symptoms and your risk factors. We will discuss the current evidence and will agree a management plan taking into account your views. We will support you to reduce your dose, if appropriate, whilst recognising that very high doses of oestrogen can result in a dependence so that reducing the dose can result in marked worsening of your symptoms. We would therefore support you to do this slowly. We will also review your progesterone dose to ensure you have suitable endometrial protection.

We will review your symptoms and may suggest further investigation, with us, your GP or another specialist, to ensure that there is no other cause for your symptoms. 

Midlife is a often challenging time and life may have lots of competing priorities, during menopause your body is going through a hormonal and physiological transition and that can be the straw that breaks the camel's back. In our experience the answer often lies in addressing the roots of good health: nutrition, movement, sleep, emotional health and reducing harmful substances.

We will work with you to identify and treat the issues, signposting to our team of wellbeing practitioners including dietitians, CBT, mindfulness & meditation, talking therapies, acupuncture, exercise classes and more.

Most cancers are not hormone dependent and HRT would not be contra-indicated.

Some cancer treatments can induce a premature menopause, in these cases it is important that hormones are replaced until the natural age of menopause to protect a women's cardiovascular system and her bones.

The evidence of the use of HRT following a hormone dependent cancer is very limited and we can not presume there is not an increased risk. We would always want to ensure that non hormonal treatments and therapies have been fully explored and with our team of wellbeing specialists. We are in excellent position to advise on a non hormonal treatment plan for women to thrive both in terms of symptoms and maintaining their long-term health.

Where symptoms are significantly impacting on a woman's life we may consider HRT if other treatments have not been successful. We will always work with an individual woman, and wherever possible the cancer specialists treating her to do this, carefully weighing up the risk against the benefit.