Hormone replacement therapy (HRT) is the main method of treating the troublesome symptoms that arise during the menopause. It is also an important preventive medicine as it effectively reduces the risk of certain life-threatening or painful conditions such as heart attacks and osteoporosis.
HRT is not suitable for everyone but understanding the advantages and disadvantages and gathering as much information as possible will help you make an informed choice about managing your menopause.
There is no organ in a woman’s body whose health is not maintained by oestrogen. So every organ in a woman’s body benefits from oestrogen supplements when her ovaries fail at the end of her fertile life.
Treatment of Hormone Replacement Therapy
HRT is a combination of the female hormones oestrogen and synthetic progesterone (progestogen). Oestrogen is given to maintain the health of vital organs such as the heart and brain and also the female sex organs and breasts. It also keeps the lining of the vagina and other body tissues elastic, the brain active, relieves anxiety and promotes sleep. It is helpful in preventing heart attacks, stroke, osteoporosis and Alzheimer’s disease.
Progestogen causes the uterine lining to shed, which means with some tvpes of HRT you will still have a monthly period, but there are other no-bleed forms for you to choose from. When hormonal medication was first prescribed in the 1960s and 1970s only oestrogen was used. It was then discovered that women on this treatment had a slightly higher risk of uterine cancer than non-users. Since then progestogen has also been prescribed as it eliminates the risk of uterine cancer and can even protect against it.
Finding The Right Type of HRT
The wide choice of HRT should mean that there is a type to suit most women. It may take time to find your optimum dose and you and your doctor may have to experiment because there is no way of predicting how each individual woman will respond to the many different oestrogens available. It is wise to have a minimum of a four-month trial as it takes that long for your body to settle down. If necessary your doctor can assess whether your hormone dose is correct by doing a blood test. Don’t alter your dose or stop without consulting your doctor first.
How Do I Take It?
Types of HRT
Tablets – Most HRT is prescribed in tablet form, is highly effective in combating physical and emotional symptoms and can be stopped immediately if it doesn’t suit you. It may be unsuitable if you have a history of high blood pressure, blood clotting, liver trouble, breast lumps or breast cancer. Some women experience breast tenderness and nausea and you may get breakthrough bleeding if you forget to take a tablet.
Creams – An applicator delivers measured doses of oestrogen-impregnated cream directly into the vagina. It reduces genital itching, thinning, discomfort and urinary problems.
Pessaries – Pellets deliver low doses of oestrogen directly into the vagina. It reduces vaginal dryness and pain on passing urine. Both creams and pessaries are easy to use but the doses are too low to deal with general menopausal symptoms or to act as a preventive medicine.
Transdermal (skin) patches – A low dose of hormone enters the body through the skin. Patches need to be changed every three to four days. Equally effective as the tablet form of HRT, it is simple to use and has few side effects. A very few women develop red, itchy skin underneath the patch and this may get worse in a hot climate.
Skin gel – The lowest and most physiological form of HRT is delivered from a gel rubbed into the skin of the thighs and upper legs. It has the fewest side effects and you can alter the dose yourself. It’s the form I favour.
Implants – A pellet containing a six-month supply of oestrogen is inserted under the skin of the abdomen or buttocks. Tablets of progestogen are usually taken as well. It gives excellent relief from physical symptoms and a high level of protection against osteoporosis. But doses are difficult to modify and insertion requires a minor surgical procedure. You can have a testosterone implant at the same time to increase your sex drive.
Ways of Taking It
Continuous therapy – The most common method. Oestrogen is absorbed daily either by taking a tablet or by wearing a skin patch twice a week. Progestogen is taken in pill form or in a combination skin patch for 12-14 days. Over 90 percent of women will have a monthly bleed but many women find periods dry up after a few months.
Cyclical therapy – Oestrogen is taken from the first to the 21st day of the cycle and progestogen for the last 12 or 13 days; both medications are stopped on the 21st day. Most women will experience a withdrawal bleed between the 22nd and 28th day but it usually lessens over time and may disappear altogether. Alternatively, progestogen may be taken once every three months. This means that you have four bleeds a year.
Combined continuous therapy (no-bleed HRT) – Continuous daily doses of oestrogen with a very low dose of progestogen. Some women bleed at first but this usually stops after a few months. This method is popular with women on long-term treatment and women who start HRT when they’re older, say, after osteoporosis develops.
