There is so much online at the moment about the menopause and this is awesome – Davina McCall has done a lot to bring this out into the open.
But there is still a lot of work to do.
I often see women in clinic who are either on the wrong kind of HRT/wrong dose or not on HRT at all even when they would really benefit from it.
This guide is to help you decide if you need HRT, how it works and how best to go about getting it.
What Is Hormone Replacement Therapy (HRT)?
Hormone replacement therapy is medication that mimics the female hormones of your body – oestrogen and progesterone. When going through menopause, the amount of circulating hormones in your body declines, and this is why you feel the symptoms of menopause.
HRT aims to give you back proper circulating levels of oestrogen to improve your symptoms.
If you still have your uterus, taking oestrogen can cause the lining of your uterus to thicken, and this is dangerous to your health if left unchecked. To balance out the oestrogen, you also therefore need progesterone.
Progesterone protects your uterus from the thickening effects of the oestrogen, so make sure that if you start HRT, you are on both oestrogen AND progesterone in some form (except if you don’t have a uterus).
What are the signs that you need hormone replacement therapy?
There are many symptoms of menopause, so this list is not exhaustive.
Signs and symptoms include:
- general fatigue
- periods heavier or lighter than normal, come on more frequently or less frequently, last longer or shorter or stop all together
- brain fog (lack of concentration and mental sharpness)
- achy joints
- itchy, dry skin
- dry eyes
- UTIs that keep coming back
- poor sleep
- night sweats and hot flushes in the day
- reduced desire to have sex
- dry vagina
- sore vulva
- irritability and tearfulness
- a feeling of anxiety/not being able to cope
- you just feel “off” for apparently no reason
How is HRT given?
If you have a uterus
You need a combination of progesterone and oestrogen. The oestrogen can be given as a combined pill, combined or separate patch, gel or spray, and the progesterone can be given in a combined pill or patch, a separate pill or mirena coil as long as it is less than 5 years old. Vaginal oestrogen cream can be given without progesterone if this is all you use for vaginal/vulval/urinary symptoms.
If you still have periods
You should be given sequential combined HRT – this is where the HRT varies throughout the month to align with your periods. For 2 weeks of the month you will have oestrogen only, and the other 2, oestrogen and progesterone. If you have a mirena coil, you don’t need to do this and can have just oestrogen-type HRT in the form of patches, gels or sprays.
If your periods have stopped >1 year
You should be given continuous combined HRT – this is where the HRT does not vary throughout the month and you shouldn’t bleed on it. Some women do have some initial spotting, but then it should settle. If it continues, it could be a sign that something isn’t right with your endometrium (the lining of your uterus) and needs to be investigated.
If you don’t have a uterus
You only need oestrogen which can be given as a patch, gel or spray. You can also take advantage of vaginal oestrogen cream if most of your symptoms involve this area of your body.
How can I get onto HRT?
The best thing to do is talk to your GP. Many are sympathetic to what you’re going through and will be only too happy to help. If the one you consult isn’t confident with prescribing HRT, seek a second opinion until you get the help you need.
Alternatively, you could ask to be referred to a menopause specialist. The wait is long on the NHS unfortunately, and unless you pay, you have to accept this. Insurance companies don’t tend to cover menopause either which I think is an oversight on their part. A private specialist can help to initiate the treatment and then you could go to your NHS GP for ongoing prescriptions.
Don’t forget to use a prescription prepayment certificate to keep your costs low.
What are the Advantages of HRT?
Oestrogen receptors are found all over the body (the portion of the cells of your body that can detect and use oestrogen), so replacing it can have affects on many organs and systems.
HRT is excellent for protecting your bones. Reduced oestrogen over time increases process of bone-loss, so you end up with thinner bones over time that are more prone to breaking. HRT can help to slow down this process and is idicated to reducing someone’s ultimate risk of a severe fracture like breaking a hip in old age (which can be fatal).
When started within the first 10 years of menopause, HRT can help to protect your heart and blood vessels, reducing your risk of heart attacks and strokes.
Brain, Mood and Concentration
Replacing your hormones can have a marked improvement in your mood and help counteract brain fog. There is also a suggestion that starting HRT can help reduce dementia risk, but the evidence for this is far from conclusive. It can have the opposite effect if started too late into menopause.
Sex life and urinary tract
Vaginal and vulval dryness can make many women’s lives miserable and it increases the risk of repeated urinary tract infections. A sore vulva does not help in the bedroom department either! Using HRT can help these symptoms, but if you’re not keen on HRT, or can’t take HRT, vaginal oestrogen can be very effective to combat these symptoms too (just make sure you check with your specialist or GP first!).
