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Menopause and Hormone Replacement Therapy (HRT)

Hormone replacement therapy can be used to manage symptoms of menopause. 

Menopause, also referred to as ‘the change’, happens when your periods stop permanently — signalling the end of reproductive function. Natural menopause usually happens when you reach your 50s (the average age is 51 in the UK). But some women may experience menopause much earlier (10% have early menopause between 40-45 and 1-2% have premature menopause before 40). Some women experience abrupt menopause due to medical interventions such as chemotherapy, radiotherapy or surgical removal of ovaries as part of medical treatments.

Natural menopause is a phase of physiological transition in midlife. Sometimes this change can be associated with distressing symptoms and they may last for a few months or sometimes several years. Treatment options for menopausal symptoms include lifestyle changes, alternative therapies, non-hormonal medications and hormone replacement therapy (HRT). You can decide whether to take HRT or not after considering its benefits versus risks in your unique situation

What changes or symptoms happen in the menopause and when is HRT needed?

As you approach menopause, the functioning of your ovaries reduces, and your body makes less of two hormones called ‘oestrogen’ and ‘progesterone’. Among other things, these hormones are responsible for bringing on your periods. You may notice your periods become less regular. They might be heavier or lighter and last for more or fewer days than usual. Your periods will become less frequent with time and eventually stop.

You may notice ‘hot flushes’ as you go through menopause (where you suddenly feel hot and go red in the face). This may be associated with bouts of sweating during the day as well as at night. It is also common to find that your vagina feels dry and uncomfortable, which may make sex painful. 

You may also experience: 

  • Tiredness
  • Irritability
  • Brain fog
  • Joint aches
  • Trouble sleeping
  • Depression
  • Weight gain 
  • Less interest in sex

These symptoms can be attributable to the changes in your hormones or to the changes in your life around the time of menopause. 

Not everyone experiences distressing menopausal symptoms and needs treatment. Some women find the symptoms do not bother them much, while others find them very distressing, and they negatively affect their quality of life. For most, the symptoms will pass within three to five years, although vaginal dryness is likely to get worse if not treated. For others, symptoms will persist for 15 years or longer.

If you are worried about your symptoms, talk to your health professional about the treatment options available. HRT will help if you have unpleasant menopausal symptoms which cannot be addressed by lifestyle or non-hormonal therapies alone.

What is HRT?

HRT stands for hormone replacement therapy. It is also abbreviated as MHT for menopausal hormone therapy. It consists of the hormone oestrogen either alone or combined with the other hormone progesterone. The aim is to replace some of the oestrogen that your body stops making when you reach menopause. Some women are also prescribed testosterone in addition depending on their symptoms.

What are the types of HRT?

Combined HRT (oestrogen and progesterone) is prescribed if you still have your womb. Taking oestrogen alone can increase your chance of getting cancer of the womb lining (endometrial cancer). Adding progesterone to oestrogen reduces the chance of getting this kind of cancer. 

Oestrogen only (no progesterone) is prescribed when you have had a hysterectomy. This is because you do not need progesterone to protect the lining of the womb (there are few exceptions such as severe endometriosis, endometrial cancer or symptoms specifically responsive to progesterone). You can take oestrogen-only HRT as there is no chance of getting endometrial cancer. 

This can be given in two ways:

  1. Continuous combined HRT — oestrogen and progesterone, taken together daily for 28 days. This means that there will be no monthly withdrawal bleeds.
  2. Sequential HRT — oestrogen only for the first 14 days then both hormones for the second 14 days. This usually results in monthly withdrawal bleeds as it tries to copy your natural cycle and give you a period.

Cyclical HRT is often prescribed for women who have menopausal symptoms but are still having periods or for those who stopped their periods less than one year ago. Continuous HRT (without bleeds) is more suitable if you have not had periods for more than one year.

HRT is available for prescription in several different forms. You can take it as:

  • Skin patch 
  • Oral tablets
  • Capsules
  • Gel
  • Spray
  • Implant 
  • Vaginal ring 
  • Progestogen-releasing uterine coil
  • Vaginal cream
  • Pessaries

Some types work best for certain symptoms. As transdermal oestrogen (patch/gel/spray) is associated with a lower risk of blood clotting than oral HRT, a transdermal route may be preferable for some women. This route is advantageous for women with diabetes, high blood pressure, high BMI and other cardiovascular risk factors, especially if you are over 60.

Progesterone types can vary in HRT. Body-identical or body-similar versions such as micronised natural progesterone or dydrogesterone appear to be safer than synthetic versions. Vaginal oestrogen creams or pessaries do not carry the same risks associated with oral or transdermal HRT. As the dose of oestrogen is low, they do not require the protective effect of progesterone. 

Talk to your health professional to decide which product is likely to suit you most.

What are the benefits of HRT and how long after starting HRT do you feel a difference in symptoms?

For most symptomatic women, the benefits of the use of HRT outweigh the risks.

