What is HRT?
Hormone Replacement Therapy, or HRT, is widely used for the treatment of menopause symptoms. HRT aims to replace the hormones that the female body stops producing during the menopause, namely Estrogen.
Menopause is a normal and natural event in all women. It occurs when the ovaries stop producing follicles leading to lower levels of estrogen and other hormones. Menopause is diagnosed when a woman does not have a menstrual period for 12 months. The peri-menopause is the stage around or near the menopause and can start anytime from 45 to 55 years of age. The average age of menopause is 51 years.
Why take HRT?
HRT is the most effective treatment for the most common symptoms of menopause. During the perimenopause and menopause, up to 80% of women experience hot flashes, with or without night sweats. Women may also experience vaginal dryness, urinary symptoms, fatigue, disturbed sleep, mood swings, decreased libido, and joint pains.
HRT is one of the most important ways to prevent and treat osteoporosis, which is the weakening of bones resulting in higher risk of fractures. Bones weaken as a result of low estrogen in menopause.
HRT has also more recently been found to have beneficial effects on the cardiovascular system through its effects on cholesterol, glucose metabolism, and arterial function. Studies have found cardiovascular benefits in healthy women starting HRT soon after the onset of menopause. The dose and type of hormones at the start of therapy appears crucial to obtaining cardiovascular benefit, and though these are still being studied, the science certainly appears to be heading in this very positive direction for women.
Does HRT improve cognitive function and prevent Alzheimer’s dementia?
At the time of writing, current data is conflicting. It is believed that low estrogen in menopause increases the risk of dementia, and some small studies suggest that starting HRT in the early menopausal transition may prevent Alzheimer’s – but the role of HRT to reduce risk has not been confirmed and will need larger and longer research.
There is consensus that women with premature menopause before reaching the age of 40 (termed Premature Ovarian Insufficiency) should be advised to take HRT and continue to do so until at least the natural age of menopause, if there are no contraindications. This has been found to have protective effects from cardiovascular disease, osteoporosis and cognitive impairment in this group of women. This is also largely true for women experiencing early menopause before the age of 45 years, whether naturally or due to surgery such as when the ovaries are removed.
Are there any risks with taking HRT?
The safety of HRT was called into question about 20 years ago when a study known as the Women’s Health Initiative reported increased breast cancer risk and heart disease from HRT. This had a major impact on menopause treatment practices which persists till this day. Since then, much higher quality research has been carried out and past findings have been re-analysed. The latest findings are that HRT is safe to use in most women – women with low underlying risk of breast cancer – if started in their 50s or who start HRT within 10 years of menopause. The risk of breast cancer with HRT is less than that with being overweight or drinking 2 or more units of alcohol a day. Most women will not be diagnosed with breast cancer as a result of their exposure to HRT. The risk of blood clots while taking HRT is similar to that for other risk factors such as being overweight or cigarette smoking. There is in fact no increased risk of blood clots from HRT gels or patches.
Caution with HRT use is advised in women with abnormal vaginal bleeding that has not been evaluated, and women with personal histories of breast cancer, established cardiovascular disease, or active liver disease.
What are the different types of HRT?
In a nutshell, HRT can be given in the form of oral tablets, gels and patches to be applied on the skin, and vaginal pessaries for insertion. HRT can be estrogen-only, which is used in women who have had their womb removed (hysterectomy). In women who have their uterus intact, they will need progesterone combined with estrogen to protect the womb lining. This is known as combined HRT, which can be given in a cyclical form to bring about a bleed like a normal menstrual cycle, or as continuous combined HRT which is period-free. Estrogen can also be given as a vaginal pessary to treat genito-urinary symptoms of the menopause very effectively, and this does not need the addition of progesterone.
How do I decide what I need?
It is highly recommended that you consult your GP to discuss if and which HRT is right for you. Your doctor will take an extensive history, do an examination and perhaps run some tests in order to assess your suitability for HRT, as well as determine which type of HRT is best for you. This is also a good opportunity to check that you are up to date with routine screening like cervical and breast screening. No two women are alike and it is essential to individualize treatment, depending on your symptoms, your medical background, as well as your personal preferences and priorities. Your trusted GP will be the one to provide the holistic and balanced approach to the care you need.
Join Dr June for a talk explaining the scientific facts on HRT on Fri 13 Aug at 10am. Register now.