Bowel cancer reduction
Studies have shown that oral combined HRT can slightly reduce your risk of developing bowel cancer. No one knows why, but there you go.
What are the Disadvantages of HRT?
In 1993 a clinical trial started in the USA called the Women’s Health Initiative (WHI). It’s aim was to look at the health effects on women taking either oestrogen-only HRT or combined oestrogen/progesterone HRT, compared to women taking an identical placebo (an inactive medication).
This study showed an increased risk of breast cancer in women using the combnied type of HRT. This effect starts around 3 years of taking HRT. Based on this data, it is thought that for women aged 50-59 years, an extra 3 out of 1000 women develop breast cancer. For comparison, for women with a BMI of over 30, there are 24 out of 1000 extra breast cancers.
Oestrogen-only HRT was show not to significantly increase someone’s risk of developing breast cancer up to 5 years of use.
The risks are low overall, and should be taken into consideration of the multiple benefits of taking HRT and not a reason to avoid using HRT.
An analysis of many studies brought together showed a small risk of ovarian cancer with one extra woman developing the condition per 1000 women. This is a very small risk and like with breast cancer, should be weighed up against the multiple benefits of using HRT.
Oral oestrogen is associated with an 2-4x increased risk of blood clots that is highest in the first year of it being used. This is not the case for topical oestrogen (patches, gels or sprays).
Abnormal vaginal bleeding
When first starting HRT, your bleeding pattern may change (e.g. spotting at odd times or increased/prolonged bleeding) but it should settle after the first 3 months of use. If it becomes problematic, a mirena coil can help. 90% of women using one find that their periods stop when using this, so if bleeding is becoming a problem, it’s worth considering. Anyone who starts bleeding after 1 year of no bleeding should discuss it ASAP with a healthcare professional as it could be the first indication of endometrial cancer. Women using sequential-type HRT beyond 5 years are more at risk of this happening, so should ideally be switched to continuous types when a woman reaches the age of 54.
Who should take HRT?
If you are over the age of 45, and have multiple symptoms, you are certainly perimenopause, even if you are still having periods. Perimenopause is the time leading up to menopause. Menopause is only diagnosed when you haven’t had a period for 12 months or more.
So anyone over the age of 45 with symptoms can start HRT as long as there are no medical reasons not to.
If you’re aged 40-45 with symptoms of menopause, then this is early menopause, and you can still consider starting HRT. Your healthcare provider could organise for you to have a blood test to check for signs of menopause.
If you’re under 40 with menopausal symptoms, then you definitely need to find out what us happening with your levels. If you are found to be perimenopausal (termed premature ovarian insufficiency), then unless there is a very good reason NOT to take HRT (like breast cancer), you definitely need to be looking at taking HRT to correct your hormone levels. This is necessary to protect your bones, heart and brain.
Who should avoid HRT?
Everyone is individual, so use this as a guide, but always confirm your own circumstances with a medical professsional before making any assumptions.
Absolute contraindication (should not take HRT)
Anyone who has had breast cancer, or has a genetic inheritence that puts them at very high risk of developing breast cancer should not take HRT. You may still be ok to have vaginal oestrogen tablets or cream though, so if vaginal dryness is making you miserable, speak to your oncologist to find out if you would be ok to use this or not.
Relative contraindication (might be able to take HRT with consideration)
When you start HRT is important
If you’re more than 10 years from menopause, or over the age of 60, HRT might not be suitable for you. The evidence from research suggests that there is a higher chance of doing more harm than good for your heart and blood vessels putting you at an increased risk of heart attacks and strokes if you start HRT too late, but as with most things in life, it’s a grey area. Ideally, HRT should be started as early as possible, because this then gives you the benefits that protect your heart and blood vessels.
You could however still have vaginal oestrogen to help with vaginal dryness, so it’s still worth asking your healthcare professional if this symptom is problematic for you.
High Blood Pressure
If your blood pressure isn’t well controlled, it’s important to get this treated first before starting HRT. Again, it’s all about your heart and blood vessels. Uncontrolled high blood pressure is already a risk factor for heart attacks and strokes, so the last thing you need is to add on HRT and push your risk further.
If you have liver disease, you should review with your liver specialist if HRT is a good idea for you or not. This is because your liver processes the HRT medication when taken in an oral form, and if your liver is damaged, you won’t be able to effectively process it and can cause worsening damage. You might be ok with patches, gels or sprays though, so it’s worth asking the question for your own circumstances.
If you have a known clotting disorder that increases their risk of developing blood clots, or history of a blood clot such as a DVT or PE need to discuss starting HRT with a haematologist. You may need to be put onto anti-coagulants (blood thinners) first.