Benefits of HRT include:

  • Reduction in vasomotor symptoms such as hot flushes and night sweats — HRT is the most effective treatment for reducing vasomotor symptoms. These usually improve within three to four weeks of starting treatment and maximal benefit is gained by about three to six months.
  • Improvement in quality of life — HRT may improve sleep, muscle aches/pains and your overall quality of life. Many women experience improved mood, less brain fog, better libido and less depressive symptoms.
  • Improvement of urogenital symptoms — HRT significantly improves vaginal dryness and sexual function. HRT is also effective in improving stress incontinence (leaking urine when you cough or sneeze). It can also relieve the symptoms of urinary frequency and prevent frequent urinary infections, as it has some effect on the urinary bladder and urethral tissues. Vaginal oestrogen creams or pessaries are the preparations of choice for urogenital symptoms.
  • Reduction in osteoporosis (brittle bones) risk — HRT is effective in preserving bone mineral density. Women taking HRT have a significantly decreased incidence of fractures with long-term use. Although bone density declines after discontinuation of HRT, some studies have demonstrated that women who take HRT for a few years around the time of menopause may have a long-term bone protective effect for many years after stopping HRT.
  • Reduction in cardiovascular disease — The effect of HRT on cardiovascular disease depends on the timing and duration of HRT as well as pre-existing cardiovascular disease. HRT reduces the incidence of coronary heart disease if it is started within ten years of menopause.

Other benefits

HRT has a protective effect against connective tissue loss in tissues such as skin, bones, joints and mucous membranes. Some studies have shown that HRT has benefits for metabolic health and it may reduce the risk of diabetes for some women. 

There may be a possible reduction in the long-term risk of cognitive decline in specific groups of women who take HRT (for example those with certain genetic markers). There is a need for further robust research to confirm these findings. Studies have demonstrated a reduction in the risk of colorectal cancer with the use of combined HRT.

Can you take HRT for the rest of your life?

There is no maximum duration of time you can take HRT. For the women who continue to have symptoms, their benefits from HRT usually outweigh any risks. As long as women have an annual review of their HRT with their healthcare professional and the benefits outweigh the risks — they can continue with HRT.

Most women aim to stop taking HRT after their menopausal symptoms diminish, which is usually three to five years after they start. However, for many, symptoms may continue longer for 10 years or beyond. If a decision is made to stop, gradually decreasing your HRT dose is usually recommended — rather than stopping suddenly. You may have a relapse of menopausal symptoms after you stop HRT, but these should pass within a few months. 

If you have symptoms that persist for several months after you stop HRT, or if you have particularly severe symptoms, HRT may need to be restarted, usually at a lower dose. After you have stopped HRT, you may need additional treatment for vaginal dryness and the prevention of osteoporosis.

What are the risks associated with HRT?

Like other medications, there are side effects and risks associated with taking HRT. For most women, the increased risks are very small, but you will need to talk to your doctor to weigh up the risks and benefits for you as an individual. 

Doctors are advised that women should take the lowest effective dose of HRT that controls their symptoms effectively. There is limited data on the use of HRT in women after 75.

The main risks of HRT are:

Large studies such as the Women’s Health Initiative (WHI) and the Million Women Study (MWS) caused concerns and controversy over the use of HRT when their findings were published 20 years ago.

However, reanalysis of some of that data and findings from recent studies over the past decade have shown that in women who need treatment of menopausal symptoms — initiating HRT during perimenopause or early menopause will provide a favourable benefit-to-risk ratio.

Venous thromboembolism

Oral HRT (combined oestrogen and progesterone or oestrogen only) slightly increases the risk of venous thromboembolism (VTE – venous blood clots), pulmonary embolism (blood clot in lungs) and stroke. The risk of VTE is increased two to three times with oral HRT. In one big study, over five years, less than 1 in 100 women taking oral HRT got a blood clot in their lungs. But this was about twice the number of women who were not taking HRT. If you've had blood clots before, you should let your doctor know and talk about whether oral HRT is suitable for you. 

Overall, the risk of blood clotting with oral HRT is a lot lower than taking the contraceptive pill or risk during pregnancy. The risk increases with age (mainly over 60) and with other risk factors such as obesity, previous thromboembolic disease, smoking and immobility. In healthy women below 60, the absolute risk of VTE is low and mortality risks from VTE are low. The type, dose and delivery system of both oestrogen and progesterone influence the risk of thromboembolic disease. 

The VTE risk appears to be higher among users of oestrogen plus progesterone than among users of oestrogen alone. The risk is increased especially during the first year of treatment. Previous users of HRT have a similar risk as never users. 

Transdermal oestrogens and oral natural micronised progesterone or Mirena coil are thought to be safer concerning thrombotic risk as they do not seem to increase the risk of blood clotting above the background risk.

