What is the menopause?

The menopause marks the end of menstruation in a woman’s life. It begins 12 months after a woman’s last period. As you approach the menopause your ovaries produce less and less of the hormone oestrogen. Although the menopause is a natural event and every woman’s experience is different, many women suffer troublesome symptoms in response to the fall in oestrogen levels. These include – hot flushes, sleep disturbances, aches and pains, mood disturbance, reduced sex drive and vaginal dryness.

 

 

What is HRT?

HRT is medication that contains female hormones taken to replace the oestrogen your body stops producing at the time of the menopause. There are different types of HRT, with different hormones, routes of administration and treatment plans.

The main preparations of HRT can be divided into:

1. Combination HRT which contain oestrogen and progesterone. This is commonly used if you have not had a hysterectomy as oestrogen alone can stimulate the growth of the lining of the womb and increase the risk of endometrial (womb) cancer.
2. Oestrogen only HRT which contain only oestrogen, mainly prescribed for women who have had a hysterectomy.

Bio-identical hormones are not currently recommended as it is unclear how safe or effective they are.

 

What are the benefits of HRT?

Hormone therapy is the most effective treatment we have available for managing the symptoms of the menopause. Menopausal symptoms usually settle after a few years but can be unpleasant. Hot flushes and night sweats can have significant effects on your quality of life and can interfere with sleep, daily functioning and can cause mood disturbances.

Lifestyle changes can help reduce hot flushes however if you have frequent and severe symptoms you may benefit from hormone replacement therapy.

Menopausal hormone therapy also reduces the risk of osteoporosis and bone fractures and can help with vaginal dryness and painful intercourse.

 

What are the types of HRT?

There are 2 main types of hormone therapy:

1. Systemic therapy – this is used to treat most menopausal symptoms as a higher concentration of oestrogen is given and absorbed into the bloodstream. It can be given in tablet form, a skin patch, skin gel or cream.
2. Topical vaginal therapy – this is used to treat vaginal dryness and urinary symptoms but has little effect on hot flushes or other systemic symptoms. Topical treatment contains low concentrations of oestrogen and comes in the form of a vaginal cream, pessary or a ring.

 

Your doctor should be able to guide you through the different types and preparations of HRT and come up with a treatment plan that is most suitable for you. You may need to try more than one option to find the one that works best for you. 

 

What are the risks of HRT?

The risks associated with HRT depend on the type of hormone therapy, the dose, how long the medication is taken and your individual health risks. Hormone replacement therapy has been shown to increase the risk of:

• Heart disease and stroke

There is a small increased risk of cardiovascular disease in women who start HRT, particularly in tablet form, over the age of 60 years. 

• Blood clots 

A tablet form of HRT increases the risk of venous thrombosis, particularly in the first couple of years of use. Studies suggest the risk of blood clots is lower in women using HRT patches or gels.

• Breast cancer

Women taking combination HRT for more than 4 years have a slightly increased risk of breast cancer. Oestrogen only HRT has been recently found to reduce the risk of breast cancer 

 

Your doctor will also consider the following when you meet up with them to discuss whether HRT is right for you: 

• Age. Women who begin HRT 10 years after starting the menopause or after the age of 60 years are more at risk of heart disease and blood clots. In women who start HRT earlier, the benefits far exceed the risks. In fact, studies have shown that women who go through early menopause and take HRT have a reduced risk of heart disease compared to those who do not.
• Personal and family history. if there is an increased risk of blood clots or breast cancer in the family then this may increase your own personal risk. If you have a personal history of breast cancer, blood clots or heart disease then HRT may not be suitable for you.

 

What are the side effects of HRT?

The most common side effects experienced by some women include breakthrough bleeding, breast tenderness and bloating. However, symptoms often settle after the first few weeks of treatment.

 

Who would benefit from HRT?

The benefits of HRT outweigh the risks if you are otherwise healthy and:

1. You have had an early menopause, ie before the age of 45 years. In fact, in women who have experienced an early menopause HRT has been shown to help reduce the risk of heart disease, stroke, dementia and osteoporosis. Experts recommend that women continue HRT until the average age of the menopause (about 51 years) unless there is a specific reason not to.
2. Severe or frequent hot flushes or other menopausal symptoms affecting your quality of life and you are within 10 years of your last period and under the age of 60 years. 

 

You can reduce your risk of developing  adverse effects from HRT by:

• Making healthy lifestyle choices including a healthy diet, regular physical activity, trying to maintain a healthy weight and not smoking.
• Finding the most suitable product for you, for example, if you are only struggling with vaginal symptoms then a topical vaginal cream would minimise the systemic side effects associated with tablets. Do speak to your doctor about the different ways of taking HRT.
• Use the lowest effective dose for the shortest period of time needed to control your symptoms. Your doctor will discuss this with you, but many women can stop HRT after 4-5 years of treatment.
• Attend for regular follow up and routine mammogram screening to ensure the benefits of HRT continue to outweigh the risks.

 

What nonhormonal options are available to help me with my symptoms?

1. Lifestyle. You may be able to manage your symptoms by reducing caffeine and alcohol intake, reducing spicy food, wearing cotton or linen clothes to keep cool and practising relaxation and breathing techniques.
2. Vaginal lubricants can help manage vaginal dryness and painful intercourse.
3. Your doctor can talk to you about nonhormonal medications which may help reduce hot flushes and other menopausal symptoms.
4. For bone health, ensure you are eating enough calcium-rich foods, are maintaining adequate vitamin D levels by being out in the sunshine and exercising regularly to increase bone strength. 

 

Summary

Hormone replacement therapy is the most effective treatment available to treat the symptoms of the menopause. Do talk to your doctor about your own individual health risks if you have troublesome symptoms. You can decide together whether HRT is a treatment option for you.

 

Dr Mohgah Elsheikh