Not strictly a contraindication, but need to think about it
Fibroids can shrink considerably after menopause (by as much as 40% in many women!) and this can be a godsend for women experiencing symptoms of pressure or bleeding caused by fibroids. Taking HRT can delay or slow down this shrinking process, so while you can take HRT, it’s worth talking to your medical professional if you start getting worse symptoms linked to your fibroids so that investigations and treatments can be initiated.
The evidence from research isn’t great in this area, but if you have endometriosis, there is a theoretical risk of reactivation of the disease, even if you’ve been surgically treated. If you need to, ask for a gynaecologists opinion about whether HRT is right for you or not and which types would be suitable.
BMI is a terrible way to assess someone’s health status, but none-the-less, studies are still being done using this method because it provides a convenient “cut-off” when evaluating data. Being termed “overweight” is not a reason to not be on HRT, but the type of HRT provided will need to be carefully considered. Topical therapies are favoured over oral therapies due to their reduced risk for causing bloodclots.
While being a smoker won’t stop you getting HRT, you have to consider your risks. Smoking puts your risk of heart attacks, strokes and blood clots up, and HRT could make that worse. It’s best to take HRT in a topical form like a patch, gel or spray to limit your risk as much as possible, and ideally stop smoking.
What are the alternatives to HRT?
The first thing to say is that herbal remedies are not regulated by a medicine authority and should not be considered safer alternatives to HRT. There is a lot of variety in their effectiveness and strength and there may be significant side effects. Some herbal remedies are not appropriate for people who have or had breast cancer, so always do your research before taking anything.
Black cohosh is said to help hot flushes although not as well as HRT. It doesn’t help with anxiety or low mood and it can interact with other medicines and there are unknown risks regarding its safety of use.
Isoflavones, phytoestrogens and soya products e.g. red clover
Studies unfortunately are not consistent in showing the effectiveness of these on menopause symptoms, and they are not recommended in women with breast cancer.
Antidepressants help with depression and anxiety, and some of these can also improve hot flushes in some women. Paroxetine 10 mg seems to be the most effective, even at low doseage and is now a recognised (licensed) treatment for menopausal hot flushes in the USA. Venlafaxine is also an option and is the preferred treatment for breast cancer survivors taking Tamoxifen (they should not take fluoxetine or paroxetine because it makes the tamoxifen ineffective). Antidepressants should not be offered for hot flushes unless HRT cannot be used.
Women often report reduction of hot flushes and night sweats with acupuncture, although clinical trials disappointingly don’t show a significant difference between “true” acuptuncture and “sham” acupuncture. It is thought that the effect is brought about with increased relaxation and reducinig stress levels which isn’t a bad thing in my book!
Clonidine is the only non-hormonal drug licenced for use for hot flushes in the UK. Studies are contradictory in how effective they are, although a few women may have significant benefit. It is a drug that. treats high blood pressure, so it may not be suitable for people with a low blood pressure. It can also cause high blood pressure if stopped abruptly, so needs to be weaned off gradually.
Cognitive Behavioural Therapy or CBT can help with low mood and anxiety caused by menopause. CBT can also improve hot flushes and sweats.
What are the myths of taking HRT?
The old thinking was that you could be on HRT for 5 years, then you have to stop. This is simply NOT the case. There isn’t a upper age limit for continuing with HRT and can choose.
How quickly will HRT start to work?
It’s different for everyone. Some people feel a difference within days of starting, while for others, it takes a few dose changes before feeling the benefits. The main point is not to give up. Even if the first dose doesn’t help, persevere with it. If after 3 months though your symptoms are not improving, speak to your healthcare provider again to take another look. Not everything can or should be explained by the menopause, so if your symptoms aren’t going away with HRT, it might be something else that needs looking into.
What about Testosterone?
While this hormones is predominantly a male hormone, women do have some circulating too, just in smaller doses. It has been thought that low testosterone can also occur in menopause, but the effects of this are not fully understood. Some women who still feel tired and have a low libido on full dose HRT may benefit from testosterone replacement as well. You may find getting hold of this more of a struggle though, as many areas restrict GPs from being able to prescribe it without you first seeing a menopause specialist. If you think you might need it, and you are an optimal dose of HRT, chat to your doctor about it. If necessary, see a private menopause specialist who will be able to help guide you on this.
Gone are the days where we should be shying away from taking HRT. Don’t accept that you have to feel bad through your transition – it’s simply not the case. The benefits of HRT for many women far outweight the risks, so if you’re struggling, speak to your healthcare provider and ask them to assess you for treatment ASAP.
Until next time,
P.S. if you’re based in or near Milton Keynes and you’re looking for a women’s only GP service, sign up to the waiting list to be the first to find out when it opens.