Stroke

The risk of stroke appears to be slightly increased when taking oral oestrogen-only or combined HRT although the absolute risk is very small below the age of 60. Transdermal oestrogen again seems to be safer. The effects of HRT on stroke may be dose-related and so the lowest effective dose is usually prescribed in women who have significant risk factors for stroke.

Breast cancer

Data regarding the true effect of HRT on the incidence of breast cancer are still contentious. Combined HRT slightly increases the risk of breast cancer. The risk is a little higher for women who take HRT over the age of 60. The risk goes up slowly in the first five years you use HRT, then more quickly if you continue using it afterwards. However, the absolute risk is small at around one extra case of breast cancer per 1,000 women per year. 

Lifestyle factors such as smoking, excess alcohol intake and obesity have a similar or greater impact on breast cancer risk as compared to HRT. Mortality from breast cancer is not significantly increased in HRT users. Breast cancers found in women who take HRT are easier to treat than those in women not on HRT. 

The risk of breast cancer with oestrogen-only HRT is far less than with combined HRT. Most studies do not demonstrate an increased risk of breast cancer in women taking oestrogen-only HRT and some studies have shown a reduced risk.

It is also important to understand that the small increased risk of breast cancer with combined HRT does not apply to women who only use vaginal oestrogen and women who take HRT for early or premature menopause until the age of 51 years.

Endometrial cancer

Oestrogen-only HRT substantially increases the risk of endometrial cancer in women with a womb (uterus). The use of continuous combined HRT (both oestrogen + progesterone) or cyclical progesterone for at least twelve days every month almost eliminates this risk. If higher than recommended (unlicensed) doses of oestrogen doses are used as part of HRT, these need to be balanced adequately with more progesterone doses.

Heart disease

Women who are over 60, start HRT more than 10 years after menopause and have cardiovascular risk factors may have an increased risk of heart disease. But the risk is small and overall, no increase in serious morbidity or mortality attributable to heart disease is noted when transdermal and body-identical HRT preparations are offered. The data are limited and the decision to start HRT after 60 should be based on individual benefits versus risks assessment.

Other risks

There is a chance that taking HRT for a year or more could increase your risk of gallbladder disease (gallstones). Current data on HRT and the risk of ovarian cancer are conflicting. Some observational research suggests that HRT may slightly increase your chance of getting some types of ovarian tumours, although the risk seems to disappear when you stop using HRT.

What are the common side effects of HRT and how can they be minimised? 

Women react differently to HRT, so there is no one preparation that is better than any of the others. 

Some of the common side effects which you may experience on HRT include:

  • Oestrogen-related — breast tenderness, leg cramps, skin irritation, bloating, indigestion, nausea and headaches.
  • Progesterone-related — premenstrual syndrome-like symptoms, fluid retention, acne, oily skin, breast tenderness, backache, depression, mood swings and pelvic pain.

Nausea can be reduced by taking the HRT tablet at night with food instead of in the morning or by changing from tablets to another type of HRT.

Does HRT cause weight gain?

There is no evidence of weight gain with HRT. Researchers have found that, although women may put on some weight when they first start to take HRT (mainly due to fluid retention), after a while their weight is the same as it was before treatment. 

Women also tend to gain weight during the menopause, so any weight gain may not be a result of HRT. Your body’s fat distribution changes, with an increase in fat around the waist and less around the hips and buttocks. You can also experience water retention when on HRT.

Many of these common side effects simply go away when you have been on HRT for a while. Sometimes a change of product helps.

Monthly sequential preparations should produce regular, predictable and acceptable period-like bleeds. Erratic breakthrough bleeding is common in the first 3-6 months of continuous combined and long-cycle HRT regimens (with no regular period-like bleeds).

If bleeding tends to be heavy or irregular on sequential combined HRT then the dose of progesterone can be doubled or increased in duration to 21 days. If there is persistent irregular vaginal bleeding after six months of starting HRT, you will need to have further investigations and possibly a change of progesterone type or dose. If you experience predominantly progesterone-induced side effects, you can change the progesterone type, dose or frequency. 

If you experience significant nausea or migraine headaches with oral preparations, patches can often be a better option. Avoiding cyclical bleeds may also help with migraines. Progesterone-related side effects can sometimes be minimised if the Mirena coil is used as the progesterone arm of HRT.

When should HRT not be taken?

HRT is usually not prescribed in certain conditions such as:

  • Pregnancy and breast-feeding
  • Undiagnosed abnormal vaginal bleeding
  • Venous thromboembolic disease
  • Active heart disease
  • Current or past breast cancer 
  • Current or past endometrial cancer
  • Other oestrogen-dependent cancers 
  • Active liver disease 
  • Uncontrolled high blood pressure 

Women who would like to consider HRT but have one of these conditions should seek specialist advice and they may be able to have HRT after input from relevant specialists alongside medications to treat the underlying condition.

Frequently Asked Questions

If you are experiencing unmanageable menopause symptoms, get in touch with London Medical today

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