Sequential combined HRT tablets and patches - Common brand names: Evorel Sequi, Femoston, Elleste Duet

What sequential HRT is for

During menopause, your body makes less of a hormone called oestrogen. This can cause symptoms.

Sequential HRT (hormone replacement therapy) is a type of HRT. It comes as oestrogen on its own and oestrogen combined with another hormone called progestogen (the medicine form of progesterone).

The oestrogen in sequential HRT works by replacing the oestrogen you've lost. If you still have a womb (you have not had a hysterectomy to remove it), increasing your oestrogen can thicken your womb lining and sometimes cause side effects. Including progestogen in the medicine can help prevent some of these side effects.

Sequential HRT is used to help ease menopause symptoms such as:

• hot flushes and night sweats
• vaginal dryness, itching or pain
• mood changes
• sleep problems

It can also help prevent weaking of the bones (osteoporosis), which is common after the menopause.

It is usually prescribed if you're at the start of menopause (perimenopause) and still have periods, or your last period was less than 12 months ago. If your last period was more than 1 year ago, you may be prescribed continuous combined HRT.

How to use sequential HRT

Sequential HRT comes as tablets and patches.

Your GP should discuss the risks and benefits with you before you start using HRT.

When you use sequential HRT:

• you'll use an oestrogen-only medicine for part of the month and a combined progestogen and oestrogen medicine for the rest of the month
• you'll usually have something like a period (withdrawal bleeding) during the times when you're not taking progestogen
• talk to a doctor if your symptoms are not getting better – it can take time to find the right type and dose to suit you

Always follow your doctor's advice. There are also many different brands of combined HRT, so instructions may be different.  Follow the information that comes with your medicine.

Find out more about when to take HRT.

How to use different types of sequential HRT

If you miss a dose of sequential HRT

Sequential HRT tablets

If you miss a tablet and it's more than 12 hours until your next dose, take it as soon as you remember.

If it's less than 12 hours until your next dose, skip the missed dose and take the next dose at the normal time.

If you miss a dose, you may have some bleeding or spotting.

Do not take or use 2 doses of HRT to make up for a forgotten dose.

Sequential HRT patches

If you forget to change your HRT patch, change it as soon as you remember. Try to continue changing your patch on the same days.

Do not use 2 HRT patches to make up for a forgotten one.

Always check the information that comes with your medicine.

If you use too much sequential HRT

Using too much sequential HRT is unlikely to cause problems but it's important to get medical advice if you take too much as it can sometimes be dangerous. It can also increase the risk of side effects such as breast tenderness, nausea and vaginal bleeding.

How to stop using sequential HRT

When you start using HRT your GP should review your medicine after the first 3 months.

If you want to stop at any point, talk to your GP, but stopping may cause your symptoms to come back.

You can usually carry on using sequential HRT until you reach menopause. Your GP may then switch you to continuous combined HRT, instead.

If you’re taking sequential HRT and you have a hysterectomy to remove your womb, your GP will review your HRT to see if it needs to be changed. You may need to switch to oestrogen-only HRT.

Side effects of sequential HRT

Like all medicines, sequential HRT can cause side effects, although not everyone gets them.

Common side effects

Common side effects of sequential HRT include:

• headaches
• breast pain or tenderness
• skin irritation where you stick the patch
• vaginal bleeding
• sleep problems
• mood swings

Sequential HRT will not usually affect your ability to drive, ride a bike or use machinery.

Serious side effects

Sequential HRT can sometimes cause serious side effects, although most of them are rare.

Possible serious side effects of sequential HRT include:

• pain and swelling in your legs (this may be a sign of deep vein thrombosis), or sudden chest pain or difficulty breathing (these may be signs of a pulmonary embolism)
• yellowing of your eyes and skin, which may be harder to see on brown or black skin – these may be signs of jaundice
• weakness on 1 side of the face (the mouth or eye may droop), difficulty raising your arms and keeping them raised, difficulty speaking (speech may be slurred) – these may be signs of a stroke
• an allergic reaction (anaphylaxis) – causing symptoms such as a swollen throat or tongue, a raised, itchy rash or difficulty breathing

There is also an increased risk of breast cancer and womb (uterus) cancer, particularly if you take or use sequential HRT for a long time. If you're worried or have any unexpected or unusual bleeding, talk to your GP.

Who can and cannot use sequential HRT

Most adults going through menopause can use sequential HRT.

But it's not suitable for everyone. For example, it may not be suitable if:

• you've had an allergic reaction or other serious side effect from HRT
• you've ever had breast cancer, are having tests for breast cancer or are high risk due to family history
• you have an oestrogen-dependent cancer
• you have thickening of the womb lining (endometrial hyperplasia), fibroids or endometriosis
• you have angina or recently had a heart attack
• you have vaginal bleeding with no known cause
• you've ever had a blood clot (thrombosis), are at risk of blood clots, or pulmonary embolism

Before taking sequential HRT, tell your doctor if you have any medical conditions.

Breastfeeding and sequential HRT

Tell your doctor if you're breastfeeding. Sequential HRT is not recommended if you're breastfeeding.

Pregnancy and sequential HRT

If you're trying to get pregnant or you become pregnant while using sequential HRT, stop using it and talk to your GP. Sequential HRT is not recommended during pregnancy.

Using sequential HRT with other medicines, food and drink

There are some medicines, remedies and supplements that may not mix well with sequential HRT.

This includes:

• medicines for epilepsy, such as phenytoin or carbamazepine
• some antibiotics, such as rifampicin
• medicines for HIV, such as tenofovir or ritonavir
• herbal remedies that contain St John's wort

Before using sequential HRT, tell your doctor if you're taking any other medicines, herbal remedies, vitamins or supplements.

Food, drink and alcohol with sequential HRT

You can eat and drink as normal while taking sequential HRT.