SERMs – The latest form of HRT is called raloxifene and is one of a group of drugs called SERMs (Selective oestrogen Re-uptake Modulators). It protects the bones and the heart and has no risk of breast cancer. But it doesn’t treat hot flushes, dry vagina or bladder symptoms as well as conventional HRT does. Nor does it protect against Alzheimer’s disease.
How Long Do I Take It?
Treatment is usually continued for between two and five years as the body gradually adjusts to oestrogen deficiency. However, HRT must be taken for at least five years if it is to prevent bone loss and heart problems. If you stop after a short time, symptoms such as hot flushes may return in a more severe form. In my opinion there is no reason to ever stop HRT if it suits you. As there is a small increased risk of breast cancer after 10 years, many doctors would say 10 years is the longest you should take it. However, the increase in risk is the same as delaying your first child until after 30 and I’m prepared to live with that risk to enjoy the benefits of HRT
Women Who Should Take HRT To Protect Them
- Women with a family history of heart attack, stroke or Alzheimer’s disease.
- Women with a personal history of heart attack, stroke or Alzheimer’s disease.
- Women with a family history of osteoporosis.
- Women with a personal history of osteoporosis or who have taken steroids.
Side Effects And Risks
Some women have reported fluid retention, nausea, breast tenderness, headache, dizziness and depression. Experimenting with different types may be the answer. About 10-15 percent of women react to progestogen and experience something similar to premenstrual syndrome. For about half of the affected women these effects subside over a four-month period. Progestogen intake can be reduced by taking it only every three months (cyclical therapy).
The possibility of a link between HRT and uterine cancer is a major concern. Fortunately, the use of progestogen eradicates the risk of uterine cancer and may even give future protection. The debate surrounding breast cancer is far from clear-cut. It is generally agreed that in the first 10 years of use, there is no increased risk. After that, the risk is increased slightly but mainly for women who already have other risk factors in their medical history. Women on HRT who develop breast cancer usually have a less invasive form and a higher survival rate. However, progestogen does not protect against breast cancer and may cause breast problems in some women.
Between ages 50 and 75, 3 women in 100,000 are estimated to die from complications of gallbladder disease. This figure doubles to 6 women in 100,000 among women on HRT.
Women At Risk
Women who fall into one or more of the following categories may be advised by their doctors not to take HRT, though if your menopausal symptoms are very severe you and your doctor can weigh up the pros and cons.
- High blood pressure.
- History of thrombosis.
- Chronic liver disease.
- History of breast, vaginal, cervical or endometrial cancer.
The first four of these could be treated for instance by a low-dose prescription such as a patch or gel or local vaginal oestrogen in the form of a cream or pessaries.
How HRT Can Help
- Hot flushes and night sweats – Over 90 percent of women find complete relief when they are prescribed oestrogen regardless of the form it takes; over 98 percent report that their symptoms have lessened.
- Vaginal dryness, soreness and painful intercourse – Can be relieved.
- Intellectual problems (poor concentration/ability to make decisions) – Improvement within a month or so.
- Skin, hair and nails – All should improve. Gum recession around the time of the menopause can also be alleviated.
- Menorrhagia (very heavy periods) – Women in their late 40s and 50s sometimes find that their periods become much heavier. HRT can help, but severe abnormal bleeding may require additional treatment.
- Sleep – Research indicates that women may dream less when they are oestrogen deficient. As this type of sleep is important to your sense of wellbeing HRT should help to make you feel rested after sleep. Take your HRT last thing at night for a really sound sleep.
- Libido (sexual drive) – This varies from woman to woman. Testosterone – the male hormone – is also manufactured by the ovaries and is thought to be largely responsible for the female sex drive. High levels of oestrogen can deplete it. Daily low doses of testosterone – or a testosterone implant – can bring about a subtle return of sexual vitality without side effects.
- Prevention of heart attacks and strokes – Acute coronary artery disease kills one woman in every four over the age of 60. HRT reduces the risk by up to 50 percent.
- Osteoporosis – This is a bone¬thinning process that occurs in postmenopausal women. It can result in fractures, curvature of the spine and severe back pain. HRT is thought to be an important form of protection.
- Reduced risk of developing cancers of the lung, colon, ovary and cervix; may delay the onset of Alzheimer’s disease.